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Archives of Pediatrics
A MONTHLY JOURNAL DEVOTED TO THE
DISEASES OF INFANTS AND CHILDREN
FOUNDED XN 1884 BY VVM. PERRY WATSON, M.D.
EDITED BY
HAROLD RUCKMAN MIXSELL, A.B., M.D.
FELLOW OF THE NEW YORK ACADEMY OF MEDICINE; ASSOCIATE ATTENDING PHYSICIAN
TO THE WILLARD PARKER HOSPITAL; ASSISTANT ATTENDING PHYBICIAN TO THE
NEW YORK NURSERY AND CHILD'S HOSPITAL; ATTENDING PHYSICIAN
TO THE NEW YORK NURSERY AND CHILD'S HOSPITAL, OUT-
PATIENT department; instructor in pediatrics,
BELLEVUE MEDICAL SCHOOL, NEW YORK
AND
CHARLES ALBERT LANG, M.B, Tok.
M.R.C.S., Eng.; L.R.C.P., Lond.
assistant attending physician to the new YORK NURSERY AND CHlLU's HOSPITAL,'
ATTENDING PHYSICIAN TO THE NEW YORK NURSERY AND CHILD'S HOSPITAL,
OUTPATIENT DEPARTMENT; ATTENDING PHYSICIAN TO THE BABIES'
HOSPITAL dispensary; INSTRUCTOR IN PEDIATRICS, CORNELL
UNIVERSITY MEDICAL SCHOOL, NEW YORK
VOLUME XXXVII
JANUARY TO DECEMBER
1920
E. B. TREAT & CO., Publishers
45 East Serenteenth Street
NEW YORK
LIST OF CONTRIBUTORS
Bergey, D. H.
Bradley, William N.
Bridgman, Olga
Byard, Dever S.
Chaplin, Hugh
Cohen, Frank
Dietrich, Henry
Elterich, Theodore J.
Emerson, Wm. R. P.
Epstein, J. W.
Faber, Harold K.
FooTE, John
Freeman, R. G.
Funkhouser, W. L.
Gelston, C. F.
GiFFORD, Mabel F.
Gin gold, David
Greiwe, John E.
Griffith, J. P. Crozer
Hassler, William C.
Heiman, Henry
Hoyne, Archibald L.
HuBER, Francis
Kastner, Alfred L.
Kerley, Charles Gilmore
Kerley, James Hoyt
KoLMER, John A.
Lambright, Geo. L.
Lang, C. A.
Larson, J. H.
London, William
LoRENZE, Edward J., Jr.
Lucas, William Palmer
Martinetti, C. D.
McLean, Stafford
Manning, John B.
Manny, Frank A.
Meyers, Alfred Edward
Mitchell, A. Graeme
Mix SELL, Harold R.
Neal, Josephine B.
Nicholson, Percival
Oppenheimer, Seymour
Phillips, John
Potter, Philip S.
Rabinoff, Sophie
Rachford, B. K.
Ratner, a. Bret
Regan, Joseph C.
Retan, Geo. M.
Richardson, Frank Howard
Root, Aldert Smedes
Rosenthal, Nathan
RoYSTER, Lawrence T.
Sammis, Jesse F.
ScHWARZ, Herman
Scott, A. J., Jr.
Shapiro, L. L.
SiDBURY, J. BUREN
Silverman, A. Clement
Sinclair, John F.
Smith, Charles Hendee
Snyder, J. Ross
Solis-Cohen, Myer
Southworth, Thomas S.
Stimson, Philip Moen
Strong, Robert A.
Tumpeer, I. Harrison
Vietor, John A.
Weston, William
Wilcox, Herbert B.
Wile, Ira S.
/
Copyright, 1920
By E. B. Treat & Co.
New York.
liNDEX TO VOLUME XXXVII.
Acid intoxication, epidemic. Rachford 651
Acidosis of the recurrent vomiting type 681
Acrodynia. Weston 513
Adenoid diphtheria, report of a case 756
Adenoids, the etiology, prevention and non-operative treatment
of 701
Alveolar sarcoma with metastases in the skull 701
American Pediatric Society, detailed report of the thirty-second
annual meeting, with full abstracts of all papers read 385
Anaerobes in the intestinal flora of infants 432
Anaphylaxis following intradermal protein sensitization tests.... 422
Anemia in infants and children, the cholorotic type of. Schwarz
and Rosenthal 1
Anesthesia in infancy and childhood, local 381
Angina, streptococcic, with purpura hemorrhagic and multiple
infarcts of the skin and subcutaneous tissue 422
Antiscorbutic property of fruits (an experimental study of dried
orange juice) 255
Antiscorbutic value of proprietary baby foods 379
Appendicitis in children, chronic 755
Ascaris, surgical lesion from 454
Aspiration pneumonia, fatal case of, caused by the ingestion of
zinc stearate 120
Ataxia, acute cerebro-cerebellar, with reports of cases 390
Athreptic infants, the artificial feeding of 122
Atresia, congenital, of the esophagus. Kastner 670
Atresia, congenital, of the esophagus 416
Atrophic infants, dextrose tolerance in 758
Atrophy, infantile spinal progressive muscular 365
Aural suppuration in early childhood; its prevention and
treatment 124
Auricular fibrillation in a young girl, case of 104
Bacillus abortus bovinus, preliminary observations on the
pathogenicity for monkeys of the 405
Bacteria in the gastrointestinal tract of guinea-pigs as influenced
by diet 433
Bacteriemia treated by repeated transfusions, a case of. Sammis. 679
Bergey, D. H. The bacteriology of summer diarrhea 462
Blood findings in a child five years after splenectomy 425
Blood injections, intramuscular, as nutritional aids 381
Blood nitrogen of infants and children, recent studies in 445
Blood sugar, studies on; the ef^^ect of blood on picrate solutions.. 387
Blood, the coagulation time of the, in the new born with special
reference to cerebral hemorrhage 376
Blood transfusion, the therapeutic aspect of 320
Bodily mechanics; its relation to cyclic vomiting and other
obscure intestinal conditions 394
Book reviews 63, 192. 384, 512
Bradley, William N. Feeding the new-born 144
Breast fed infant, the food requirement of the. Dietrich '. 278
iv INDEX
Breast feeding, the duration of, in 1,000 cases from private
practice. Manning 214
Breast milk, observations on the salt content of 361
Bronchi, physical signs of foreign bodies in 749
Butter fat and the child's weight. Larson 610
Byard, Dever S. Diphtheria prevention 22
Cardiac disease in children, the place of tonsillectomy in the
management of 690
Cardiac, the psychology of the, and the doctor 687
Cardiospasm, a case of 417
Catharsis and laxatives in infancy and childhood, the abuse of... 121
Cereal feeding, thick, in malnutrition in infancy, further studies
in. Mixsell 486
Cerebrospinal fluid of acute disease, observations on the 314
Chickenpox complicating scarlet fever 747
Childhood delinquency, some medical aspects of 636
Cholecystitis, acute, in children as a complication of typhoid fever 757
Chorea, an electro-myo-graphic study of 189
Chorea complicated by gangrene of the fingers, a case of 704
Chorea, pathogenesis of '. 461
Chorea, the etiology of. Tumpeer 717
Chylous ascites, Lambotte-Handley drainage in a case of. Huber. . 600
Circulatory reactions in normal children after exercise 368
Cirrhosis of the liver, familial; 537
Coagulation time of blood in the new-born, the 754
Cohen, Frank. Cyanosis of the new born 666
Congenital defects in the lower bowel recurring in three successive
children of one family 60
Constipating qualities of orange juice 188
Convulsions in infancy and childhood, a study of the relationship
of, to epilepsy ., 753
Cranial sinus thrombosis in children, some remarks on.
Oppenheimer 65
Cyanosis of the new born. Cohen 666
Dehydrated infants, fluid injections in 115
Diabetes, juvenile 512
Diarrhea due to the streptococcus mucosus, case report on an
epidemic of hemorrhagic 395
Diarrhea in breast-fed infants 665
Diarrheas of infancy and childhood, a clinical classification of the.
Royster 523
Dietetic reform, the urgent need of, and thei duty of the medical
profession toward all the young of the nation 435
Dietrich, Henry. The food requirement of the breast fed infant.. 278
Diphtheria bacilli, rapid diagnosis of 138
Diphtheria carrier, the. Funkhouser 558
Diphtheria, institutional control of 703
Diphtheria prevention. Byard 22
Diphtheria toxin, studies of the effect of, on the heart 380
Drugs in treatment of children 309
Duodenal stenosis 1 19
INDEX V
Dysentery in children, vaccine therapy of 461
Dyspituitarism so-called; absorption of membranous bones,
exophthalmos and polyuria 408
Eczema in early life, the predominance of seborrheic. Southworth 338
Eczema in infants 746
Effort syndrome in children, the. Kerley 449
Electrocardiography in children 447
Elterich, Theodore J. Tetany — report of an unusual case........ 89
Emerson, Wm. R. P., and Manny, Frank A. Weight and height
in relation to malnutrition 468
Empyema in children, the diagnosis of 752
Encephalitis, bacteriologic findings in epidemic 746
Encephalitis, epidemic or lethargic, in children. Neal 321
Encephalitis, focal hemorrhagic. Root 538
Encephalitis lethargica 503
Encephalitis lethargica, epidemic 388
Endocarditis in infancy, malignant 186
Enuresis in children, essential 269
Epilepsy, Jacksonian, surgical treatment of 186
Epithelioma of appendix in a child 317
Epstein, J. P. Intraperitoneal administration of sodium bi-
carbonate solutions 656
Examination of a group of French children, results of the.
Gelston 235
Faber, Harold K. A study of the growth of infants in San
Francisco with a new form of weight chart 244
Fat metabolism of infants and young children 189
Feces, a simple method of determining the reaction of 314
Feeding, maternal, three pertinent questions on 352
Food dislikes of childhood, the relation of acquired, to the ills
of middle life 350
Food requirements of children after the first year, the 429
Foote, John. An infant hygiene campaign of the second century. 173
Freeman, R. G. Pneumonia in infancy and childhood with
physical signs 11
Funkhouser, W. L. The diphtheria carrier 558
Gelston, C. F. Results of the examination of a group of French
children 235
Gifford, Mabel F. Speech disorders and defects 305
Gingold, David. An early diagnostic sign in basilar meningitis.. 19
Gonococcus vulvitis in little girls 383
Greiwe, John E. Report of a case of diaphragmatic hernia 593
Griffith, J. P. Crozer. The dietetic treatment of summer diarrhea 455
Growth of infants in San Francisco, a study of, with a new form of
weight chart. Faber 244
Hassler, William C, and Bridgman, Olga. Mental examinations
as an aid to pedagogical methods in the public schools.... 289
Health classes for children. Wile 162
Heart block, a case of complete 103
Heart disease, circulatory reactions to test exercises in children
with 689
vi , INDEX
Heart disease, new ideas of, applied to pediatrics 366
Heart displacement apparently due to mediastinal emphysema
following aspiration pneumonia 420
Heart malformation, specimen of congenital 104
Heiman, Henry. The organization of a modern pediatric service. 682
Heliotherapy; its general use in pediatrics. Lucas 193
Hemorrhage of the new born, the importance of lumbar puncture
in intracranial. Sidbury '. 545
Hemorrhage, seric-serum for controlling 59
Hernia, massive congenital diaphragmatic, with dextrocardia 508
Hernia, operation for diaphragmatic 172
Hernia, report of a case of diaphragmatic. Griewe 593
Hernia, true congenital diaphragmatc 510
Home, the advantages of, over institutional care 562
Hoyne, Archibald L. An unusual instance of multiple infections. . 606
Huber, Francis. Lambotte-Handley drainage in a case of chylous
ascites 600
Ileocolitis, the prophylaxis of. Snyder 554
Indican and the sulphates in infants' urine in health and disease.. 288
Indigestion in children from 6 to 12 years of age, the treatment of. 347
Indigestion in children, the treatment of 343
Infant feeding, certain phases in the development of modern 750
Infant hygiene campaign, an, of the second century. Foote 173
Infants' hospital, further developments of 426
Infantile asthmatic nervosis, etiology and pathology of 186
Infantile paralysis, unusual localization in 544
Infections, multiple, an unusual instance of. Hoyne 606
Inferiority complex in childhood 631
Influenza bronchopneumonia, human serum in treatment of 18
Influenza, etiology of 213
Influenza in children, catarrhal jaundice associated with 61
Influenza in children, new treatment of 62
Influenza, Pfeififer's bacillus in 313
Injections of patient's own milk to stimulate secretion 599
Intestinal flora, toxic action from 102
Intravenous injection of calcium, the effect of, in tetany 757
Intubation of the larynx 371
Intussusception in infants, with a report of five cases 751
Intussusception treated by resection, case of 485
Kastner, Alfred L. Congenital atresia of the esophagus 670
Kerley, Charles Gilmore. The effort syndrome in children 449
Kerley, Charles G., and Lorenze, Edward J., Jr. Report of three
interesting cases 733
Kolmer, John A. Immunity in syphilis with special reference to
congenital or prenatal syphilis .^ 129
Larson, J. H. Butter fat and the child's weight 610
Lead poisoning from nursing bottles 316
Lucas, William Palmer. Heliotherapy; its general use in
pediatrics : 193
Luetin, the value of, in an outpatient department. Meyers 223
INDEX vii
Lymphatic leukemia, with report of a case. Scott 726
Lymphosarcoma, a case of 419
Malaria among children in Palestine, some experiences with.
Rabinoflf 494
Malnutrition, weight and height in relation to. Emerson and
Manny 468
Malt soup extract, has it an antiscorbutic value? 437
McLean, Stafford. Seasonal incidence of tetany — a report of
forty-seven cases 85
Manning, John B. The duration of breast feeding in 1,000 cases
from private practice 214
Medical supervision of the boarded-out child 439
Megacolon in children, treatment of congenital 557
Megaduodenum : Hirschprung's disease 88
Meningeal hemorrhage, subarachnoid 749
Meningismus from severe throat infection 748
Meningitis, atypical epidemic 725
Meningitis, basilar, an early diagnostic sign in. Gingold 19
Meningitis, caused by lead poisoning, in a child of 19 months.
Strong 532
Meningitis, the foot phenomenon in 732
Meningitis, tubercular, in infancy 318
Meningococcus sepsis, the choice of sera in the treatment of.... 315
Mental examinations as an aid to pedagogical methods in the
public schools. Hassler and Bridgman 289
Meyers, Alfred Edward. The value of leutin in an outpatient
• department 223
Milk, frozen Mixsell 270
Milk in the diets of infants and young children, the misuse of.. . . 430
Milk in infant feeding, boiled vs. raw 319
Milk, lactic acid, a brief report on 434
Milk modifications, the calorie as a unit in figuring 316
Milk, women's, a study of the lactose, fat and protein content of. 702
Mitchell, A. Graeme. The newer knowledge of the new-born.... 151
Mixsell, Harold R. Frozen milk 270
Mixsell, Harold R. Further studies in thick cereal feeding in
imalnutrition in infancy ' 486
Mongolian idiocy 10
Mother's instructions to a new nurse 310
Mumps, the duct sign in 421
Myositis ossificans 507
Myxedema, early congenital 185
Nasal catarrh, autogenous vaccines in treatment of chronic 222
Neal, Josephine B. Epidemic or lethargic encephalitis in
children 321
Nephritis chronic, in children 362
Nephrolithiasis in a girl of three years 615
Nervous child, the 184
New-born, care of 92
New-born, cerebral hemorrhage of the 256
New-born, feeding the. Bradley 144
New-born, the newer knowledge of the. Mitchell 151
viii INDEX
New-borns, the acidotic state of normal 255
New York Academy of Medicine, Section on Pediatrics S3
103, 503, 562, 615, 623, 687.
Nicholson, Percival. Acute otitis media in influenza from the
pediatric standpoint ■ 706
Nutritional disturbances, the circulatory system in 443
Nutrition, how pediatric teaching of, may affect the nation's
welfare 355
Nutrition in childhood, the measure and development of. Retan.. 32
Open air classes 678
Opthalmia, phlyctenular, and its relation to tuberculosis 396
Oppenheimer, Seymour. Some remarks on cranial sinus
thrombosis in children 65
Osteoperiostitis tardy, with inherited syphilis 669
Otitis media, acute, in influenza from the pediatric standpoint.
Nicholson 706
Outpatient work, recent developments in. Smith 40
Paralysis of the neck 243
Paralysis of the respiratory muscles, a case of 416
Paraplegia from idatid cyst of the cord 126
Pediatric service for the modern general hospital, a model.
Richardson 93
Pediatric service, the organization of a modern. Hciman 682
Peritonitis, acute general, in infants 750
Peritonitis, plastic 21
Phillips, John, and Lambright, George L. Premature sexual
■development j 282
Pleurisy in infants, serotherapy of purulent , 31
Pleurisy, purulent in young children 640
Pneumococcus cerebral abscess, primary., 62
Pneumonia in infants and children during the recent epidemics.. 397
Pneumonia in infancy and childhood without physical signs.
Freeman 11
Pneumonia, segregation of 385
Poliomyelitis, the influence of epidemic upon the susceptibility to,
and the symptomatology of other contagious diseases.
Regan 257
Polyencephalitis with narcolepsy, acute 185
Potter, Philip S., and Silverman, A. Clement. Case of Raynaud's
disease in an infant of six weeks 744
Precipitins for t^^ albumin in stools 431
Premature infant, the problem of the. Sinclair 139
Protein therapy, principles of foreign 128
Psychopathic individuals, the institutional treatment of 634
Pyloric stenosis in infancy 448
Pylorospasm successfully treated 127
Rabinoff, Sophie. Some experiences with malaria among children
in Palestine 494
Rachford, B. K. Epidemic acid intoxication 651
Rachitic children, dental anomaly found in 61
Raynaud's disease, case of, in an infant of six weeks. Potter and
Silverman 744
INDEX ix
Rectal feeding 576
Regan, Joseph C. The influence of epidemic poliomyelitis upon
the susceptibility to and the symptomatology of other
contagious diseases 257
Report of three interesting cases. Kerley and Lorenze, Jr 733
Retan, George M. The measure and development of nutrition in
childhood 32
Richardson, Frank Howard. A model pediatric service for the
modern general hospital 93
Rickets, a preliminary study of the effect of, on the jaws 318
Rickets in relation to housing 304
Rickets, some observations on 411
Rickety children, cod-liver oil for 277
Root, Aldert Smedes. Focal hemorrhagic encephalitis 538
Royster, Lawrence T. A clinical classification of the diarrheas of
infancy and childhoood 523
Saliva and oral hygiene 317
Sammis, Jesse F. A case of bactericmia treated by repeated
transfusions 679
Sarcoma of the kidney 413
Sarcoma of the thymus, primary 417
Schwarz, Herman and Rosenthal, Nathan. The cholorotic type
of anemia in infants and children 1
School children who, through lack of emotional control, develop
habits of truancy 635
Scott, A. J., Jr. Lymphatic leukemia, with report of a case 726
Section on Diseases of Children, American Medical Association,
seventy-first annual session, special detailed report, with
full abstracts of all papers read 342
Sex conflict in adolescents 628
Sexual development, premature. Phillips and Lambright 282
Sidbury, J. Buren. The importance of lumbar puncture in in-
tracranial hemorrhage of the new born 545
Sinclair, John F. The problem of the premature infant 139
Sinus arrhythmia 107
Sinus-thrombosis following measles 747
Skin tuberculin reaction in children 655
Smith, Charles Hendee. Recent developments in outpatient work. 40
Snyder, J. Ross. The prophylaxis of ileocolitis 554
Social maladjustment as seen in the children's clinic at Cornell
University 637
Socially, maladjusted, a study of the 623
Sodium bicarbonate solutions, intraperitoneal administration of.
Epstein 656
SoUs-Cohen, Meyer. A method of determining the appropriate
dose of tuberculin for the individual tuberculous child.... 641
Southworth, Thomas S. The predominance of seborrheic eczema
in early life 338
Spasmophilia, calcium by the vein in 341
Speech disorders and defects. Giflford 305
Stenosis, hypertrophic; failure of gruel feeding 414
Strong, Robert A. Meningitis, caused by lead poisoning, in a
child of 19 months 532
X INDEX
Summer diarrhea, the bacteriology of. Bergey 462
Summer diarrhea, blood culture in 60
Summer diarrhea, the dietetic treatment of. Griffith 455
Symptomatology of childhood, some peculiarities in the. Wilcox. 577
Syphilis, hereditary, a study of the incidence of 401
Syphilis and rachitis, inherited 467
Syphilis, hereditary, cause of membranous perienteritis 592
Syphilis in children of school age with heart disease 688
Syphilis in infants and children, the relative efficiency of the
different mercurial preparations in the treatment of
congenital 399
Syphilis, vitiligo mask with inherited 493
Syphilis, immunity in, with special reference to congenital or
prenatal syphilis. Kolmer 129
Syndrome in childhood, the suboxidation 616
Teeth, the temporary; disorders due to their neglect 374
Tetany, report of an unusual case. Elterich 89
Tetany, seasonal incidence of — a report of 47 cases. McLean 85
The upturned edge of the liver over acutely distended empyema-
tous gall-bladder; a diagnostic sign of some value 756
Thrombosis, a case of portal 415
Thymus, enlarged; symptoms and treatment 126
Tonsillectomy, the cause of abscess of the lung after 755
Tonsillectomy, end results of. Victor 721
Tuberculin for the individual tuberculous child, a method of
determining the appropriate dose of. Solis-Cohen 641
Tuberculosis bacillus in the tonsils of children clinically non-
tuberculous 190
Tuberculous arthritis 505
Tuberculous, prenatal 703
Tumors of the kidney in children, observations on 373
Tumpeer, I. Harrison. The etiology of chorea 717
Ulcerated meatus in the circumcised child 407
Umbilical colic of Fried jung in older children, the 752
Urine of children, nature of the reducing substance in the, suffer-
ing from nutritional disorders 393
Vaccine therapy in pneumococcus infections, clinical results of. . 187
Vegetable oils in certain abnormal conditions of infancy and
childhood, the clinical value of 357
Vietor, John A. End results of tonsillectomy 721
Vomiting in children, recurrent 122
Wassermann tests in children, the results of routine 126
Weston, William. Acrodynia 513
Whooping-cough, an experimental and clinical therapeutic
study of 614
Whooping-cough, use of fresh vaccines in 410
Wilcox, Herbert B. Some peculiarities in the symptomatology of
childhood 577
Wile, Ira S. Health classes for children 162
Xanthochromia of the cerebrospinal fluid, the significance of, with
report of a case in a premature infant 391
/
Archives of Pediatrics
JANUARY. 1920
HAROLD RUCKMAN MIXSELL, A.B., M.D., Editor
CHARLES ALBERT LANG, M.B.. M.R.C.S.. Associaie Editor
COLLABORATORS :
L. EuMETT Holt, M.D New York
W. P. NoRTHRUP, M.D New York
Augustus CAiLLft, M.D New York
Henry D. Chapin, M.D New York
Francis Huber, M.D New York
Henry Koplik, M.D New York
Rowland G. Freeman, M.D. ...New York
Walter Lester Carr, M.D... New York
C. G. Kerley, M.D New York
L. E. La FfiTRA. M.D New York
Royal Storrs Haynes, M.D... New York
Oscar M. Schloss. M.D New York
Herbert B. Wilcox, M.D New York
Charles Herrman, M.D New York
Edwin E. Graham, M.D Philadelphia
T. P. Cro^r Griffith, M.D.Philadelphia
"J. C. Gittings, M.D Philadelphia
A. Graeme Mitchell. M.D. .Philadelphia
Charles A. Fife, M.D Philadelphia
H. C. Carpenter, M.D Philadelphia
Henry F. Helmholz, M.D Chicago
I. A. Abt, M.D Chicago
A. D. Blackader, M.D Montreal
Fritz B. Talbot, M.D Boston
Maynard Ladd. M.D Boston
Charles Hunter Dunn, M.D Boston
Henry I. Bowditch, M.D Boston
Richard M. Smith, M.D Boston
L. R. De Buys. M.D New Orleans
S. S. Adams, M.D Washington
B. K. Rachford, M.D Cincinnati
Irving M. Snow, M.D Buffalo
Henry J. Gerstenberger, M.D. .Cleveland
Borden S. Veeder, M.D St. Louis
William P. Lucas, M.D... San Francisco
R. Langley Porter, M.D..San Francisco
E. C. Fleischner, M.D San Francisco
Frederick W. Schlutz. M.D.Minneapolis
.TuLius P. Sedgwick, M.D. . .Minneapolis
Edmund Cautley, M.D London
G. A. Sutherland, M.D London
J. D. Rolleston, M.D London
J. W. Ballantyne, M.D Edinburgh
James Carmichael, M.D Edinburgh
John Thomson, M.D Edinburgh
G. A. Wright, M.D Manchester
PUBLISHED MONTHLY BY E. B. TREAT & CO., 45 EAST 17tH STREET, NEW YOBK.
ORIGINAL COMMUNICATIONS
THE CHLOROTIC TYPE OF ANEMIA IN INFANTS
AND CHILDREN.
By Herman Schwarz, M.D., and Nathan Rosenthal, M.D.,
New York.
The fact that many cases of severe anemia are encountered
in infants is a matter of common knowledge. Badly nourished
children, or those developing rickets, frequently show all de-
grees of pallor. The ease with which children become anemic,
through any one of many causes, is equally well known. How-
ever, of late years, the treatment of all types of infantile anemia,
from whatever cause, has taken almost exclusively the form of
addition of green vegetables and fruit juices to the diet. As is
frequent in medicine, certain dietetic or laboratory principles,
2 ScH WARZ & Rosenthal : The Chlorolic Type of Anemia
deservedly popular, assume a complete preeminence at the expense
of older and valuable methods of treatment.
It is our purpose to show (1) that a type of anemia corre-
sponding in blood picture, at least, to the chlorosis of adults
exists in infants and occasionally in older children, and (2) that
the administration of iron, in this condition, meets with an excel-
lent response.
Of the legion of causes which are responsible for infantile
anemia, we shall consider here only those which produce a blood
picture similar to that of chlorosis in adults. Therefore, the
anemias due to acute or chronic loss of blood, helminthiasis, min-
eral i)oisons, malignant growths, rickets, syphilis and tuberculosis
arc excluded. Food, either too much qualitatively or quantita-
tively, or too little, as in voluntary or involuntary starvation,
will be considered later. The anemia produced by a scanty
supply of breast milk, or produced by too long continued nursing,
may be excluded also, since, in these cases, the blood picture of
chlorosis is usually not found. In the actual starvation of pro-
fessional fasters the blood shows very little change from normal ;
the red and white blood cells may be sHghtly diminished and the
blood volume increased; according to Tauszk^ the hemoglobin
is not necessarily diminished. Starvation in young animals at
times has produced a chlorotic blood picture, and this factor may
possibly have the same effect in very young infants.
The work of Bunge and his associates, especially Abderhalden,
has shown that a di£t containing but very little iron can produce
in young animals a blood very similar to that of chlorosis; in
older animals and adults, under similar conditions, however, this
form of anemia is not produced.
The cHnical features of this form of anemia in infants and
children are not necessarily distinctive, and it requires a red blood
count and a hemoglobin determination in order to discover its
presence. Iron medication frequently produces the same brilliant
results as it does in the chlorosis of adults, and for this reason
we wish to present some of our observations, in order to show
that, this type of anemia once demonstrated, iron administered in
sufficiently large doses gives a rapid and rema'-kable result.
It is surprising how little this simple or perhaps essential
IMiemia is described in our textbooks on children's diseases. The
ScHWARZ & Rosenthal: The Chlorotic Type of Anemia 3
literature is largely French, and to the French must be given
the credit of calling attention to it.
In 1/71, Sauvage described 5 cases of chlorosis, one of which
was in an infant. Nonat", in 1860, thought chlorosis more fre-
quent in infancy than at any other age. He described 68 cases,
47 girls and 27 boys,' 3, cases being less than 1 year old. Several
years later, Germain See also showed the occurrence of this form
of anemia in infancy. Gueneau de Mussy (Legons sur la chlo-
rose) accepted chlorosis as occurring in infancy. Arochambeau,
in 1882, described an anemia in infancy corresponding to the
chlorotic type. On the other hand, Potain, Hayem, and Czerny
considered that chlorosis existed only at puberty or later, and
denied its occurrence in infants. Since then Halle and Jolly^
have given an excellent description, including the blood findings,
of a ca.se a^ an early age. Rist and Guilemot* described similar
cases under the name of oligosidermie. Petrone,' in 1905, de-
scribed several cases of chlorosis in young children. Since 1907
very little attention has been drawn to this form of anemia and
no new cases have been cited. The condition, however, has been
described from Finkelstein's clinic, by Kunckel, as occurring in
prematures and twins.
Frequency: In order to illustrate the frequency with which
this form of anemia is found in infants and children, it is only
necessary to state that within a few months we have been able
to collect 40 cases.
TABLE I
Age When First Seen. No. of Cases.
Under 3 months 14
3 to 6 months 5
6 to 9 months 10
9 to 12 months 0
12 to 18 months 3
18 to 24 months 3
2 to 3 years 2
3 to 8 years 3
Age: The condition seems more common in early infancy
than in any other period. This statement, however, is condi-
tioned by the age when our children were first seen. The pre-
ceding table shows that of 40 cases, 14 were discovered earlier
4 ScHVVARz & Rosenthal : The Chlorotic Type of Anemia
than the third month ; 29 were seen before the first year ; 3, how-
ever, as late as the eighth year. Of the 29 cases occurring imder
one year, there is no doubt in our minds that the condition had
existed a greater or shorter time before it was discovered.
Very often the appearance of the child does not lead one
to suspect the presence of an anemic condition. In 18 of these
40 cases, blood examinations were not made until they had been
under observation weeks or months. Cases of this type |)rob-
ably begin in early infancy and do not become apparent until
the children are between 12 and 16 months old.
Etiology: From an analysis of our cases, made as we were
collecting them, it soon became apparent that this form of anemia
occurred in premature children, in twins, and in those who had
a rather stormy feeding history during the first 3 months of
life. In cases of children with such a history, although without
any appearance of pallor, examination of the blood often showed
this type of anemia. Three cases at birth weighed below 4
pounds ; 8 cases at birth weighed between 5 and 6 pounds ; 5 were
prematures and 4 were one of twins. In 20 of the 40 cases,
there was a feeding history of a stormy nature. Nine cases,
however, did very well on the breast. Constipation was not a
factor.
Diet: Of 28 cases, of which we' could get a history of the
feeding for the first 3 months, 14 had the breast alone, 10 had
breast and bottle, and 4 the bottle alone. The feeding in the
older children was in most instances a rational one, being fairly
mixed. In a few cases, however, the condition seemed to be
definitely in connection with the feeding: in one case, an 18
months infant had been treated for a number of months on a
salt-free diet; another, a 2}^ year old child, was still on a fluid
diet fed from the bottle.
Sex: Of our cases, 28 were boys and 12 girls. This is the
reverse of that found by Nonat and certainly does not coincide
with the chlorosis of adults, which almost never occurs in the
male. In 13 cases, cited by Leenhard, 8 were boys and 5 girls.
However, this is of little importance because with more cases
the proportion may possibly change.
History: At times there was a family history of chlorosis, or
other forms of anemia, although this was not usually the case.
ScHWARz & Rosenthal : The Chtorotic Type of Anemia 5
The children were brought to us either for feeding or general
follow-up work. There were no special symptoms ; occasionally
loss of appetite or capricious appetite ; rarely constipation. In-
testinal derangement was not a common feature.
Clinical Examination: These children presented one of 2
types ; the first, premature, congenitally weak, usually under
weight ; the second, one with a good panniculus adiposis, well fed
and happy. Pallor was in some cases marked, in others hardly
discernible. The color was rather a grayish than a whitish yel-
low or waxy. The mucous membranes were pale but never
excessively white. Eczema or other manifestations of exudative
diatheses were absent.
Physical Examination; Apart from the general types, nothing
was characteristic. Systolic murmurs were present in only 3 of
the entire series. The spleen was only rarely felt.
Blood Examination: The examination of the blood in these
cases shows that the hemoglobin-'^ is greatly diminished but the
red blood count rarely falls below 3,000,000 and is more fre-
quently between 4 and 5,000,000. There is a great disproportion
between the number of red blood cells and the hemoglobin. The
index is always less than 1.0, and usually between 0.4 and 0.6.
The leucocyte count ranges between 6 and 10,000, with a dif-
ferential count presenting no deviation from the normal. A
tendency to lymphocytosis is noted at times, but this is difficult
to judge accurately on account of the tender age of some of
the children. The red cells occasionally show poikilocytosis and
anisocytosis. Nucleated red cells are rarely found. Blood plate-
lets range between 200,000 and 300,000. Blood volume was nor-
mal in 5 cases, estimated by means of Epstein's method.
Iron Metabolism: In 2 of our cases an iron metabolism experi-
ment was made. Case I, premature, weight at birth, 3 pounds :
it 11 months, the time at which our metabolism experiment was
made, his weight was 19 pounds, 4 ounces, his hemoglobin was
50 per cent and the red blood count, 4,140,000. He was given
the following diet : whole milk, 32 ounces ; barley water, 8 ounces ;
milk sugar, 1 tablespoonful ; farina, twice a day. The results
are seen in the table below :
*The hemoglobin estimation was done with Kiittner's apparatus. The standard
color tube is equivalent to IS gr. of hemoglobin per 100 c.c. of blood when the
color matches this at 100 on the scale of the calibrated tube. Kuttner, Jour. A. M. A.,
1916. Vol. XLVI, 13701373.
6 ScHWARz &: Rosenthal : The Chlorotic Type of Anemia
Iron Nitrogen
Total intake, 3 days 7.81 mg. 15.212 gm.
Output —
Feces 7.44 " 1.537 "
Urine 0.8 " 10.633 "
Balance —0.43 " +3.042 "
Case II, a boy of 2 years, with moderate degree of pallor,
hemoglobin 50 per cent, red blood count 4,704,000, was given a
general mixed diet during a 3-day metabolism experiment. We
realize fully that 3 days is probably much too short a period, but
circumstances were such that an extension of the time was im-
possible.
Iron Nitrogen
Total intake, 3 days 11.42 mg. 22.381 gm.
Output—
Feces 14.036" 0.616 "
Urine 0.6 " 17.364 "
Balance —3.21 " -f 4.401 "
From these two cases it will be seen that the nitrogen balance
showed a retention of 3 to 4 gm., whereas the iron balance was
negative in both instances.
In the discussion of these results it might not be inadvertent
to review briefly some of the chemistry of hemoglobin and its
bearing upon the iron metabolism.
Hemoglobin can be split up very easily into a protein portion,
called globin, and an iron containing substance called hemo-
cromogen. On the addition of glacial acetic acid, 100 gm. of
hemoglobin yield about 4 gm. of hemocromogen. Loosely com-
bined with oxygen, hemoglobin changes into oxyhemoglobin.
Oxyhemoglobin split up yields globin and hematin. By the action
of sodium chloride and glacial acetic acid, hematin can be further
split up into hemin, which contains four pyrrol rings to which the
iron molecule is attached. The action of hydrobromic acid on
hemin reduces it to hematoporphyrin, which does not contain
iron. Hemopyrrhol is the final end product.
In 100 gm. of ash in the newborn there are about 0.8 gm. of
FcoOa ; 38 to 40 per cent of this iron is in the blood ; the remainder
is deposited in the tissues (Hugounenq). The actual amount of
hemoglobin in the body rises from birth, but the amount as com-
ScHWARZ & RosENtHAL : The Chlorotic Type of Anemia 7
pared with the body weight diminishes. The amount of iron
deposited in the tissues, especially in the liver of the new-born,
diminishes soon after birth. In other words, the iron in com-
bination with hemoglobin, or the hemocromogen radical, increases
from birth, but the iron .not so combined (reserve iron) dimin-
ishes. It is thus easy to understand why the new-born should
have such a large amount of hemoglobin and reserve iron, and
that this hemoglobin iron should increase, for the great extent
of body surface in the new-born requires a large amount of
oxygen-carrying material. Therefore a great amount of hemo-
globin must be manufactured. The hemoglobin iron is increased
at the expense of the non-hemoglobin iron.
The next question that comes before us is that of the absorp-
tion of inorganic iron. Can it really be absorbed? By giving
inorganic iron, for instance, the urine shows no increase in the
excretion of iron. It has been shown, however, that iron in-
jected intravenously produces a marked increase in the intestinal
excretion of iron. It has been further proven that inorganic iron
is easily taken up by the small intestine, the lymph channels, the
leucocytes and probably the lipoids (McCabe). It can be fol-
lowed to the liver and other organs and shown to be excreted
into the large gut, often at the site of Peyer's patches. Thus it
is absorbed in the same manner as is calcium, taken up by the
small intestine and excreted into the large intestine. But this
does not necessarily mean that the iron is used in the organism,
for bismuth and silver can be followed in a similar manner. How
then can it be proven that the iron given per os is really used in the
organism? The answer is still in doubt. In order to produce
hemoglobin, pyrrhol derivatives are necessary for the cromogeti.
Tryptophan is possibly needed for the pyrrhol rings. In milk,
however, there is very little or no tryptophan. In changing the
diet, different amino acids are taken in, so that more substances
are absorbed which may help in the formation of hemoglobin.
The iron for the pyrrhol rings must be obtained from com-
pounds easily broken up ; that in the food must be removed from
its combinations in order to be attached to the pyrrhol rings and
make up the hemocromogen or its oxygen equivalent hematin.
This may take place in the liver, in the spleen, in the bone mar-
row or in the lymph ; furthermore, the protein jjortion of the
8 ScHWARz & RosENTriAL: TJic Chlorotic Type of Anemia
hemoglobin, namely the globin, must be obtained. This protein
is made up principally of the amino acid histidin, which is not
present in milk and must first be synthetized. Then only can the
globin and the hemocromogen combine, and hemoglobin be
formed. There still remains the formation of the stroma of the
red blood cells, and the hemoglobin has yet either to be taken
up by the stroma or produced by it. Only then is hemoglobin
represented as a functioning part of the body, and available for
the carrying of oxygen.
From the foregoing it will be seen that hemoglobin metabolism,
if one may use this term, cannot be solved from the standpoint of
the iron metabolism, for any of the links of the chain thus de-
scribed may be broken and so cause one or another form of
anemia.
Very little work has been done on the iron metabolism in
anemia, but a number of experiments by von Noorden showed
that in cases of chlorosis the iron balance may be negative. How
much importance can be laid to this may be judged from our short
resume of the hemoglobin metabolism. That the iron balance
has something to do with the hemoglobin is undoubted, but just
how much, is unknown.
The etiology of this type of anemia in infants is still obscure.
A perusal of the histories shows that the prematures, the con-
genitally weak, twins, those born with low birth weights, and
those having difficulty in the nursing hygiene during the first few
months, have a predisposition for this form of anemia and develop
it with great regularity. The hemoglobin of the child born at
term is between 125 and 150 per cent. In the premature and
twins, however, the hemoglobin often ranges much higher, and
sinks much more rapidly, so that within an even shorter time than
in the normal child the hemoglobin has dropped to 50 or 60 per
cent, the red blood cells behaving no differently from those of a full
term infant. The exact cause of this great fall in the hemoglobin
of the premature and twins has been only imperfectly explained
by Hugounenq. He showed that the greater proportion of the
salts, calcium, iron, etc., are deposited in the fetus in the last 3
months of pregnancy. The premature, therefore, fails to get the
required amount of iron deposited in the liver, and brings into
the world a diminished iron depot. Twins, having to divide the
ScHWARZ & Rosenthal : The Chlorotic Type of Anemia 9
salts that the mother can deposit, also show this deficiency. This
may explain why twins and prematures regularly become anemic
and rachitic. In fact, we have been able to prevent this anemia
and rickets in prematures and twins by the regular and early
administration of iron and cod liver oil.
Work is in progress to show whether there is a real or ap-
parent iron and calcium deficiency in these cases. The amount
of iron deposited in the last three months of pregnancy is two
to three times as muc;|i as that of the first six months. Therefore
it is easily conceivable that a child, bringing a diminished iron
depot into the world, uses it up, cannot replenish its hemoglobin
from this source, gets little or no help from its food, and becomes
anemic. Increase in hemoglobin has been achieved in a few of
these cases, reported elsewhere, simply by placing the children in
the fresh air, without any change in diet, so that this congenital
deficiency of iron alone, may not explain the condition. However,
on the other hand, our results with fresh air have been anything
but brilliant. The amount of iron deposited in the body may
not be the sole fault ; there may be a break in this complex chain
which we have designated as the hemoglobin metabolism. The
clinical experiment tends to demonstrate that deficiency of iron in
the body is a great factor.
Other Causes: Constitutional dyscrasia, such as the exudative
diathesis, neuropathic tendencies, and so forth, seem to play but
a small part in this type of anemia. Gastrointestinal conditions
and dietetic errors may be factors as seen in two of our cases : in
one of these nephritis was suspected in a 14 months old baby and
for 2 months an almost salt-free diet was instituted ; at the end
of that time the child had a hemoglobin of 48 per cent and a red
blood count of 4,920,000. In a second case, a 2^ year old child,
weighing 17 pounds, had never had solid food. This child re-
ceived thin cereal, 2 eggs and more than one quart of milk, by
means of the bottle. Its hemoglobin was 40 per cent, its red blood
count 5,550,000. This case was given a more consistent diet and
large doses of iron. Within three weeks the child's hemoglobin
was 56 per cent, the red blood count 4,520,000, although it was
still impossible to induce the child to take any solid food, the only
change in the conditions being the administration of iron. Blood
volume wa? normal. The absence of signs of rickets iii many
10 ScinvAKz & RosEXTHAT, : The Chlorotic Type of Anemia
instances, and the relatively few cases with enlarged spleens,
exclude syphilis or general infections as an etiological factor in
this type of anemia. When one observes the apparent well being,
the increase in weight, the good appetite and excellent stools, yet
withal the increasing pallor, one is forced to acknowledge that
there is some factor present in addition to the diet.
How long this condition may exist, whether it may continue
into the real chlorosis of puberty, we cannot as yet say ; that it
may continue as long as 6 or 8 years some of our cases show ;
that they tend to get well themselves we have clinical proof ; that
the administration of iron often improves the general condition,
the appetite, the weight and especially the appearance, can easily
be proven. Increase of 20 and 30 per cent within a few weeks
are readily achieved.
BIBLIOGRAPHY.
1. Taus-zk: W. K. Rund., 1898, Vol. 18.
2. Nonat: Tiaite de la chlorose, Paris, 1864.
3. llalle et Jolly: Un cas ses chlorose du jeune age, Arch, de med. des enfant, 1903,
page 664, \'ol. 6.
4. Rist et Guilemot: L'oligosidermie, Bull, et mem. de la Soc. med. des Hosp. Vol.
23, page 1103.
5. Petrone: .Sugli stati cloroaneimci nelF infanzia, Pediatria, 1905, Vol. 13, page 287.
Mongolian Idiocy (Journal A. M. A., Jan. 10, 1920). First
noticing the almost universal observation that Mongolian idiocy
occurs only in one member of a family, Irving H. Pardee gives the
history of a family of Italians with eleven living children. The
parents were intelligent and rather above the average of Italian
immigrants and the children normal, excepting the two youngest,
aged, respectively, 7 and 4 years, who presented the characteristic
picture of Mongolian idiocy. There was no specific history or
evidence of such disease. The family history supports the view
that such cases develop from a parent in whom the germ plasm
has become defective through exhaustion. The history of over
half the reix>rted cases of Mongolian idiocy, so far as obtainable,
showed that the idiot child was the last one of a large family.
While similar features of Mongolian idiocy and myxedema have
been emphasized of late and made the basis for thyroid medication,
no results so far have been obtained. In the family here in ques-
tion there is a strong endocrine heredity, especially on the maternal
side, but medication along these lines has so far failed. Further
work will probably throw some light on this possible ctiologic
factor, — Journal A, M. A,
PNEUMONIA IN INFANCY AND CHILDHOOD
WITHOUT PHYSICAL SIGNS.*
Rowland Godfrey Freeman, M.D.,
New York.
The question whether a real pneumonia can exist in the chest
without physical signs has long been discussed. The possibility
of making a positive diagnosis of pneumonia without physical
signs is not definitely stated in most textbooks. The author,
however, of one of our best textbooks on pediatrics, Edmund
Cautley of London, ^ys: "Definite physical signs may be slight,
delayed until the fourth or fifth day, not present until after the
crisis, absent throughout, or missed because they are so deeply
seated. Central pneumonia is frequent in children, especially in
the upper lobe, and the physical signs may be limited to persistent
rapid breathing and high fever."
This would seem to be correct excepting for the statement
that definite physical signs fail because the lesion is deep-seated,
for, as I shall show by roentgenograms, they sometimes give no
signs when they are peripheral and not central.
The best opinion is that in children a positive diagnosis of
pneumonia can be made without the presence of physical signs in
the chest when there exist several of the following symptoms :
fever, overactivity of the alae nasi, a pneumonic type of respira-
tion with a pause at the end of inspiration accompanied by expira-
tory grunt, a relationship betwen respiration and pulse approxi-
mating 1 to 3, and particularly if there is the added sign of
rigidity of the upper extremities with no rigidity of the lower
extremities, an eflfort on the part of the child to protect a sore
chest. Notwithstanding this fact it is not uncommon in consulta-
tion with prominent men to have surprise expressed on stating the
opinion that a pneumonia can exist without physical signs.
There is one type of case in which this is a matter of great
importance: children who have acquired a respiratory infection
in which the ears have became involved and have been opened,
the temperature persists high, and there is a question whether a
mastoid operation should be done or not, the local condition not
indicating necessarily a mastoid. The pediatrist examines the
*Read at the seventieth annual session of the A. M. A., Section on Diseasr? i>l
Children, held at Atlantic City, N. J., June 11, 12 and 13, 1919.
u
12 Freeman : Pneuuionia zvithout Physical Signs
Fig. 1. — Case 1. X-ray showing a peripheral consolidation of the right thorax.
Fro. 2.— Case 1. X-ray taken 3 days after Fig. 1, showing partial absorption of the
consolidation.
Freeman : Pneumonia without Physical Sif;ns
13
chest for signs of pneumonia without finding any indications
that would locate a consolidation, but the ear specialists are not
apt to be satisfied that there is a pneumonia present unless the
physical signs can be demonstrated.
Since the adoption of the routine use of the roentgen ray in
hospital cases, pneumonias have been discovered when no physical
signs of their existence have been found, and even after their
demonstration by roentgen ray and the determination of the pneu-
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Fig. 3. — Temperature chart and record of pulse and respiration of Case 1. It should
be noticed that neither the pulse, respiration, nor their relationship would lead one
to suspect pneumonia.
monia, subsequent physical examination has proved entirely
negative.
It seems important, therefore, to demonstrate, as far as pos-
sible, the existence of such cases without physical sig^ns, in view
of the fact that, at the present time, it is often difficult and impos-
sible to obtain satisfactory roentgenograms of sick children in
private homes.
There is urgent need of a roentgen-ray apparatus which can
be used in private houses without the great expense at present
involved in such roentgen-ray work.
14 Freeman : Pneumonia without Physical Signs
The first case is one to which I referred in a previous article,*
a child who had entered the Roosevelt Hospital with a remitting
temperature. The respirations recorded were usually below thirty,
and there were no physical signs in the chest, nor was there any
other cause for the temperature found until a roentgen-ray plate
of the chest was obtained. This gave a very definite shadow
of pneumonia situated apparently beneath the right axilla. The
Fig. 4. — X-ray of C'ase 2 on admission to the hospital, showing consolidation in ttie
right thorax.
day after the first roentgenogram was taken the temperature
remained normal and three days later another roentgenogram of
the chest showed a diminishing shadow. It is interesting to note
that this consolidation was apparently connected with the root
of the lung.
The second case was seen by me in consultation and gave a
history of sudden onset; there had been a temperature ranging
from 100 to 105° F. each day for four days. There was no
•Freeman, R. G.: The Value of the x-ray in Intrathoracic Lesions in Children,
Archives of Pediatrics, XXXII: 891 (Dec.) 1915.
Freemax : Pueumonia without Physical Signs 15
marked evidence of catarrhal inflammation and no physical signs
were found over the chest, although the physician in charge
stated that he had heard some rales over the right base on a
previous visit. The following night the child's temperature rose
to 106.5° F., receding in the morning to 99° F., and the next
night the temperature rose to 107.5° F. The following morning
the child was brought to the Roosevelt Hospital, where a roentgeno-
gram of the chest showed a shadow beneath the right axilla. The
roentgenologist though^ it looked more like fluid than pneumonia,
and on two successive days a large needle was inserted in the
Fig. 5. — X-ray ul Case J, ilit day following admission to the hospital, showing a
diminution in the area of pneumonia.
area involved, but no fluid was obtained. The temperature,
however, dropped rapidly so that it reached normal in two days,
and a roentgenogram five days after admission showed the shadow
clearing. This child at no time showed any physical signs over
the area involved, although examined by several physicians. The
respirations, moreover, were never more than normal.
One questions why a pneumonia involving a small area of the
16
Freemax : Pneumonia without Physical Signs
Fig. G. — X-ray of Case 2, 5 days after admission to hospital, uhicli shows only a
small area of consolidation remaining.
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showing the very high .temperature recorded,
moderately increased in number.
Freeman : Pneumonia without Physical Signs 17
lung, such as this, should be accompanied by a temperature on one
night of 106>^° F. and on the following night of 107/2° F., with
rapid recovery as soon as the child was brought to the hospital.
The only explanation I have to offer is that until he was brought
to the hospital he was being medicated every fifteen minutes day
and night by a homeopathic physician and thus was not allowed
to obtain the rest he needed.
The third case was recently admitted to the Roosevelt Hos-
«
Fig. 8. — X-ray of Case 3, showing the shadow in the outer portion of the thorax.
pital with a history of bronchitis for four weeks, and the patient
was quite sick for twenty-four hours with fever and cough. A
member of the stafif on going over the child on admission reported
some signs over the right upper lobe, but when I went over the
case with him later neither of us could find any signs at all. The
roentgenogram showed a consolidation in almost the same area
as the two preceding cases, and after the roentgenogram was seen
we both went over the child again with negative findings. After
forty-eight hours in the hospital a throat culture positive for the
18 Freeman : Pneumonia imthout Physical Signs
Klebs-Loffler bacillus was found and the child was transferred
to a hospital for contagious diseases.
An interesting point about these cases is that they all involve
approximately the same portion of the right lung, and, as the
consolidation in none of these cases runs up to the apex, it might
be considered an involvement of the right middle lobe. If, how-
ever, it was the right middle lobe it should have been possible
to obtain signs over the anterior portion of the chest, and it seems
to me much more probable that the involvement was of the right
upper lobe and that the signs were obscured because in order to
hear them one would have to listen through the right scapula. It
is most remarkable that they gave no signs in the axilla.
211 West 57th Street.
Human Serum in Treatment of Influenza Bronchopneu-
monia (New York Medical Journal, April 19, 1919). Under the
jurisdiction of the United States Naval Hospital at New York,
842 cases of pneumonia have been treated by E. W. Gould and
others. Three hundred and twenty have come under Gould's im-
mediate supervision at the Naval Hospital. The mortality rate
among these 320 cases has been 26.16 per cent. Many of the pa-
tients were in an advanced stage of the disease or even in a mori-
bund condition on arrival at the hospital. Thirty cases of so-
called influenza pneumonia were treated by the use of human
serum from convalescing patients with a loss of only two cases.
The rapid and complete subsidence of symptoms unusual in most
cases of influenza pneumonia gave hope that a specific line of treat-
ment had been found. The author was able to confirm the con-
tention of Redden that the amount of lung involvement in the
donor is necessarily a reliable criterion in determining the value
of his serum. He is impressed with the belief that the human
serum from convalescent pneumonias undoubtedly contains valu-
able antibodies, and that its use in cases infected with homologous
strains will give satisfactory results ; but with the present limited
ability to isolate the infecting organisms of the donor and the
recipient, the method cannot yet be placed on a practical basis
where definite results can reasonably be expected. Furthermore,
this method cannot be used except in large, well equipped hospi-
tals where access can be had to many willing donors. — Journal
A. M. A.
AN EARLY DIAGNOSTIC SIGN IN BASILAR
MENINGITIS
By David Gingold, M.D.,
Attending Pediatrist, Wyckoff Heights Hospital.
Brooklyn, N. Y.
The difficulty of making a positive diagnosis of tuberculous
meningitis in the early stages of that disease is recognized by all.
In the majority of cases the onset is very gradual, the symptoms
vague and indefinite. The child may give no signs other than
those of some digestive disturbance for days, sometimes weeks.
The diagnosis is especially difficult in young infants, since the
yielding cranium keeps the intracranial pressure below the fatal
limits, and very often weeks will pass before any definite signs
appear.
A symptom that has served me well during the past 7 years
as an aid in making an early diagnosis of basilar meningitis is
what, for want of a better name, I should call a "reflex" strabis-
mus. By flexing the head on the chest, either a bilateral or a
unilateral internal strabismus develops, which will last as long as
the head is kept in flexed position, and disappears as soon as the
head is relaxed. In many cases the strabismus is accompanied
by a retraction of the upper eye lids. In some cases I have also
noticed a contraction of the pupils. This "reflex" strabismus was
present in the early stage of almost every case that came under
my observation in the past 7 years. In the late or paralytic stage
flexion of the head failed to produce a strabismus.
The "reflex" strabismus, above described, proved, in my ex-
perience, to be such a reliable symptom that I have often made a
diagnosis of basilar meningitis days before any other meningeal
symptoms appeared. The following case will serve to illustrate :
Baby Gertrude C., 11 months old. First saw case December
14, 1918. Family history negative. Both parents healthy. Four
brothers and sisters healthy.
Personal History. — Normal delivery at full term. Breast fed.
No previous illness.
Present Illness. — Began December 12, with cough and tem-
perature. No vomiting. Dr. S., who saw the child several
times, thought it a case of influenza.
19
20 Gingold: Early Diagnostic Sign in Basilar Meningitis
Physical Examination. — Child well nourished, face flushed,
head normal. Anterior fontanelle normal, no bulging. Pupils
normal. No retraction of head. Abdomen slightly distended.
Oral Examination — A slight congestion of pharynx and ton-
sils. Tongue coated.
Heart negative. Pulse 110.
Lungs — Respiration, 40; few scattered moist rales.
None of the recognized symptoms of meningitis were present.
By flexing the head on chest to elicit neck signs, a double
internal strabismus developed, I did not hesitate to make a diag-
nosis of basilar meningitis, although there were no meningeal
signs other than the above described "reflex" strabismus.
December 15 — I again saw the child and found no material
changes. Temperature 102° F., pulse 120, respiration 36. A
double internal strabismus on flexion of the head was present.
No other sign of meningeal involvement.
December 17 — Had the child transferred to my service in the
Wyckoff Heights Hospital. It then had a slight rigidity of the
neck, a "reflex" strabismus, and a Babinsky oii the right side.
All other recognized symptoms of meningitis were absent. By
lumbar puncture, 10 c.c. of a clear fluid was removed. No
tubercle bacilli found in that fluid.
December 19 — The child developed a marked facial paralysis.
The rigidity of neck disappeared as well as the "reflex" strabismus
on flexing head. Another lumbar puncture was made and 28 c.c.
of a slightly turbid fluid removed ; tubercle bacilli found. Child
died January 1, 1919.
Although I could cite many cases similar in character to the
above, I fully realize that the number of cases observed by me
will not warrant extravagant claims for this early "reflex" stra-
bismus. However, to me it has been of such inestimable value in
making a diagnosis of basilar meningitis days before the recog-
nized symptoms appear that I feel justified in bringing it to the
attention of the medical profession for further observation.
What appeals to me as a reasonable explanation of this early
"reflex" strabismus is that by flexing the head we suddenly in-
crease the already increased pressure at the base. This causes
either pressure on the abducens with a paresis of the external
rectus, or it causes pressure on the oculomotor nerve with a spasm
GiNGOLD : Early Diagnostic Sign in Basilar Meningitis 21
of the internal rectus. The last mentioned theory will also ac-
count for the action of the levator palpebrae and the myosis noted
in some cases.
The many textbooks referred to below failed to reveal any
mention of above described "i-eflex'' strabismus. Strabismus is
generally referred to as a late manifestation in basilar meningitis.
Holt says, "occasionally there is a strabismus." Fischer says,
"strabismus as well as facial paralysis are frequently seen as evi-
dence of paralysis." Chapin and Pisek speak of strabismus and
ptosis as usually appearing in the final stage. Dunn mentions
strabismus as an occasional symptom. Griffith says, "paralysis of
the movements of the eye balls is common, either of oculomotor
or abducens." Koplik mentions the presence of palsies of intra-
cranial nerves as indicative of a lesion at the base of the brain.
Dr. M. Thiemich, of Breslau, in his description of tuberculous
meningitis, mentions lesions of the oculomotor and abducens
nerves as a late manifestation, occurring in the second stage of the
disease, due to pressure. None of above quoted authors mention
how these lesions of the abducens and oculomotor can, by flexing
the head, be brought out in the early stage of basilar meningitis,
long before there is sufficient pressure to produce paralysis.
119a Sumner Avenue.
Plastic Peritonitis (Archives de Medicine des Enfants,
Paris, October, 1919). L. Morquio has encountered at Montevi-
deo 4 cases in which a child developed acute peritonitis, and a
certain region in the abdomen swelled and became painful. In-
stead of the anticipated suppuration, however, the hard tumor and
the pain subsided, and another patch developed at some other
point. The disease (progresses by waves in this way, but spon-
taneously subsides at last by the end of the third month, and the
children seemed to be healthy when examined up to 10 years later.
The ages ranged from 3 to 13. In one case an operation was done
for the assumed appendicitis but the appendix seemed to be nor-
mal. In another child, infection from the genitals seemed prob-
able ; in another the process started in the sigmoid region. But
in all the peritoneal picture was the same. The complete and per-
manent recovery excludes tuberculosis. — Journal A. M, A,
DIPHTHERIA PREVENTION.*
By Dever S. Byard, M.D,,
New York.
The state epidemiologist of Massachusetts some months ago
writing of diphtheria strikingly titled his publication "Diphtheria
the Uncontrolled." The disappointing degree to which modern
methods have offset the old statistics of its occurrence perhaps
prompts this wide-flung challenge, and certainly warrants our own
inquiry as to our competency in the important medical responsi-
bility of diphtheria prevention.
Some statistical briefs compel our interest. The last census
report for the registration area in the United States gives for that
year (1916) the total deaths from all causes as 1,100,921 — 14 per
100,000. The deaths under 1 year were 164,660 (16.4 per cent
of total deaths). Of children under 5 years 234,081 died (25.4
per cent of the total deaths). Diphtheria killed 10,367 (over 1
per cent of the total dead) ; 908 under 1 year, 1,696 at 1 year,
6,532 under 5 years.
Of the total deaths under 5 years, diphtheria contributed ap-
proximately 3 per cent of the victims, and of the total fatalities
from this disease nearly 65 per cent were in children less than 5
years old. Accepting the average mortality rate as a factor for
conservative reckoning, we estimate that there were approxi-
mately 110,000 ill of diphtheria in the registration area in this
year, and over 250,000 in the whole United States. Of these
nearly 175,000 were in the child group before the fifth year.
Diphtheria causes approximately as many deaths in the United
States as either of the diseases, whooping cough, measles, or
scarlet fever. It is estimated that the average fatalities in the
United States from these diseases for the period 1916 to 1918
were: Diphtheria 19,150, whooping cough 10,200, measles 9,500,
scarlet fever 8,200.
The actual death rates severally for the United States regis-
tration area of these diseases were:
1914 1915 1916 1917 . ;
Rate per Rate r>er Rate per Rate per
Disease Deaths 100,000 Deaths 100.000 Deaths 100,000 Deaths 100,000
Diphtheria 11,786 17.9 10,544 15.7 10.367 14.5 12.453 1«.5
Measles 4.461 6.8 3.409 5.4 7.947 11.1 10.749 14.3
Srarlet Fever 4.340 6.6 2.419 3 6 2,355 3.3 3,157 4.2
Whooping Cough 6,816 10.3 5,421 8.1 7,284 10.2 7,817 10.4
*Read at the meeting of Tlie Hospital Graduates Club, October 23, 1919,
22
Byard: Diphtheria Prevention 23
The United States Public Health Report for July 4, 1919,
states that the summary of the Census Bureau Mortality Statistics
for 1917 shows that: "Next to that for influenza, the highest rate
appearing for any epidemic disease in 1917 was for diphtheria,
16.5 per 100,000, representing. 12,453 deaths."
Sixteen per cent of all deaths from 5 to 9 years are caused by
diphtheria. The administration of antitoxin has reduced the mor-
tality of diphtheria in 25 years nearly 75 per cent.
DEATH RATE FROM DIPHTHERIA PER 100,000 POPULATION IN U. S.
REGISTRATION AREA.
1900 1905 1910 1915 1916 1917
43.3 23.8 21.4 15.7 14.5 16.S
The Schick test has made the use of antitoxin in exposed sub-
jects an intelligent and impressive proceilure. As a preventive
its use, however, is limited, the duration of its protection being
uncertain, though certainly transient, an average immunizing dose
probably lasting 3 to 4 weeks. In spite of this valuable agent,
and beyond any effective control through quarantine, intensive
culturing ,etc., there has been during the period of antitoxin ad-
ministration in the United States only an approximate 30 per cent
occurrence reduction in this disease, the last four years showing
an estimated occurrence reduction in the United States of less than
8 per cent.
1914 1915 1916 1917 1918
State Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths
Conn 2,662 228 2,161 193 1.870 187 2,367 224 2,348 201
Mass 8.080 652 9,282 721 7.282 557 10,322 836 6.921 594
New Jersey.. 7,378 611 6.941 501 5.580 444 5,326 447 4,465 485
New York .. 22,537 2,006 20,806 1,754 10,133 1,518 19,183 1,745 16,501 1,772
Vital statistics constantly challenge our methods, but the con-
tinuing frequency and mortality of this preventable disease in-
sistently reproach our practice. An arraignment of preventive
neglect confronts us in the records of our own Greater City of
New York, and warrants restatement of figures available and
probably familiar.
The average number of cases of diphtheria in New York from
1905 to 1913 is recorded as 17,281. For the 3 years, 1913-1915,
inclusive, the average was 15,641. For the years 1916-1918, in-
clusive. 12.520. In 1917 there were 12,624 cases. Of these 1,158,
or 9.7 per cent, died — 133, or 10.5 per cent, under 1 year, 150 at
1 year. That is, 23 per cent of the total mortality were in those
under 2 years of age, 842, or 65 per cent, under 5 years. Fgr
24 Byard: Diphtheria Prevention
this present year, 1919, for the period January 4 to September 20,
10,226 cases have occurred. Nine hundred and seventy-one have
died — 96 under 1 year, 206 under 2 years, 407 between 2 and 5
years, 213, 5 to 15 years — a total of 719, or 75 per cent, before the
fifth year, approximately 25 per cent at or under 2 years.
DIPHTHERIA IN NEW YORK CITY 1912-1918.
Year Cases Deaths
1912 15,269 1,125
1913 14,535 1.333
1914 17,129 1,489
1915 15,279 1,278
1916 13.521 1,031
1917 12,584 1,158
1918 11,455 1,245
In this city, favored beyond others by the initiative and com-
petency of our research laboratory in its investigation and man-
agement of the diphtheria problem, our last 4 years have shown
no considerable occurrence reduction, and we maintain a mor-
tality record averaging 10 per cent. Two babies and 1 slightly
older subject die here each day of this disease. Beyond its
economic waste, one reckoned medical item being the loss through
quarantine of over 1,700 days attendance in hospitals, day nur-
series, etc., this preventible disease contributed 1^ per cent of the
total deaths last year in our country — 3.25 per cent of those who
died were under 5 years.
For the prevention and control of diphtheria, all the needed
information and agents are at hand. With every exclusion prop-
erly taken, the purport of these statistics is our — the community
physicians' — outstanding neglect. Beyond doubt we have not
adequately utilized this available means for prevention, viz : the
toxin-antitoxin inoculation for active immunization of those
susceptible to this disease. This agent has been made possible
through the researches of Dr. Park and his associates. His and
Dr. Zingher's reports of their extensive experimental and clinical
use of it have shown its safe dependability for general administra-
tion. Its therapeutic use is the result of an extended series of
investigations as to the possibility of safely producing antitoxin
in a human through the injection of the combination of diphtheria
toxin and antitoxin. In this, the mixture, although the toxin,
has been so neutralized as to be no longer poisonous, still con-
tains some toxin in loose combination. To this antigen the body
responds by a continuous production of antitoxin. As furnished
by the Research Laboratory of the Health Department and by
Byard: Diphtheria Prevention 25
several dependable firms, 1 c.c. of the mixture represents approxi-
mately 3 to 5 L plus doses of toxin either neutralized to the guinea
pig ; that is, containing 65-70 per cent L plus dose to each unit of
antitoxin, or as recommended by Drs, Park and Zingher slightly
toxic that is, 80-90 per cent L- plus to each unit of contained anti-
toxin. The dose is ^ c.c. for those under 1 year, 1 c.c. for sub-
jects 1 year and over. Three subcutaneous injections are given
at weekly intervals.
Interest is assumed in a brief resume from the reports of
Drs. Park and Zingher. Nearly 5,000 subjects have been inocu-
lated. Of this number, within the last year, 2,100 were infants,
500 infants and children at milk stations, 700 in the schools.
Three injections furnish most satisfactory results. About 30 per
cent become immune at 3 weeks, 95 per cent in 8 to 12 weeks.
Dr. Park beheves that between 95 and 97 per cent of susceptible
individuals will thus be efifectively protected, and if a small per
cent failure occurs in the first series that immunity may be con-
ferred to these through later inoculations. Tests to date cover-
ing about 4 years show the protection thus gained to be effective,
and it is hoped in producing this immune state that a continuous
process of antitoxin bearing activity is established and that a life
protection against diphtheria has been secured. Full doses of
antitoxin at the time of inoculation and an exceptionally high
grade of material immunity found in some infants may alter the
operation of the injection. This need not be considered an ob-
stacle to its administration to infants, for Dr. Park has reported
that of 50 infants who received toxin-antitoxin within the first
few days of life, when 85 per cent have maternal immunity, 8
months later 70 per cent of these were still found immune to
diphtheria, where the ordinary expectation of immunity would be
only 30 per cent. In 10 to 20 per cent of subjects, a slight con-
stitutional reaction, with varying temperature and mild indis-
position, appears within the first and third days. Local reactions
to the inoculation are slight swelling, sensitiveness and varying
slight or larger areas of redness. In general both these reactions
are inconsiderable in severity. The most marked expressions are
in those presenting pseudo-reaction to the Schick test; that is,
older subjects. In the infant and young child reactions are rare
and really mild, the presumption being that at this early age they
have no hyper-sensitiveness to the protein of the diphtheria
26 Byard: Diphtheria Prevention
bacillus. Assured of the harmlessness and efficacy of active im-
munization, the problem of diphtheria prevention and control is
the determination of susceptibles and their active immunization.
An antitoxin content of 1/30 of a unit to each c.c. of blood is
reckoned as affording individual immunity. The Schick test,
reliably indicating the presence or absence of this protection,
eliminates unnecessary procedure. Dr. Park's findings show that
the expectation of the Schick test as performed in young subjects
is at 3 months 15 per cent are susceptible; at 6 months to 1 year,
60 per cent ; at 1 to 3 years, 70 per cent ; at 2 to 3 years, 60 per
cent ; at 3 to 5 years, 40 per cent ; at 5 to 10 years, 30 per cent.
With such gradual accumulation of immunity, the adult liability
to diphtheria sinks to be less than 15 per cent.
These Schick determinations parallel all vital records as to
the age incidence of diphtheria and emphasize particularly the
susceptibility of the child of the first 5 years, the pre-school group.
Confirming the dependability of the Schick test. Dr. Zingher
reports that more than 1,200 patients, suffering from scarlet fever,
giving a negative Schick reaction, were admitted to the Willard
Parker Hospital, and that although none of these received either
active or passive immunization not one developed clinical diph-
theria, although from 15 to 20 per cent of them became carriers
of virulent diphtheria bacilli. Noting the permanence of the re-
action. Dr. Zingher reports that over 3,000 children above iy2
years of age giving a negative reaction showed by re-tests that
this persisted during the period of observation, which covered
more than 3 years.
The Research Laboratory of the New York Department of
Health, through its recommendations and publications, has taken
a splendid initiative in demonstration and information regarding
immunization. All the proper agencies for publicity of the De-
partment of Health give suggestion and direction to this preven-
tive effort. The program for inoculation of all susceptibles, which
they urge, is prudent and practicable, and I presume to emphasize
their plea for those from early infancy through the school-age
period. Here immunization is expedient and urgent. About 10
per cent of deaths in all records occurs before the first year and
over 20 per cent before 2 years. Inoculation generally done
upon infants at 6 months would give a safeguarding protection.
At this age few would fail to develop immunity. Dr. Zingher
Byard: Diphtheria Prevention 2^
suggests that all from infancy to 18 months be inoculated without
reference to Schick test findings. Subjects at 18 months and over
should receive the injection only if shown by the Schick test to
be susceptible. Immunity to this disease conferred through public
and private agencies must ultimately take its place with the present
required vaccination for protection against small pox.
An inquiry made recently of 115 physicians in general prac-
tice, all of them averaging^ a considerable number of children
patients, gained information that 110 had never performed the
Schick test, 86 had never observed a Schick reaction, and that the
total active immunizations in older children done by 2 members
of this group totaled 5. In the wide campaign to which our
responsibility commits us, community interest allows no distinc-
tion of subject, and I presume to doubt, if we physicians, in a
definite, intensive way, in our private practice and in all our
hospital opportunities, are sufficiently contributing to the estab-
lishment of an immune population. Looking to this beneficient
result let us briefly survey the field in Greater New York for our
preventive measures. We have 141,564 babies under 1 year,
610,870 children under 5 years, 527,175 children between 5 and 9
years — a highly susceptible age group, totaling 1,279,609.
Their medical supervision is roughly expressed as follows:
30,000 in 157 public charitable homes and asylums, and other
child-caring institutions.
255,000 are treated in the regular hospitals having indoor chil-
dren's service.
350,000 are more than casually met in outpatient practice.
500,000 are some or all time private patients.
3,238 homes are under inspection as boarding out housings for
infants.
103 day nurseries present an average daily attendance of
7,352 children between the ages of 1 and 6 years.
There are 24,420 babies enrolled in the 60 Health Department
Milk Stations and 24 other dairy, food and diet kitchens in our
city, the census of whose aggregate weekly attendance is 1 10,526.
In several child-holding institutions, where, under Dr. Park's
and Dr. Zingher's direction — immunity and immunization — the
Schick toxin-antitoxin regimen have extensively been determined,
diphtheria has practically been eradicated. To secure an identical
28 Byakd: Diphtheria Prevention
immunity for the large remaining group of susceptibles, those
under our care, whether in our private or charitable administra-
tion, is obviously our community problem. How have we met
this opportunity and responsibility ? Excepting the work of Dr.
Park and his associates in the institutions referred to, a careful
survey of our 107 hospitals, 112 dispensaries, 157 asylums, 3,238
supervised infant boarding homes, 84 milk stations and 103 day
nurseries, fails to find, save for the institutions directly under Dr.
Park and his associates, any aggressive fixed program for needed
active immunization.
In all these institutions, where we have a suggestive, if not an
operative control, and in all private homes, a wide eflfort to deter-
mine susceptibility should be made and definite immunization
undertaken where needed. In private practice, the time for the
procedure has of course varying aspects of expediency, but the
matter is none the less urgent, none the less indispensable. The
records of our Health Department show that during 1 week in
September this year (1919) over 275 cases of diphtheria were
under treatment in private homes. Lately in the Wilkes Dis-
pensary of St. Mary's Free Hospital for Children, active immuni-
zations against diphtheria have been done in infants and children..
Parental interest and cooperation have resulted from specific
propaganda for prevention, as expressed in weekly clinic talks,
posters and information cards.
Since April, 1918, I have regularly been suggesting this in my,
own practice as a preventive measure. The response is briefly
summarized:
April 14, 1918-August 20, 1919.
Total 249 cases were innoculated.
2 at 3 months.
30 infants under 6 months )- 6 at 4 months
48 infants 6 to 9 months
22 at 4 to 6 months.
22 at 6y2 to 7 months.
26 at 7 to 9 months.
10 at 9 months.
42 infants 9 to 13 months 1. 21 at 10-11 months.
11 at 11-13 months.
Byard: Diphtheria Prevention 29
30 infants 13 to 20 months
16 at 23 months to 3 years.
12 at 14-15 months.
14 at 16-18 months.
4 at 18-20 months.
_ V 16 at 23 months to 3 y
47 children 2 to 5 years | 3^ ^^ 3^^ ^^ ^^^ ^^^^^
40 children 5 to 7 years
10 at 5 years.
23 at 6 years.
7 at 7 years.
^ 7 at 8 years.
12 children 8 to 9 years | 5 ^t 9 years.
Babies of less than 20 pounds weight, or 1 year of age, were
given 1/2 c.c. ; all over this weight or age, 1 c.c. All except 5 sub-
jects received 3 injections at intervals of one week. (At the time
of the third injection in these 5 cases, 2 were severely ill — 1 pneu-
monia and 1 acute double otitis — the other 3 temporarily removed
from the city.)
Reactions. — Mild indisposition with temperature 101° to
Wy2° F. occurred in 5 of the 78 babies under 9 months, in 6 of
the 77 between 9 and 24 months and in 8 of the 94 between 2 and
9 years. Reactions were mostly marked after the first dose. In
2 cases, brothers, ages 9 months and 5 years, a marked erythe-
matous rash appeared after 15 hours, covering the neck, trunk,
both having temperature 102°-103° F. for 2 days. In this case
the older boy had given a marked pseudo and positive Schick
reaction. Four other children, ages 3 to 5, cousins (parentage,
sisters marrying brothers), all giving a positive Schick reaction,
had temperatures 103°-104° F. for 2 days, with rather widely
distributed exanthematous rashes after the first injections. No
marked later reactions.
Of the 149 babies immunized under 20 months, 18 were Schicked
before inoculation. There were positive: 1 at 4 months, 2 at 6
months, 1 at 8 months, 4 at 9 months, 5 at 12-13 months, 5 at 15
months. All the remaining 99, being those over 20 months, were
shown by the Schick test previous to inoculation to be susceptible.
One hundred and sixty-four of those inoculated were done last
year and it has been possible to Schick test 146 of these at a date
not less than 8 months after inoculation. Of the 20 babies done
30 Byard: Diphtheria Prevention
under 6 months, 18 were tested and were negative. (This in
dudes the 2 done at 3 months and also 3 of the 5 cases who re-
ceived only 2 inoculations.) Of the 32 under 9 months, 29 cases
were negative, 1 slightly positive, 2 not tested. (The slightly
positive subject was a child 7 months old when inoculated and 1
of the 5 received only 2 doses.) Of the 33 from 9 to 13 months,
29 were negative, 4 not tested. Of the 18 from 15 to 20 months,
16 gave negative Schick tests, 2 not tested. Of the 28 from 2 to
5 years, 25 were negative, 1 slightly positive, 2 not tested. Of
the 25 from 4 to 7 years, 19 were negative, 6 not tested. Of the
8 from 8 to 9 years, all were negative.
Of the 146 tested to determine conferred immunity, 2 only
gave a slightly positive Schick. One of these, an infant, had but
2 inoculations. The 8 infants under 1 year, who were proved
susceptible before inoculation, all became negative after injection.
Of 30 children, 2 to 9 years, injected in the period January to
April, 1919, then positive to Schick test, 1 only remained slightly
positive in September, 1919.
Injections were begun only when children were well and had
had normal temperatures for the preceding day. Eight second
and twelve third inoculations were made upon children slightly
to considerably ill — two (2) with acute otitis requiring paracen-
tesis, four (4) with bronchitis, temperatures 100° to 101° F,, four
(4) infants with mild afebrile gastrointestinal disturbances. Not
one of these children appeared worse for the added inoculation.
Four babies, less than 2 years old, had definite prolonged ex-
posure to diphtheria 4 to 6 months after active immunization. A
few Klebs-Loeflfler bacilli were found in the nose and throat cul-
tures of three of the subjects. No diphtheria resulted.
Two children (5 to 7 years) , 8 months after immunization, were
continuously for a day and night with a third child who 24 hours
later became ill with diphtheria and afterwards died. Neither
protected child showed illness, although Klebs-Loeflfler bacilli per*
sisted in their nose and throat cultures for several days.
Practically all parents of infants under 18 months chose inocu-
lation without a preliminary Schick test. All eagerly desired the
later Schick to confirm the establishment of protection.
Immunization was advised to 87 families, accepted by 68 (of
the 19 heads of families declining inoculation, 8 were physicians).
Ten subjects were children of physicians, 10 were children of
Byard: Diphtheria Prevention 31
those professing Christian Science beHef, 42 were children of
parents of the manual laboring class.
The remaining 217 children were of the average well-to-do
parent.
Our community, as we meet it in private or hospital relation,
convinced of the efficacy and safety of active immunization, will
cooperate in the matter of diphtheria control. The splendid
pioneer work of Drs. Park and Zingher needs no comment. The
initiative and popularity of a wide community program for immu-
nization now rests with the pediatrist and general practitioner.
These foregoing brief records are offered as purely clinical
experiences, which present the possibility of such preventive
effort among the children of the average conservatively informed
parent.
BIBLIOGRAPHY.
1. Park. Zingher and Serota: Jour. A. M. A., 1914, Vol. 63, p. 859.
2. Park and Zingher: Am. Public Health Journal, 1916, Vol. 6, p. 43.
3. Park: Procdgs. Soc. Expmn. Biol. & Med., .\pril 16. 1916.
4. Z-iigher: Tournal of Inf. Diseases, Chicago, 1917, Vol. 21, p. 493.
5. Zingher: Am. Journal Diseases of Children. Aug.. 1918, Vol. 16, pp. 83102.
6. Crum: Statistics of Diphtheria, Am. Pub, Health Jnl., 1917.
7. Carey: Bost. Med. & Sur. Jnl., July, 1919.
8. Annual Reports. Dep. of Health, N. Y. City.
9. United States Public Health iReports.
10. United States Census Reports.
155 East 70th Street.
Serotherapy of Purulent Pleurisy in Infants (Archives
de Medecine des Enfants, Paris, Oct., 1919). The three cases
reported by P. Nobecourt and J. Paraf, in infants 2, 4 and 5
months old, testify to the excellent results from antipneumococcus
serum in bronchopneumonia complicated with purulent pleurisy.
The pneumococcus of type II was cultivated from the pleural
effusion and from the nose and throat secretions. The treatment
included also hot baths, cool moist packs of the thorax, injections
of camphorated oil and inhalation of medicated oxygen. The
antiserum was injected into the pleura after evacuation of the
purulent fluid, and into the lung, in doses of 5 or 10 c.c. and 3 c.c.
respectively. One of the children was injected with it also by the
vein. The injections were kept up for three to five days, and a
total of 30 c.c. in two and of 60 c.c. in the third case was thus used.
Unmistakable improvement followed the serotherapy, and the in-
fants all recovered from their pneumococcus infection. — Journal
A, M, 4,
THE MEASURE AND DEVELOPMENT OF NUTRI-
TION IN CHILDHOOD.*
By George M. Ret ax, M.D.,
Syracuse, N. -Y.
During the past year the state of nutrition of our American
children has occupied a prominent place in the thought of the
medical profession. This is shown by the large amount of work
done towards the correction of malnutrition both in the school-
room and in clinics and by the increasing literature dealing with
this subject.
The results of this work demonstrate a new responsibility of
the physician, which is a more careful consideration of the nutri-
tion of children. This would tend to correct a large percentage
of malnutrition now existing. These cases of malnutrition should
be corrected, for malnutrition in children reduces their resisting
power to infection and retards their normal development.
The measure of nutrition is the best single indicator of a child's
state of health. There is no other single observation that could
be made on a group of children that would lend so much knowl-
edge of their health as a series of weights over a period of time.
This is especially true if these weights were compared with a
normal standard.
The first step in considering a nutritional problem is to adopt
a correct standard of measurement. This step is of vital impor-
tance. The first part of our paper deals with the study of this
subject.
There are five possible factors that could be used as a basis of
measurement. These are w^eight, height, age, sex and nationality.
There are three relationships that should be considered. The
relation of age to weight, the relation of age to height and the
relation of height to weight. The bearing of sex and nationality
on our problem will also be considered.
Until of recent date the standard used was the relation of age
to weight. In a child, age is a measure of the time of growth.
It does not necessarily constitute a measure of the rate of growth.
Chart No. 1 gives a graphic representation of the relation of
weight to age as a measure of nutrition. Weight is shown along
* Read at the annual meeting of the Medical Society of the State of New York,
at Syracuse, May 7, 1919.
32
Retan : Measure and Development of Nutrition
33
the ordinate, each small square representing one pound. Age is
shown along the abscissa, each large square representing one year.
Normally nourished children are represented by dots, badly nour-
ished children are represented by crosses.
There are two striking truths brought out by the study of this
chart. First, that there is a great variation in weight for any
given age. Second, that th# relation of age to weight does not
separate the normally nourished children from the undernourished
children. This is shown in the chart by the fact that many crosses
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Chart No. 1.
are seen among the dots. This would prove that the standard
based on the relation of age to weight as a measure of nutrition
is not correct.
The relation of age to height camiot be used as a standard of
the measure of nutrition. Height is a measure of the development
of stature and as age measures the time of growth, their relation-
34
Retan : Measure and Development of Nutrition
ship would measure the rate of development in stature. It has
naught to do with nutrition.
The relation of height to weight is the correct standard. It is
plain that a child of a given weight would present a grade of
nutrition in exact proportion to his height.
Most scales of nutrition have been based on average weights.
Inasmuch as 20 per cent of all children have been found to be
undernourished and but 2 per cent have been found to be over-
nourished, the average of all children would not be the average
of normally nourished children. Furthermore, this method will
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Chart No. 2.
give a concrete number as the normal weight of- a given child, but
there can be no concrete number for the normal weight, since
normal weight is a variable and should be represented by a zone.
Chart No. 2 was made during a physical examination of school
children ranging between the ages of 5 and 16 years. They were
Ketan : Measure and Development of Nutrition 35
weighed and measured with their shoes on, but with the clothing
removed from their chests. They were divided into three classes
of nutrition and were placed on the chart in the following man-
ner : badly nourished cases were represented by crosses, normally
nourished cases by dots, while overnourished cases were repre-
sented by circles. Line A was then drawn along the upper border
of the malnutrition cases antt line B was drawn along the upper
border of normally nourished cases. The zone between lines A
and B is the zone of normal nutrition and the zone below line A
is the zone of malnutrition. Line C was then drawn midway be-
Chart No. 3.
tween lines A and B. Line C represents the average weight of
normally nourished children. All children are thus arbitrarily
placed in four zones of nutrition. The zone of overnourished
children is above line B. The zone of excellently nourished chil-
36
Retan : Measure and Development of Nutrition
(iren is above line C, since children in this zone are above the
normal average. The zone of passably nourished children is
below line C, since children in this zone are below the normal
average. The zone of badly nourished children is below line A.
In this chart there is seen no such diffuse occurrence of crosses
among the dots as in Chart No. 1. On the contrary, the crosses
appear in a definite group along the lower border of the dots.
Chart No. 3 gives the zones as formed in Chart No. 2. This
chart can be used to measure nutrition. In measuring the nutri-
tion of a given child one can place his weight and height on this
chart and obtain a mental picture of his nutritional relationship.
IN
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Chart No. 4.
For example, let us take a child of 53 inches in height. If he
weighs 55 pounds he would fall on a ix)int 6 pounds below the line
of malnutrition and 17 pounds below the average weight of normal
children. This makes his degree of malnutrition apparent. If
Retan : Measure and Development of Nutrition Z7
he weighs 70 pounds he would closely approach the weight of an
average normal child and if he weighs 80 pounds he would be
8 pounds above the weight of the average normal child. If he
weighs 90 pounds he would be seven pounds above the upper limit
of normal nutrition and 18 pounds above the weight of the average
normal child.
In measuring children on^ must decide in what manner they
will be dressed for observations. In individual cases it is best
DOI
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Chart No. 5.
that the children be entirely undressed for measurement of weight
and height. This would be the best method for private practice.
However, working in schools and in some clinics this method
would be out of the question. Suflficiently accurate observations
can be made by removing coats, sweaters and blouses. Some ob-
servers also remove shoes. In using the relation of height to
weight as a standard I have found that it is not necessary to
38 Retan : Measure and Development of Nutrition
remove shoes. The loss in height from the removal of the shoes
compensates for the loss in weight from the shoes. Chart No. 4
shows a series of children weighed and measured both with and
without shoes, the two observations on each child being con-
nected by a line. The lower end of the line represents the weight
and height without shoes. The upper end of the line represents
the weight and height of the same child with shoes. You may
observe that these lines are sufficiently parallel to the average nor-
mal weight line to make very little difiference in the measure of
t^he nutritional state of the child.
The factors of sex and nationality must be considered. Chart
No. 5 gives a comparison of the nutrition of girls and boys. This
chart was made from the scale of Boas and Burke. The boys are
represented by a black line. The girls are represented by a
broken line. You will observe that these lines run nearly together
and cross in places, showing no constant variation. This would
tend to prove that a separate scale of measurement is not necessary
for each sex. Furthermore, it is to be borne in mind that the
nutritional standard is represented by zones based on the relation
of weight to height and not by fixed lines based upon averages.
It is obvious that nationality plays no role in the measure of
nutrition when the nutritional standard is represented by zones
based on the relation of weight to height.
Malnutrition should be considered in the same light as actual
disease. Its cause should be determined and remedied.
The principal causes of malnutrition may be classified as:
A. Physical defects. 1. Adenoids. 2. Hypertrophied ton-
sils. 3. Decayed teeth. 4. Eye strain.
B. Habits. 1. Food habits, (a) Cofifee, tea and alcohol:
(b) Insufficient food; (c) Candy between rheals. 2. Lack of
sufficient rest.
C. Hygiene. 1. Sleeping in congested, unventilated rooms.
D. Disease. 1. Any actual diseased condition as tuberculo-
sis, syphilis, etc.
These causes of malnutrition suggest the proper procedure to
follow in their correction. Each malnourished child should re-
ceive a careful physical examination, then any physical defect
found which has a bearing on the case should be remedied.
The majority of all malnutrition cases are either caused by
Retan : Measure and Development of Nutrition 30
infected tonsils and adenoids or by faulty diet and often a com-
bination of the two.
The result of tonsillectomy on nutrition is shown by the fol-
lowinj^ data. This q;ivcs a summary of the weii^hts of 95 children
who have had their tonsils removed for at least one year. These
children have lived under the same conditions following- tonsil-
lectomy and have received tfie same diet. Six pounds was used
as an average yearly gain for basis of comparison. Sixty-eight
cases or 71.5 per cent gained more than 6 pounds. Separating
the cases into dififerent rates of gain gives the following table :
Above 20 pounds, 4, or 4.2 per cent; between 20 and 15
pounds, 10, or 10.5 per cent; between 15 and 10 pounds, 22, or
23.1 per cent; between 10 and 6 pounds, 32, or 33.6 per cent;
less than 6 pounds, 27, or 28.5 per cent.
Three cases failed to gain during the year and two cases lost
in weight. One of the two cases that lost was an active case of
pulmonary tuberculosis.
We have made an investigation to determine the diet of 530
school children between the ages of 5 and 12 years. The diets
were separated into 3 classes. First class : normally balanced diet
of sufficient food value, 58 or 10.9 per cent. Second class : suffi-
cient in food value, but not balanced, 245 or 46.3 per cent. Third
class : insufficient in food value, 227 or 42.7 per cent. Three hun-
dred and fifteen or 54 per cent were in the habit of drinking coffee
with their meals.
These data show that nearly half of our children receive insuffi-
cient food and that over half of our children are in the habit of
drinking colTee. This demonstrates the importance of consider-
ing diet in relation to any nutritional problem.
It is beyond the scope of this paper to discuss the difTerent
methods of correcting malnutrition. Excellent methods have been
elaborated for school and dispensary practice. These have been
reported in detail in medical literature. Our references to them
are appended to this paper.
REFERENCES.
1. Emerson. Wm. R. P.: Am. J. Dis. Child, 17:251, 1919.
2. Wilson, M. G.: Arch. Ped., 36:37, 1919.
3. Smith, C. H.: Am. J. Dis. Child, 15:373, 1918.
RECENT DEVELOPMENTS IN OUTPATIENT WORK*
By Charles Hendee Smith, M.D.,
New York.
In nearly every hospital the service is divided into two distinct
parts, the wards and the outpatient department. In the past, the
wards have been attended by the older and better men, who have,
in general, won their position by their ability and experience.
The outpatient physicians have been the younger, more recent
graduates, who have had little experience, and who work prac-
tically without direction. The connection between the two serv-
ices is merely nominal in most institutions. The accident of be-
ing within the same grounds or under the same roof often seems
to be the only bond. The visiting physicians to the wards rarely
have it as part of their regular duties to direct the management
or act as constituents in the outpatient department. The chiefs
of clinic are in a few hospitals also assistant attendings on the
wards, but this has been the case for only a few years. Vacancies
in the ward and visiting stafifs are sometimes filled from the out-
patient department, but quite as often by appointment of men
from "outside."
There are two main reasons that induce a physician to work
in an outpatient department, namely, the hope of promotion to
the ward service and the opportunity to acquire knowledge or
experience by handling patients. The young dispensary physi-
cian soon finds that the probability of advancement is very small.
Under the plan on which most outpatient departments are con-
ducted the possibility of learning is limited to what a man can
teach himself and this is insufficient to hold many men for long.
The result is undermanning by physicians and overcrowding by
patients, which means hasty, careless work, unsatisfactory to both
the patient and to the man who is forced to do it.
What are the actual dififerences between the two kinds of
work? As far as a children's service is concerned, it may be
stated briefly as follows : The patients in the wards are the acutely
ill (pneumonia, pleurisy, meningitis, etc.), cardiacs (more or less
decompensated), unusual or obscure cases for diagnosis, feeding
cases (including acute digestive disturbances), and a large num-
*Read at the seventieth annual session of the A. M. A., Section on Diseases of
Children, held at Atlantic City, N. J., June 11, 12 and 13, 1919.
40
Smith : Recent Developments in Outpatient Work 41
ber of minor or chronic cases, many of which do not belong in
a ward at all. The patients are away from their homes and
parents, unhappy, homesick, and too often uncomfortable or even
comparatively neglected. All these are artificial conditions for a
child. An adult may adjust his mind and his habits to them with
comparative ease, a child does so only with difficulty. The most
that can be done for the child is to effect a cure of his acute ill-
ness. When he is discharged from the ward he goes back to his
old environment, which may be responsible for his illness and
which has not been influenced by the child's stay in the hospital.
In contrast, the child coming to the outpatient department
comes with his mother to see a doctor, which is not an altogether
abnormal circumstance. He lives at home under normal condi-
tions for him. The home surroundings and manner of life are
the most important things in every child's life. It is generally
possible to influence these factors by education of the mother
directly or by efficient social service work. Moreover, the pa-
tients who come for treatment have all the conditions that are
of interest to the physician and to the hygienist. These include
the acutely ill patients, the rare cases and all the others seen in
the ward, for a great part of the ward cases come through the
outpatient department. In addition there are the numerous con-
ditions that never appear in the ward at all and yet really make
up the larger part of ipediatric practice. Feeding cases in par-
ticular can usually be handled much better at home, because the
mother's love and care more than compensate for the superior
scientific preparation of food in the ward. We all know that the
best place for a baby is at home unless the mother is utterly
hopeless.
Does not, then, the outpatient material offer more interest,
more experience with the kind of patients seen in private practice,
and greater hope of successful treatment than that seen in the
wards?
There has been a change in the medical world during the last
decade, and the outpatient department is slowly coming into its
proper place. Dr. Richard Cabot was among the first to voice
this when he said that he had been released from routine ward
work and allowed to devote his time to outpatient work.
When the Children's Medical Division of Bellevue Hospital
42 Smith: Recent Developments in Outpatient Work
was reorganized under Dr. La Fetra's direction three years ago,
these principles were recognized as being fundamental :
1. The two branches of the service shall be coordinate and of
equal importance.
2. There shall be a close connection between the two.
3. The outpatient department shall be organized so as to be
of the greatest possible interest to the men working in it.
The closest connection between the services is maintained by
having the attending staff identified in both. This staff, as re-
cently enlarged, is composed of a director, three attending physi-
cians, four assistant attending physicians, six adjunct assistants,
and an infinite number of outpatient assistants. The fourteen
attendings all have definite duties both in the wards and also in
the outpatient department during the entire year, except when
on vacation. Either the director or the senior attending physi-
cian comes to the latter daily for consultation on interesting cases.
One of the full attendings has direct charge of the work and is
there part of every afternoon. The assistant and adjunct at-
tendings work in the outpatient department and in the wards
three and four days a week each. The clinic assistants who have
no ward appointments are urged to visit the wards frequently,
and make rounds several times a week with the visiting staff.
]u addition two of the six interns are on duty in the outpatient
department daily, serving for six weeks each, in rotation, which
gives another useful bond between the two services. All this
insures an adequate staff for the outpatient department. The
close association between the two is extremely valuable for it
enables us to send patients back and forth from the outpatient
department to the wards and to have them under the observation
of the same man in both places.
In order to lighten the burden of the ward work so that the
attendings may have the time necessary for the outpatient work,
two or more men are on duty at once on each ward. Each man
is obliged to make complete rounds only three or four days a
week. On the other days he may go in and see the patients of
greatest interest, and spend as much or as little time as he is
able. This plan gives the ward patients the added advantage of
double observation. The two men on each ward usually make
rounds together once or twice a week, which eliminates the pos-
Smith: Recent Developments in Outpatient JVork 43
sible disadvantage of having two men caring for the same pa-
tients. In practice this works out very well.
The organization of the actual work differs in few respects
from that in any other dispensary, except that every eflfort has
been made to save waste motion and time otherwise lost, for the
attendance is large (75 to 125 daily) and system is needed to
handle so many children. At the door of the waiting room the
head nurse examines each child and questions the mother as to
her reason for coming. All with rashes, sore throats and sus-
picious coughs are shunted directly into an isolation room and
examined at once by a physician. The seats in the waiting room
are also arranged so that the children of different ages do not
mingle with each other while waiting. This enables a mother
to bring a small infant with very little risk of contact with the
older children who are so much more apt to have infectious dis-
eases. By these simple precautions most of the infectious dis-
eases are weeded out and the risk of cross infection is reduced
to a minimum. We have very few cases of this and practically
none among the infants. The tables on which children are ex-
amined are all separated by screens or by a distance of several
feet, so that the contacts are reduced here also. There are about
thirty such tables, and including the children whose histories are
being taken at small desks in the various rooms from forty-five
to fifty children may be scattered through the different rooms at
one time. This relieves the congestion in the waiting room and
also reduces contacts. (Definite whooping cough cases are kept
in an outer hallway, medicines prescribed and directions given.
The mother is told to return each week but not to bring the child
unless he becomes very sick.)
If there is no suspicion of infectious diseases the children are
taken in turn into the different rooms, the history is taken or
return note is made by volunteer or social worker. The weight,
height and temperature are taken, and the child is prepared for
examination on a table behind a screen. The doctor then makes
his examination, records it, and prescribes his treatment, which
he may explain to the mother in full, or he may turn her over
to a volunteer or social worker, who does this just as well in the
routine case. In this way the physician can handle a large num-
ber of children with minor troubles in a short time, and has
plenty of time for the interesting patients.
44 Smith : Recent Developments in Outpatient Work
Time is also saved by the extensive use of printed matter,
and by the use of rubber stamps whenever possible. Each physi-
cian's desk has a small box which contains a number of slips
stamped with the prescriptions in common use, so that it is rarely
necessary to write out an order for medicine.
In order to facilitate the handling- of the patients and the
study of cases of interest, on admission the children are divided
according to age into three groups: infants (up to 15 months),
runabouts (15 months to 4 years) and older children (4 to 12
years). (We are fortunate enough to have eight good-sized
rooms, besides the waiting room, so that each group or class may
have a room to itself.)
In addition to the age grouping, classes have been formed
according to disease whenever feasible. The largest of these
have been the cardiac class, the nutrition class, the vaginitis class
and the syphilis class. The infants' room is of course principally
an infant feeding class. In the runabout room are treated not
only the acute conditions for which the children first come, but
chronic cases like rickets, chronic indigestion and anemia. In
addition, well children are followed up and urged to come back
for weighing and advice after the original acute conditions have
cleared up. Many children graduate into this room from the
infants' room and continue to come for observation only. Al-
though not under our direction, the class for children of tuber-
culous families is held in one of our rooms and is in charge of
one of our assistant attendings.
Other small classes that have been in existence for a lotiger
or shorter time have grouf>ed cases of eczema, recurrent bron-
chitis, enuresis. A^accinatiflfis are done in a separate room at the
clinic on two days a week, and this amounts to a class, as it re-
quires organization on a definite plan to efificiently handle the
considerable number who come for vaccination, return dressings
and certificates.
The advantages of grouping children who have the same
disease or conditions are numerous and obvious.
First among these is the possibility of saving the effort of the
physicians, because nearly all of the children in a class can be
handled on a common plan of study and treatment. One set of
social workers, nurses and volunteer assistants can be trained to
Smith: Recent Developments in Outpatient JVork 45
go through a regular routine so that there is tremendous saving
of time. In many classes, talks can be given with advantage to
the entire group of mothers and children. The children become
imbued with a "class spirit" and the element of competition is a
most valuable aid toward making the children try to help the
physicians get results.
Just as soon as a number of cases of one kind are grouped
together it is impossible to avoid making comparisons. The
similarities and differences in the various histories, physical signs
and in the course and progress of the disease, begin to stand out,
in fact, scientific study becomes possible. One cannot watch
400 cardiac cases for three years without learning something.
Yet these 400 cases might have drifted through an ordinary clinic
during the same time under the observ^ation of many men, with
no systematic plan of study of treatment, and no one would have
been the wiser. The existence of a special class is soon widely
known, and many cases are referred to it by school nurses and
the other agencies at work in the city.
The class system also enables the physician to concentrate on
a single subject each day. Each man attends three to six days
a week. On one day he is on duty in the room for older children.
Here he sees new cases mostly, with such return cases as have
not been referred to a special class. Each man is in the infant
room one day, so that all have some feeding cases. Another day
every man works in a special class, and on that day he is not
required to see any patient outside it. It is quite simple to have
patients return on the proper day, so that they can be easily
followed by the man interested. If they return on the wrong day
they are seen by another doctor, but told to come back next time
on the proper day. This rotation of service and concentration
on a single subject has proved itself to be one of the strongest
means of holding the men. If the individual case ceases to be of
interest, the study of groups opens up a whole new field. ^
The work in the various classes cannot be described in de-
tail here. Some of it has already been published, and other
reports are in preparation. The cardiac class is fortunate in
1. A small bulletin board sliows the various rooms and the men who are
working in each one. The names are printed on small strips by means of gummed
letters and are fastened with thumb tacks so that it is possible to rearrange tliein
quickly.
46 Smith : Recent Developments in Outpatient Work
being- endowed by a fund established in memory of Dr. John
lluddleston, which insures its continued existence. There are
over four hundred children enrolled, and under more or less close
observation. The principal effort made thus far has been to try
to help the hearts by improving the general condition of the
children. This has been done by treating- remediable defects
(teeth, tonsils, etc.), and by training- the child in good habits of
eating and living-. A gain in weight has been made the main
object and almost always is accompanied by improvement in the
conditions of the heart. The children are kept under observation
until they go to work.
In the nutrition class an effort has been made to determine
whether undernourished children of school age can be made to
gain weight when treated in large numbers by the class system.
More than 300 have passed through the class and 100 attend regu-
larly in groups. The results are not so perfect as in small classes,
but about 60 per cent of the children can be made to gain very
well. This type of large class is necessary if any impression is
to be made on the enormous problem of undernutrition.
The vaginitis class has treated 125 cases in the past year. Al-
though the results are not always brilliantly successful, yet these
unfortunate little girls must be watched and treated. The mother
must be educated to take the precautions necessary to prevent the
spread of the infection, and also must be encouraged by the
thought that something is being done for the children. The fact
that 50 per cent of the vaginitis is contracted in various hospital
wards makes it all the more incumbent for every hospital to main-
tain a systematic means of treating the victims of this disease.
The syphilis class has 97 positive cases on file, and has taken
156 Wassermann tests during the past year. In few diseases is
it so important to have an automatic mechanism for treatment and
for follow-up of the delinquent cases. The taking of Wasser-
mann tests and treatment by injection has been simplified so that
this class now runs very well. One social worker spends her
entire time on the follow-up of the vaginitis and syphilitic cases.
One or two nurses and one volunteer assist in the conduct of the
classes.
The infants' room is perhaps the most efficient of the classes.
Under the direction of one of the volunteers, who is assisted by
Smith : Recent Developments in Outpatient Work 4/
several others, this room is conducted so smoothly that it is a
pleasure to work in it. About 1,000 infants are under observa-
tion during the year, and the attendance averages about 150 a
week. The follow-up system is kept very well and, by postal or
by a house visit, patients are urged to return if they do not attend
regularly. One social worker spends all her time on the infants,
largely on the bottle fed babies.
The matter of record forms is of great importance in simplify-
ing a clinic's organization. We believe firmly in the printed form
for histories and physical examinations. By means of these the
history can be taken rapidly and easily by the physician, or by
any intelligent person, after a very small amount of training.
Actually most of our histories are taken by our volunteer workers
— a few by social workers or nurses. The form insures a com-
plete history on every child, always insures its being taken in the
same order, with each fact always in the same place, so that it
may be rapidly found at any time. The contrast to the incom-
plete, rambling, and often illegible histories taken on the blank
page in general use in hospitals is more than striking. The sav-
ing in time is about 50 per cent. It would take from five to seven
minutes for every case merely to write out the headings on our
history form.
The physical examinations are also recorded under printed
headings. The physician can write down the greater part of the
examination in a few seconds by the use of symbols (N for nor-
mal, O for absent, -f- for enlarged, etc.). Here again the printed
form gets better and more complete results than the blank page.-
Two objections to the printed forms are advanced by those
who have not used them. One is that there is not always enough
room for unusually long notes, under any one heading. It is,
however, very simple to write "see next page" and to continue
to any desired extent. The second objection is that form histories
are inelastic and tend to become set and meaningless. The answer
to this is that they need not be and actually are not in practice.
It has interested me to observe the opponents of the form history
system in three different institutions during the last eight years.
After a few months, without exception, they have been convinced
2. The same advantages apply to form hospital histories. Since the introduction
of those forms into our ward service the improvement in the histories and physiuil
examination b-as been noteworthy.
48 Smith : Recent Developments in Outpatient Work
that for routine work of this kind the form is the best solution.
The form gets complete records of all cases ; the blank page rarely
does of any case.
In the infants' room the notes on return visits are also made
on a form arranged in vertical columns so that the date, weight,
temperature, food taken, vomiting, stools, remarks and treatment
appear always in the same column and are easily compared and
followed. The doctor may add any other facts he desires and
write in the proper columns his observations, directions for feed-
ing and prescriptions. The result is a complete return note iat
each visit. Our records of feeding cases compare very favorably
with carefully kept records of private patients. A chart that
shows the weight curve and the calories taken, graphically plotted,
adds to the completeness of the record. Weight charts are also
used in several of the other classes and are useful in interesting
the children in their own gains.
The treatment of the patients is greatly expedited by having a
large number of printed sheets giving directions for diet and all
sorts of instructions for the care of the child. This is the usual
clinic literature but is elaborated to the fullest degree. On each
doctor's desk is a pile of sheets of various kinds. These include
"Rules for the Care of the Child," "Directions for the Care of a
Sick Child," "Suggesiions for Nursing Mothers," "How to Prer
pare Bottles," "Barley Water," "Home Record Sheets," "Bed
Wetting Directions," "Diet List for Second Year," and also diet
lists for children from 2 to 6 years and from 6 to 12 years.
This literature must be given out with care to impress on the
mother the fact that it has been written for her child especially,
and must be explained, additions made or iportions scratched if
necessary in a way that will make her feel that it means something,
otherwise it will be thrown away at the door. Properly used
printed matter is indispensable. Even if it fails to accomplish its
purpose in every instance, it helps a great many at least. It is
impossible to write out full directions for all and futile to take the
time to do it. I have made an especial effort for several years to
inquire as to the diet and habits of children whose mothers have
been given this kind of printed directions in the proper manner.
In a very large majority of cases directions are used and followed
with care. Even the most ignorant riiother really wants to learn
Smith : Recent Developments in Outpatient Work 49
how to best care for her child. If she is not properly directed it
is the fault of the physician or of the method used.
Two years ago two young women with very little training or
experience came to the outpatient department to act as volunteer
assistants. They started in by taking temperatures, weighing
babies and assisting in minor ways, but became more and more
useful and in a short time one of them was placed in charge of the
conduct of the infants' room. About this time this country en-
tered the war and it was evident that there was to be a great short-
age of doctors. An appeal was sent out and immediately a large
number of women responded. A system was devised by which
they could be used in various ways to save the time of physicians.
Some of them have worked from two to six days a week for the
last two years and their devotion and faithfulness have made it
possible to carry on the work, which must otherwise have fallen
into utter disorganization. At times during the influenza epidemic
the medical staff was reduced to one or two men, but with the aid
of 15 or 20 volunteer women the work was covered, and no
child was turned away without a full history being taken and a
complete examination and adequate directions for treatment being
given.
The volunteer work has been described in some detail else-
where."* Briefly, their main help is in the taking of histories,
making return notes, taking weights, heights and temperatures,
assisting the doctors in giving and explaining directions to the
mothers as to diet and care of the sick children, keeping follow-up
systems, sending postals, and in many ways acting as a link be-
tween the doctor and the social service system. Some of them
can do simple laboratory tests, von Pirquet tests, etc. Each of
the rooms is in charge of a volunteer, who keeps the work mov-
ing, sees that the children are brought in, assigns them to the
others who take histories, and, in general, acts as clinic manager
for that room. Besides the definite duties assigned, each volun-
teer does dozens of small things each day, every one of which
expedites the work and saves the time of the doctors.
The volunteers have not stopped this work since the war
ended, nor does their interest seem to lag. Many of these women
have found that this is a direct way of doing practical work that
3. Modern Hospital, May, 1918.
50 Smith : Recent Developments in Outpatient Work
helps the poor of the city. I feel very strongly that this volunteer
work in clinics is the greatest new thing that has come out of the
war into civilian medical work. It can be made so attractive to
volunteers of the right type that their interest can he held even
in peace times. The kind of work they can do does not need long
training, but does require personality and enthusiasm which can-
not always be obtained by paying salaries.
In most institutions doctors have been taking histories in
laborious long hand and doing all the comparatively unskilled
work mentioned above after years of study and experience. It is
hard to imagine a more ineflficient use of the time of highly trained
men. Hospitals cannot always pay for clerks or secretaries, but
if this volunteer work can be continued the outpatient department
need never slide back into the old methods. The waste of time
of the physicians eventually means a lack of time for essentials
and slipshod, inaccurate work. If the physician is relieved of
the work which the volunteer does, he is enabled to spend his time
in careful examinations, laboratory tests, actual study of the
patients and in giving full directions for treatment.
The modern outpatient department depends for results on so-
cial service quite as much as on medical care. We are blessed at
Bellevue by having a most efficient Social Service Department.
One worker has charge of the older children in the general clinic.
One spends her entire time on the infants, especially for bottle fed.
The cardiac and nutrition classes each have a full-time worker.
The vaginitis and syphilis classes have another. There is also a
worker for the ward patients. The follow-up work of this staflf
is of the highest type. Full social service reports are entered on
the medical histories where they are easily available, and are of the
greatest assistance to the physicians. Each worker attends the
outpatient department only two or three times a week, but keeps
in close touch through the volunteers. Every child discharged
from the ward has a follow-up card made out and an effort is
made to get back all the cases of interest.
The educational function of a large children's service is many-
sided. No small obligation is placed on the men who have the
privilege of conducting such a service to see that the educational
possibilities are not wasted.
The education of the interns comes first, and the value of the
Smith : Recent developments in Outpatient Work SI
outpatient department in teaching them cannot be too strongly
emphasized. Tlie intern who graduates from the average hospital
has generally had excellent training in the diagnosis and treatment
of acute disease, but practically nothing else. He has had no
experience in handling the type of case which will comprise about
90 per cent of his private practice. This experience our interns
get by working in our outpatient department. Each one serves
six afternoons a week for about half the time he is on the service.
It has been interesting to note the change in attitude toward this
work since this plan was initiated. Each new set of interns re-
sented the innovation somewhat and felt that it was rather an
imposition to force them to do outpatient work. It was necessary
to remind some of them that this work was not optional but part
of their regular duties. It did not take long for the value of the
work to sink in, however, and they realize now that this outpatient
work is one of the most valuable features of their internship.
Teaching of students should also be done in the outpatient
department as well as in the wards. It is, of course, instructive
to see a case of pneumonia or meningitis, but how much more
important that the newly graduated physician should know how
to treat an acute cold or tonsilitis, an acute digestive upset in an
infant, know how to handle a normal breast or bottle-fed baby,
how to recognize and treat undernutrition in older children, and
most of all, how to deal with a mother, instead of merely giving
orders to a nurse. On our service the undergraduate students
spend alternate teaching days in the wards and the outpatient
department, and just as much stress is laid on one type of teaching
as on the other.
The teaching possibilities of a hospital should not be confined
to undergraduate students and interns. A large number of prac-
ticing physicians come to us asking for graduate instruction. Al-
though we have had no regular course as yet, we have encouraged
these men to come and work with us for as long a time as they
have found it profitable. They have been given free access to the
wards and the laboratory during the mornings. They spend the
afternoons in the outpatient department and make ward rounds
with the attending physicians. There is an increasing demand
for this kind of opportunity, and it is the duty of the hospitals to
meet the demand. We do not encourage men to come for only
a few weeks, but think they can spend from two to six months
52 Smith : Recent Developments in Outpatient Work
in this way with great profit. We believe that this ought to yield
better results than merely listening to a short course of lectures^,
for, if properly directed, it is the work a man really does himself
that teaches him. We are planning to extend and systematize this
course in the future to meet the perfectly just demand of the better
men of the country for a share in the opportunities that we enjoy.
The education of the volunteers and the nurses is no small
matter. The medical information that they acquire cannot fail
to be of value to any person.
The last and most important educational function is the edu-
cation of the mothers and children. . If a mother brings a child
to a hospital with a cold or sore throat and is allowed to go away
with merely a little medicine, that institution is not doing its full
duty. She ought to receive careful instruction as to the nursing
and feeding of the child during his acute illness (vvhich is even
more important than the medicine). In addition no mother
should be allowed to go away without being questioned as to the
diet, habits and mode of life of the child. She should have a list
showing what the diet should be after the acute illness is over, and
advice as to regular hours of eating, sleep, fresh air, exercise,
bathing and so forth. Much of this may be on the printed leaflet;
but the personal word must be added to drive it home. Food
exhibits, wall charts, class talks, all are useful educational aids.
The real test of an outpatient department organization is its atti-
tude toward the child applying for treatment. If he is merely a
"case," he will receive little besides treatment for the chief com-
plaint for which he comes. If he is a "patient," then he is con-
sidered as a sick child who needs a study of his whole life, diet
and habits, as well as care of his temporary ailment. The ques-
tion should not be: How can we cure his acute ailment with the
least eflfort? but. How much can we do for this child and mother?
Through education in health habits lies the hope of bringing
up in the world a better race than we have today. This health
education should be done in the schoolsj but advice given by physi-
cians in a hospital often carries more weight than school instruc-
tion. Every outpatient department should have a sysytem that
insures more or less automatically that this educational work is
done.
66 West Fifty-nfth Street.
SOCIETY REPORT
THE NEW YORK ACADEMY OF MEDICINE— SECTION
ON PEDIATRICS.
Stated Meeting, Held December 11, 1919.
Dr. Murray H. Bass, in the Chair.
SOME REMARKS ON CRANIAL THROMBOSIS IN CHILDREN.
Dr. Seymour Oppenheimer presented this paper. (To be
published in a later number of Archives.)
Discussion — Dr. Herman Sciiwarz said that he could not
allow this paper to pass without expressing his appreciation of
the clear picture of marasmic sinus thrombosis that Dr. Oppen-
heimer had given us. He would like to ask Dr. Oppenheimer
his experience with otitic thrombosis in infants. In Dr. Schwarz's
experience, with the exception of the one case that he had seen
with Dr. Op|>enheimer, he had never seen another case. This
is important in diagnosing fluctuating ear temperatures in infants.
Dr. Oppenheimer, in reply to Dr. Schwarz's inquiries, said
the youngest case of sinus thrombosis that had come under his
observation was the one to which Dr. Schwarz had referred and
which he saw in consultation. Unfortunately that case had many
complications ; in addition to the sinus thrombosis the child had
a meningitis, diphtheria, and a brain abscess. The child died.
Last year he had seen 3 children with sinus thrombosis under
the age of 2 years, but up to that time he had never seen a case
of sinus thrombosis in a child under 5 years of age. He had had
the opportunity of studying about 150 cases of his own and pos-
sibly he had seen 50 others in consultation with other men. Of
these, there were about 12 cases in children under 10 years of age.
As to the relative frequency of sinus thrombosis as a complica-
tion of mastoid disease, he believed that about 4 per cent of all
cases of mastoid disease developed some type of intracranial com-
plication, and probably 60 per cent of these complications were
in the nature of a sinus thrombosis.
some experience with malaria among children in PALESTINE.
Dr. Sophie Rabinoff presented this paper by invitation. (To
be pubHshed in a later number of Archives.)
53
54 New York Academy of Medicine — Section on Pedi-atrics
Discussion — Dr. Gaylord W. Graves said that he would like
to ask a question with reference to the effect of quinine given at
different stages of the attack. It had been said that it took sev-
eral hours for quinine to saturate the blood plasma and it was
customary for physicians to treat malaria by giving quinine every
few hours. Dr. Tuttle at the Presbyterian Hospital had sug-
gested that in the case of a patient who had passed through a
chill one should wait until the next chill and at its height give 10
grains of quinine. They did this in a case and the patient had
no subsequent chill. The quinine was repeated, but at such an
interval that it was evident that the initial 10 grain dose did the
work.
On one occasion a man came into the hospital with a tempera-
ture of 105° F. and his condition was diagnosed as typhoid fever.
Next morning his temperature was 98° F., and as there were no
signs of perforation, a blood smear was examined and the
malarial parasite found. The man was then given quinine with
tincture of capsicum which was supposed to hasten the absorption
of the quinine. Two days later he had a very slight chill (tem-
perature not over 103° P.). It was evident that the large dose
of quinine, although given late, had mitigated the severity of the
chill one-half. The day following admission, he had another
chill, making it seem likely that there were 2 broods of parasites.
Quinine given at the height of this chill controlled the infection
so that there was no chill 2 days thereafter. After several months
the patient was seen outside the hospital for an illness diagnosed
as influenza. Several days later the spleen was found enlarged
and the temperature found to be 104° F. At this point quinine
was given and no further chill occurred, although blood examina-
tion revealed the malarial parasite.
Dr. Tuttle although giving no positive explanation had sug-
gested the theory that continuous administration of quinine dis-
couraged the emigration of parasites from the corpuscles, while
if one waited until they were really out and then hit them "on the
head," as the speaker interpreted the theory, the effect was more
pronounced.
He would like to know if the psychological moment to admin-
ister quinine was at the height of the chill Or before, as was cus-
tomary.
pR, Hugh Chaplin said that in chronic cases of malaria they
New York Academy of Medicine — Section on Pediatrics 55
had noticed a slight, rather constant rise in the evening tempera-
ture to 100° or 100.5° F., rarely over that. They had one child
with an attack of malaria in the Orient, treated for about a month
with quinine, and after that for a number of months the child had
a slight rise in temperature in the evening. There were other
possible explanations for this rise in temperature as possibly a
slight indigestion or a tuberculous family history, but neither were
sufficient to account for this rise in temperature in this case. They
did not find the organisms until later when the child had a chill
and then the organisms were found to be present. Was the chill
in this case due to organisms that had been lying dormant during
this period ?
Dr. H. L. Dowd said in the treatment of malaria the adminis-
tration of bicarbonate of soda and lemon juice, which because of
its acetic acid acted on the blood cells favoring absorption of the
bicarbonate of soda, had been an aid. They had used cacodylate
of sodium as a preparation associated with quinine hydrobromide,
both given hypodermically.
Dr. Charles Hendee Smith said there were 2 things that
seemed important in the treatment of malaria. He supposed that
in the Orient, where they could not control the patients, it was
impossible to make them continue taking the quinine long enough,
but he had found that one could not stop quinine and be sure
there would be no recurrence if it is administered less than 6
months. It should be given in small doses for that length of time
at least. He did not think that point had been sufficiently empha-
sized in the paper. Another point is, that rest in bed prevents
the recurrence of paroxysms, as well as though quinine had been
uiven. Then if one got the patient up he would have another
chill, and one would find the parasite. The point was that one
got a great deal more good out of the quinine if the patient was
in bed. For that reason it was advisable to put the patient to
bed for a week on full doses of quinine and then when he got
uj) to keep on giving small doses of quinine for many months.
.\ member stated that at Camp Jackson, though the men were
herded in a crowded condition, their health was good until Octo-
ber, when the epidemic of influenza broke out and Type 1 pneu-
monia appeared. During the convalescence from pneumonia they
found the tertian in these men who were previously healthy,
56 New York Academy of Medicine — Section on Pediatrics
Dr. Herman Schwarz asked Dr. Rabinoff, what was the
niortality in the cases she had seen. It was mteresting that in
Italy a great proportion of infant mortahty is made up of deaths
due to malaria.
Dr. Murray H. Bass asked Dr. Rabinoff what her experience
had been with reference to malaria in very young infants. He said
that he had written a paper some 6 or 7 years ago in which he
reported the case of an infant in whom the malarial parasites were
found a short time after birth, and he had decided that the disease
was of congenital origin. He thought it important to emphasize
the fact that the malarial parasites might be found in the blood
of infants a few hours after birth inasmuch as this possibility
might be overlooked. The case that he reported had been treated
for gastrointestinal disease and no one suspected malaria until the
blood examination was made. There was nothing to sugges.t
malaria except that the baby had a large spleen.
Dr. Rabinoff, in closing, said that in regard to the treatment
of malaria, in a series of experiments it was shown that quinine
by the mouth was mostly excreted in from 3 to 6 hours, and in
giving large initial doses at the time of the paroxysm, one con-
trolled the organisms in the blood, but this had no effect on the
spores developing later. For that reason it was necessary to con-
tinue giving the quinine at short intervals, and she had found
that quinine must be continued for a long time after the acute
attack was controlled. The spores were supposed to develop in
5 or 6 days and they were responsible for subsequent relapses.
With reference to the question of the mortality among infants,
she herself had not seen any deaths due to the malaria itself,
except in one case with convulsions, in which death occurred
during the attack, and in this instance the pathologist thought
there was a direct obstruction of cerebral vessels which was
responsible for respiratory failure. But in many cases there was
extreme anemia and a state of lowered vitality due to malaria,
which offered no resistance to other intercurrent infections.
Among their chronic patients were children who ran a daily
temperature of 100° or 101° F., and they gave a history of having
had that condition for weeks. Rest in bed was very important.
Many cases treated in the home without success, when admitted
to the hospital and put to bed would have normal temperature
New York Academy of Medicine — Section on Pediatrics 57
within a day, and there would be no further rise in temperature
while they were in the hospital.
In regard to Dr. Bass's case of. malaria in a young infant, Dr.
Clarke of Johns Hopkins has examined the fetal and maternal
blood in cases of malaria in young infants and found that in these
cases there had been some trauma in the placenta, which per-
mitted the organism to pass from the maternal to the fetal blood.
HEALTH CLASSES FOR CHILDREN.
Dr. Ira S. Wile read this paper. (To be published in a
later number of Archives,
Discussion — Dr. Charles Hendee Smith said he had very
little to say except to congratulate Dr. Wile on his paper, for he
knew what an enormous amount of work it represented. There
were so many difYerent aspects that might be discussed that it
was difficult to know what to start upon. One of the most inter-
esting points was that one can get results at once in almost any
child that came into the class. The child gains in weight for a
few weeks and then, as some one had said, "Grows weary in well-
doing" and slumps. A continuous gain depends entirely upon the
boosting ability of the man in charge of the class. It is necessary
to reach people from many different side? — social, economic, etc.
This kind of a class reaches the cause of ill health and malnutri-
tion by educating mothers to take proper care of their children in
the home. Caring for a child in the home gave much better per-
manent results than sending the child away from home for a
short time, as when this is done the child very frequently falls
back when he returns to his home. Sending a child away to
give him a start might be all right but it did not correct the
cause of the trouble. One reached the cause of the trouble by
educating the mother and improving conditions in the home.
There could not be too many of these classes. There should be
one in every hospital and in every school. Until we can get the
public school teachers to attack this problem we shall not have
the kind of people that the country should have. Until the nation
realized that the foundation of good health lay in education we
would go on having hospitals and dispensaries, which have to
do what they can of this kind of work.
Dr. Jacob Sobel said the most significant thing in connection
with this paper was that Dr. Wile had started something, and by
that he meant that Dr. Wile was a pioneer in starting classes for
58 Nc7v York Academy of Medicine — Section on Pediatrics
children of the pre-school ag^e in connection with hospitals. This
was a subject in which lie had been interested for many years.
To show how little eft'ect one pre-school age class had on this
very large problem one need only stop to consider that there were
approximately 475,000 children of pre-school age in New York
City. It would require a large number of clinics and a large per-
sonnel to care for the children of this class. This was probably
the most pressing question before the country today. The proper
care of the pre-school child bore the same relation to the school
child as the problem of prenatal care bore to the infant. How to
care for these 475,000 children in New York was a serious prob-
lem. It was not a municipal problem alone, because the munici-
pality could scarcely handle it. There were from 275,000 to 300,-
000 children of school age physically examined annually in New
York City, and this required a large number of doctors and
nurses. This being the case, one could readily appreciate what a
working force would be required to examine 475,000 children of
pre-school age. The only solution of the problem was along the
lines in which Dr. Wile was working and in accordance with Dr.
Smith's suggestion. If we are going to make any impression it
was not only necessary to have muncipal clinics and pre-school
clinics, but these health classes must be associated with every
hospital, dispensary, settlement, day nursery and school, etc. Dr.
Wile not only laid emphasis on the treatment and follow-up of
physical defects but said they paid attention to the mental condi-
tion as well. Dr. Sobel said he did not know just what Dr. Wile
meant by that, but he believed this should include the emotional
as well as the mental make-up. It was true, as Cardinal Newman
said, "If you give me a boy until he is 7 years of age I care not
who has him afterward." The care of the child at this most
important phase of his life should not be overlooked. He hoped
the time would come when the municipality would spend more
money in this direction, for if they would spend more money on
the pre-school child they would not require so much for the
school medical inspection. Pre-school examinations could be
carried out at community centers, at public and other schools, and
the child prepared for school entrance and to assimilate knowl-
edge; this would mean a saving- for the children, a saving of
expense to the municipality and a saving to the State and the
Nation.
New York Academy of Medicine^^Section on Pediatrics 59
Dr. Wile, in closing, agreed with Dr. Sobel that public mcwiey
could not be spent to better advantage than in giving proper
attention to children of the pre-school age.
Many times physical defects in children were passed over in
the public clinics or by private practitioners. This was a point
which needed stimulation of the attention. If they all got together
it would be possible to make a slight dent on the while problem.
BUTTER FAT AND THE CHILd's WEIGHT.
J. H. Larson, Secretary of the New York Milk Committee,
made this presentation. (To be published in a later number of
Archives.)
Seric-Serum for Controlling Hemorrhage (Presse Medi-
cale, Paris, Sept. 18, 1919). H. Dufour and Y. Le Hello noted
that an anaphylactic reaction in a patient with hemorrhagic pur-
pura seemed to modify the blood in such a way that the tendency
to hemorrhage was arrested. This suggested that a therapeutic
anaphylaxis might be induced which would arrest hemorrhages
impossible to control by other means. They selected for this the
method of passive anaphylaxis induced by injection of a small
amount of serum from a rabbit in a state of anaphylaxis. They
injected the rabbits several times at regular intervals with small
doses of diphtheria antitoxin by the vein. They are bled the
twenty-first day after the first injection, and their serum injected
into guinea-pigs sensitizes the latter immediately, and induces
manifest hypercoagulability. Injected subcutaneously in human
beings, it almost immediately induces hypercoagulability and has
thus arrested hemorrhage in numerous cases. Normal rabbit
serum does not seem to modify the coagulation of the blood in
man. A number of cases are described in which this seric-serum
against hemorrhage, as they call it, arrested grave hemophilic
and other postoperative hemorrhages, severe recurring uterine
hemorrhage in a young woman, and fulminating epistaxis. They
declare that nothing to compare with this prompt arrest of the
tendency to hemorrhage has ever been realized with other meas-
ures. The seric-serum was injected in the dose of 10 c.c. and
the effect was evident in about four hours, one hour or two hours
in the different cases. In none of the cases were more than two
injections needed. — Journal A. M. A.
DEPARTMENT OF ABSTRACT
Webster, Reginald: Blood Culture in Summer Diarrhea
(Medical Journal of Australia, June 7, 1919, p. 460.)
In a series of 11 cases of summer diarrhea with blood in the
stools, Webster states that 5 yielded a positive blood culture while
6 were sterile. In the 5 cases with a positive blood culture, the
bacillus fecalis alkaligenes was cultivated in 3, while the bacillius
dysenteriae was cultivated in 2. Of 16 milder cases of diarrhea,
all were sterile — longitudinal sinus. Five c.c. of blood, obtained
from the sinus when possible, and when not from the anterior
jugular vein, were inoculated into 50c.c. of a bouillon, the basis of
which was liver extract. Ox liver was utilized in making the meat
infusion in order to obtain the advantage of the presence of bile
salts. The medium was then prepared as ordinary broth, and
rendered -f- 10 to phenolphthalein. In those instances in which
growth appeared, the primary broth cultures were transferred to
MacConkey plates ; likely colonies were then selected for souring
in glucose and mannite-litmus-peptone water, together with other
available carbohydrates and litmus milk. C. A. Lang.
Walker, Allan S. : Congenital Defects in the Lower
Bowel Recurring in Three Successive Children of One
Family. (Medical Journal of Australia, March 15, 1919, p.
216.)
Walker reports 3 cases of congenital defects in the lower bowel
recurring in 3 successive children of one family. A healthy
woman, aged 30 years, gave birth to an apparently normal male
child in October, 1915. In 36 hours the child showed great
abdominal distension, the bowels had not moved and there seemed
to be considerable pain. Examination revealed an imperforate
rectum, though the anus and the rectum for 7 cm. to 8 cm. were
normal. Under ether the abdomen was opened and the lower
normal part of the rectum was found to end within the peritoneal
cavity ; the remainer of the rectum, the sigmoid and descending
colon were absent. The ileum was drained as a means of relief
for the pain. The child died 24 hours later.
In May, 1917, a female child was born. The rectum was
patent as far as the finger could reach, but a similar condition
60
Departtnent of Abstracts 61
rapidly developed. On opening the abdomen a firm, cord-like
structure, about 0.5 cm. thick, was found running up from the
occluded lower gut and attached to the abdominal wall by a small
f®Id like a rudimentary mesentery. No large bowel was found,
so nothing more was done. The child died in 18 hours.
In January, 1919, a third child was born. The child seemed
normal, but within 24 hours there was abdominal distension, pain
and temperature. Examination revealed a blind end in the rec-
tum less than 5 cm. from the anus. Considerable quantities of
fluid rapidly collected in the peritoneal cavity and the child soon
died. Operative interference was refused. The mother has one
living healthy child, born 6 years before the first of this series,
and has had no other pregnancies. The family history was en-
tirely negative. C. A. Lang,
Bronson, E. : Catarrhal Jaundice Associated with In-
fluenza IN Children. (British Journal of Children's Diseases,
April-June, 1919, p. 73.)
During the epidemic of influenza (1918), the author was im-
pressed by the fact that she was seeing an unusually large num-
ber of instances of catarrhal jaundice in the medical out-patient
department of the Hospital for Sick Children, Great Ormond
Street, London. These cases were divided into 3 classes: (1)
Children in whom jaundice followed exposure to influenza, but
who did not develop it; (2) children who developed jaundice as
a sequel to an attack of influenza; (3) doubtful cases in which
there was no known exposure to influenza. She gave a short his-
tory of some 18 cases and reports that except during the influenza
epidemic not more than 2 cases of jaundice a month were seen by
her in the Out-patient Department. C. A. Lang.
Cervone, v.: Dental Anomaly Found in Rachitic Chil-
dren. (Bullettino Scienze Mediche, June, 1919.)
Besides the usual dental anomalies found in rachitic children
an accurate study of the patients in the Pediatric Clinic of Bologna
revealed one peculiarity hitherto not recog:nized. This is an exag-
geration in size of the lower canines that actually resemble those
of carnivora, Out of 54 subjects studied, 52 had this feature.
Usually the "anomaly is found more pronounced in children in
62 Department of Abstracts
whom the rachitic characteristics are most evident. It is usually
in the lower jaw and in the first teeth.
Regarding the explanation of this feature the author ventures
to suggest that it might be a reversion or sig^ of degeneration —
hereditary in rachitic stock. It might also be caused by a patho-
logical process taking place in the tooth formation, due to changes
produced in the tissues by rachitis.
The subject admits of further discussion and Cervone only
offers this preliminary study in the hope that pediatrists will be
interested. C. D. Martinietti.
Gautiez, a.: New Treatment of Influenza in Children.
(Accademie de Medecine, Paris, December 3, 1918.)
During the recent epidemic of influenza, particularly in cases
showing cardiac weakness, Gautiez has been using twice a day a
hypodermic injection of serum prepared according to the following
formula:
Quinine bichloride, grammes 0.50; arrhenal (sodic dimetyl-
arsenate), grammes 0.50; sterile physiologic serum, 400 cc. Re-
sults have been uniformly good. C. D. Martinetti.
Valabrega, M.: Primary Pneumococcus Cerebral Ab-
scess. (Archivos Latino- Americanos de Pediatria, Nos. 1 and 2,
1917.)
A perfectly healthy boy of 7 became suddenly ill with convul-
sions characterized by clonic contractions of the left arm. Head-
ache followed, and later vomitus, torpor and strabismus.
In the last 24 hours there was temperature reaching 42 C.
Lumbar puncture disclosed a clear liquid under pressure but unlike
meningeal fluid. On the 24th day of illness, the patient devel-
oped coma and Cheyne-Stokes respiration in addition to the other
symptoms. Death followed. The autopsy showed a small globu-
lar abscess in the left frontal lobe containing about 100 cc. of
dense greenish pus in which many pneumococci were present.
The abdominal viscera were not examined on account of strenu-
ous opposition on the part of the family.
Valabrega thinks that this pneumococcus infection may have
reached the brain through the circulatory system.
C. D. Martinetti.
BOOK REVIEWS
The Practical Medicine Series, 1919. Volume IV. Pedia-
trics. Edited by Isaac A. Abt, M.D., Professor of Pediatrics,
Northwestern University Medical School; Attending Physi-
cian, Michael Reese Hospital, with the collaboration of A.
Levinsox, M.D., Associate Pediatrician, Michael Reese Hos-
pital. Orthopedic Surgery. Edited by Edwin W. Ryerson,
M.D., Associate Professor of Surgery, Rush Medical College;
Professor of Orthopedic Surgery, Chicago Polyclinic. Chi-
cago. The Year Book Publishers.
Little but good can be said by the reviewer of this small volume
as a compendium of pediatric and orthopedic progress for the
year 1919; it covers the field. As its name indicates, it is a com-
pilation of the world's literature, well edited and boiled down.
In a word, it gives a rapid summary for the man who runs. Of
especial interest are the abstracts of epidemic stupor, the disorders
of nutrition, and the arthritides. It is well bound and printed, and
will more than hold its own with the other seven volumes of the
series.
The Diseases of Infants and Children. By J. P. Crozer
Griffith, M.D., Ph.D., Professor of Pediatrics in the Uni-
versity of Pennsylvania, Philadelphia ; Physician to the Chil-
dren's Hospital of Philadelphia, and to the Children's Medical
Ward of the University Hospital ; Consulting Physician to St.
Christophejr's Hospital for Children, Philadelphia; Corre-
sponding Member of the Societe de Pediatrie de Paris, With
436 illustrations, including 20 plates in colors. Volumes I
and II. Philadelphia and London. W. B. Saunders Company,
1919.
This book appears in 2 volumes and contains almost 1,500
pages. It is a very full review of medical pediatrics, with just
enough attention paid to the surgical and special branches to
justify their inclusion. In these volumes Dr. Griffith has really
compiled a compendium of various textbooks, and has taken freely
facts from foreign and domestic pediatric journal literature. He
has also offered his own wide experience in private practice and
in hospital work. This adds to the general rounding out and
63
64 Book Reviews
elaboration of the book. An attractive semi-departure in a work
of this kind are the references in footnote form which appear
throughout. A reader, desiring to consult the original, is there-
fore enabled to do so with ease and despatch. It is profusely
illustrated with 436 illustrations, which include 20 colored plates.
Those showing colored drawings of the stools are especially fine
and vie with those showing vaccination, the Schick test, and
Koplik's spots. Needless to say, it is well printed and well bound.
We feel that as a book of reference it is absolutely reliable, up to
date and offers valuable data to both the student and to him who
reads and runs.
Diseases of Nutrition and Lntfant Feeding. By John Lovett
Morse, A.M., M.D., Professor of Pediatrics, Harvard Medi-
cal School ; Visiting Physician at the Children's Hospital ;
Consulting Physician at the Infants' Hospital and the Float-
ing Hospital, Boston, and Fritz B. Talbot. A.B., M.D., In-
structor in Pediatrics, Harvard Medical School; Chief of
Children's Medical Department, Massachusetts General Hos-
pital ; Physician to Children, Charital:)le Eye and Ear In-
firmary ; Consulting Physician at the Lying-in Hospital and
at the Floating Hospital, Boston. Second Edition revised.
New York. The Macmillan Co., 1920.
In the reviewer's opinion, this book still remains the best
book on metabolism, nutrition and infant feeding written in the
English language. It has preserved the style, the ideas, and the
ideals of the first edition, published in 1915, and the authors have
added new data which brings the literature up to April 1, 1918.
The very few real additions to scientific pediatrics since that date
have, therefore, not been included. Thirty-eight pages have been
added to this edition. In addition, an author's index is a feature,
thus facilitating reference work. Another feature of interest are
the captions at the top of almost every page, allowing one at a
glance to see what the page contents will be. For the man who
wants a complete review of recent pediatric progress plus the edi-
torial and vast professional experience of its two authors, here
^is a book without a peer.
Archives of Pediatrics
JANUARY. 1920
HAROLD RUCKMAN MIXSELL, A.B.. M.D.. Editor
CHARLES ALBERT LANG, M.B.. M.R.C.S.. Associate Editor
L. Emmett Holt, M.D
W. P. NORTHRUP, M.D
Augustus Caill£, M.D
Henry D. Chapin, M.D
Francis Huber, M.D
Henry Koplik, M.D
Rowland G. Freeman, M.D. .
Walter Lester Carr, M.D.
C. G. Kerley, M.D
L. E. La FfiTRA, M.D
Royal Storrs Haynes, M.D.
Oscar M. Schloss, M.D
Herbert B. Wilcox, M.D...
Charles Herrman, M.D — .
Edwin E. Graham, M.D —
J P. Crozer Griffith, M.D
J. C. Gittings, M.D
A. Graeme Mitchell, M.D.
Charles A. Fife, M.D
H. C. Carpenter, M.D
Henry F. Helmholz, M.D..
I. A. Abt, M.D
A. D. Blackader, M.D
COLLABORATORS :
..New York Fritz B. Talbot, M.D Boston
..New York Maynard Ladd, M.D Boston
..New York Charles Hunter Dunn, M.D Boston
..New York Henry I. Bowditch, M.D Boston
..New York Richard M. Smith, M.D Boston
..New York L. R. De Buys, M.D New Orleans
..New York S. S. Adams, M.D Washington
..New York B. K. Rachford, M.D Cincinnati
..New York Irving M. Snow, M.D Buflfalo
..New York Henry J. Gerstenberger, M.D. .Cleveland
..New York Borden S. Veeder, M.D St. Louis
..New York William P. Lucas, M.D... San Francisco
..New York R. Langley Porter, M.D..San Francisco
..New York E. C. Fleischner, M.D San Francisco
Philadelphia Frederick W. Schlutz, M.D.Minneapolis
Philadelphia Julius P. Sedgwick, M.D. . .Minneapolis
Philadelphia Edmund Cautley, M.D London
.Philadelphia G. A. Sutherland, M.D London
.Philadelphia T. D. Rolleston, M.D London
.Philadelphia J. W. Ballantyne, M.D Edinburgh
Chicago Tames Carmichael, M.D Edinburgh
Chicago John Thomson, M.D Edinburgh
. . .Montreal G. A. Wright, M.D Manchester
PUBLISHED MONTHLY BY E. B. TREAT & CO., 45 EAST 17TH STREET, NEW YORK.
ORIGINAL COMMUNICATIONS
SOME REMARKS ON CRANIAL SINUS THROMBOSIS
IN CHILDREN.*
By Seymour Oppenheimer, M.D., F.A.C.S.,
Associate Otologist, Mt. Sinai Hospital; Consulting Otologist, Willard Parker
Hospital, and Gouverneur Hospital, etc., etc.
New York.
In general it may be said that the symptomatology of sinus
thrombosis in children is in a measure that of the condition in
adults. It may, however, be of value to the pediatrician that
we go over the subject, for to the pediatrician usually falls the
primary observation and tentative diagnosis of the condition in
our little patients, and it is of the utmost importance that he
*Read before the Section on Pediatrics. New York Academy of Medicine, De-
cember 11, 1919. For discussion see page 53, January, 1920, Archives of Pediatrics.
65
66 Oppenheimer : Cranial Sinus Thrombosis in Children
be siifificiently acquainted with the condition to early recognize
its development, and the resulting necessity for prompt opera-
tive intervention by the otologist. The greatest problem which
confronts us is not so much in etiology or in operative technic,
as its early diagnosis. With the usual symptoms as they
appear this is often most difficult and many times impossible.
Historical: Hooper, as early as 1826, correctly recognized
both sinus phlebitis and sinus thrombosis. Other early observa-
tions recorded are those of Abercrombie, 1835; Bruce, 1840;
Virchow, 1845; and Sedillot, 1849. Bouchut, Von Dusch,
Knapp, Lapersonne, Coupland, Verneuil, Reverdin and other
writers added further observations and case reports on the sub-
ject in succeeding years. In 1893 MacEwen published his
classical work on pyogenic infectious diseases of the brain and
spinal cord.
There are 2 recognized forms of thrombosis — primary or
marasmic; and secondary, or infective, sometimes termed in-
flammatory. Marasmic thrombosis occurs much less frequently
than the infective, and is almost invariably located in the longi-
tudinal, rarely in the lateral, and still more rarely in the cav-
ernous sinus. It occurs in weakly people, prostrated by ex-
hausting diseases. Occurring most often at the 2 extremes of
life, it is met with in the young most frequently during the first
2 years of life and more especially during the first 6 months of
infancy. Exhausting diarrhea is one of its most potent causes
in children, although acute and chronic pulmonary affections
also play an important etiological part. Gowers believes that
primary sinus thrombosis is of frequent occurrence, and it is
not an uncommon cause of infantile hemiplegia. It may occur
in connection with chlorosis and anemia, the so-called autoch-
thonous sinus thrombosis. Of 82 cases of sinus thrombosis in
chlorosis, 32 were in the cerebral sinuses. The longitudinal
sinus seems to be most frequently involved in these latter cases
usually associated with venous thrombosis in other parts of the
body. In the terminal stages of malignant disease, tuberculosis
and other chronic diseases, there may gradually develop thrombi
in the sinuses and cortical veins, to which stagnatory throm-
botic processes Virchow's name has long been attached, "the
marasmic or marantic clot." It is seen at times in conditions
pf infantile atrophy, ancj sometimes occurs in the course of
Opi'Enhefmer: Cranial Sinits Thrombosis in Children 67
such acute infections as pneumonia, pertussis, diphtheria, and
nephritis. The actual cause when thrombosis occurs is a con-
dition of lowered vitality leading to feebleness of the circulation
and an altered condition of the blood. In infants, profuse diar-
rhea diminishes the quantity of blood and removes a large por-
tion of serum from the brain as well as from other parts of
the body. Consequently there is a diminished volume of the
cranial contents, shown at first by depression of the fontanelles
and subsequent overlapping of the cranial bones at their
sutures.
In this state the cerebral vessels and sinuses are apt to dilate,
causing a further retardation of the already slow flowing blood
stream, which, coupled with the enfeebled heart's action and
the inspissated blood, tends to establish thrombosis of the
sinuses. Holt considers marantic sinus thrombosis very rare
after 5 years of age. Jansen and Heine pointed out that non-
septic sinus thrombosis may occur as the result of a mechanical
compression of the sinus wall, as from a cerebral tumor, or pres-
sure from pus and detritus in a purulent mastoid cavity. Lebert
(1854) and Tonnele were among the first to recognize this con-
dition clinically.
The diagnosis of primary sinus thrombosis in children is dif-
ficult and is seldom determined during life. There are none of
the characteristic symptoms of temperature which are found in
infective thrombosis ; oftentimes the symptoms are prone to be
masked by the disease which precedes it and which is the cause
of the thrombosis. In a larger number of cases the disease is
latent in children, the symptoms few and uncertain and very
rarely is a positive diagnosis made.
Pathology: Marasmic thrombosis, though generally con-
fined to the longitudinal sinus, may extend into other sinuses,
so that the lateral, sigmoid and even the cavernous sinus and
jugular veins may become implicated in its extension. In only
comparatively few cases is the superior longitudinal sinus alone
afi^ected. In the majority of cases reported, where the throm-
bosis extended further than the longitudinal sinus, both lateral
sinuses became involved. The clots are dense, resistant, strati-
fied and non-adherent to the vein walls. They rarely occupy
the entire lumen of the vessel and tend to become organized or
68 Oppenheimer: Cranial Sinus Thrombosis in Children
absorbed, and very rarely undergo disintegration. In chronic
cases the clot becomes sufficiently tunneled to permit re-estab-
lishment of the circulation. As a result of the thrombosis there
is great congestion of the meningeal and cerebral vessels with
edema, the degree depending upon the extent and location of
the clot. The capillaries in the affected area of the cerebral
cortex burst, giving rise to innumerable minute hemorrhages,
which, along with the congestion and edema, produce cerebral
softening. In severe cases the ventricles become distended with
serous fluid and rarely the sero-sanguineous effusion passes
into the retro-ocular tissue, with a resultant exophthalmos. As
a rule the frontal lobes are least affected by this softening
process, the parietal and occipital lobes being the ones generally
involved. Meningeal hemorrhages from marasmic thrombosis
are not uncommon. Where recovery ensues, atrophy and in-
duration of the affected area are stated to be the consequence.
Symptomatology: Symptoms of marasmic sinus thrombosis,
unaccompanied by hemorrhage, are few and uncertain in the
majority of cases in which this lesion is found postmortem.
Often the disease is wholly latent. Even when symptoms are
present they are not often sufficiently characteristic to permit a
diagnosis during life. The symptoms are those of meningeal
or cortical irritation and are indistinguishable from symptoms
produced by more common conditions. In the chlorosis cases
the head symptoms have been marked as a rule.
Children affected with marasmic thrombosis are prone to
convulsions. These convulsions are usually general and are
accompanied by unconsciousness. Bouchet observes that con-
vulsions occurring at the beginning of an acute malady are not
of serious import, usually heralding one of the exanthemata or
a phlegmon; but when they occur at the end of an acute and
exhausting disease, or during a chronic illness which has greatly
reduced the little patient, then marasmic thrombosis is to be
feared. Occasionally the convulsions are unilateral, and may
even be confined to one member. Gerhardt and Petrens have
observed an inequality in the feel of the jugulars of the 2 sides
among marasmic children. Epistaxis is an occasional symptom.
Strabismus, tremors of the lower extremities, contractures and
muscular rigidity are frequent and probably due to a menin-
Oppenheimer: Cranial Sinus Thrombosis in Children 69
gitis. Thrombosis of the retinal vessels is occasionally observed.
The prognosis is bad in marasmic thrombosis and a majority
of the cases die in a few days.
In view of the impossibility of a definite diagnosis in most
cases, the treatment must be wholly symptomatic. Roborants
and stimulants are indicated, a position in bed should be assumed
which is favorable both to the arterial and venous circulations,
care taken that the clothing does not constrict the neck. The
internal administration of potassium iodide and calomel has
been recommended in the autochthonous forms, but no treat-
ment is likely to prove of any avail.
Secondary Inflammatory or Infective Sinus Thrombosis:
Secondary or infective sinus thrombosis is much more frequent
than the primary or marasmic form and follows extension of
inflammation from parts contiguous to the sinus wall. It is
the term usually applied to thrombosis which arises from in-
vasion of the sinuses by pathogenic microorganisms.
It occurs almost as frequently in children as in adults. It
generally afifects one of the dual sinuses, while marasmic throm-
bosis aflfects the single median or azygos sinuses. It is local
in origin, secondary to some inflammatory lesion of infective
character and occurs in the sinus nearest the seat of the primary
disease. Infective thrombosis is often associated in its later
stages with meningitis, and not infrequently with small cerebral
or cerebellar abscess.
In recent years a distinct advance has been made in our
knowledge of the etiology, diagnosis and treatment of the intra-
cranial complications of suppurative otitis media and investiga-
tions made have demonstrated with clarity that aside from trau-
matism, epidemic cerebrospinal meningitis and tubercular
meningitis, the majority of all cases of intracranial infections
take origin in the ear. The nasal accessory sinuses are account-
able for the smaller percentage of such infections.
The 3 chief causes of sinus thrombosis may be stated to be
sepsis, damage to the vessel wall, and stasis. In children, in-
fective sinus thrombosis may follow skull fractures, scalp
wounds, anthrax of the lip, mouth, nasal and orbital cavities,
erysipelas of the face and forehead; furunculosis of the lips,
face or neck.
70 Oppenheimer: Cranial Sinus Throml)osis in Children
But by far the most frequent cause is a suppurative middle
ear lesion. Observations demonstrate that sinus thrombosis
affects males more frequently than females ; the right lateral
sinus more often than the left. This is probably due to the
right sinus usually being larger and approximating the mastoid
cavity proper more closely. In infective sinus thrombosis, the
lateral sinus is most frequently involved. In a series of 57 fatal
cases in which ear disease caused death with cerebral lesions,
lateral sinus thrombosis existed in 22 (Pitt). Tubercular caries
of the temporal bone is often directly responsible, or the disease
may extend direct from necrosis on the posterior wall of the
tympanum. The thrombus may be small or may fill the entire
sinus and extend into the internal jugular vein. In our expe-
rience in about one-third of the cases operated the thrombus
was suppurating.
The cause of the thrombosis may be from direct infection
through the sinus wall from a perisinus abscess, or by extension
of the thrombosis and infection of the small veins from the
middle ear or mastoid, which become thrombosed through the
osteitis accompanying an acute infection. The latter mode of
infection is probably the more common and is well illustrated
in those cases where thrombosis of the jugular bulb is found
in acute suppurative otitis media, without involvement of the
mastoid (primary jugular bulb thrombosis).
A factor in the production of sinus complications is the nat-
ural feebleness of the rate of blood flow in the veins and the
tendency to localized lacunae of blood stagnation resulting from
the differences of caliber of the vein as it pursues its tortuous
course in this location. In reviewing various published reports
on the subject of the relative frequency of intracranial compli-
cations of otitic origin, about 35 per cent of these complica-
tions were in the nature of a thrombosis of the cranial sinuses.
While infective sinus thrombosis may be a less frequent com-
plication in children than in adults, a study of the statistics of
institutions treating large numbers of cases of otitic disease
shows 15 per cent occurred in children under 10 years of age.
Sinus thrombosis may develop not uncommonly as a com-
plication of a diphtheritic infection of the middle ear or of
scarlet fever, but more often from measles and influenza.
Oppenheimer: Cranial Sinus Thrombosis in Children 71
Anatomy and Pathological Anatomy: At this point it may
be of value to review, in a general way, the gross anatomy of
the brain, particularly as to its venous supply, after which the
difference between the brain anatomy of the child and of the
adult may be taken up, with reference to the question of sinus
thrombosis.
The superior cerebral veins collect the blood from the upper
portions of the cerebrum, and after anastomosing with one
Fig. 1 — Horizontal Section Showing Communication of the Lateral with the Trans-
verse and Cavernous Sinuses.
another and with the inferior cerebral veins, empty into the
superior longitudinal sinus. The inferior cerebral veins enter
the lateral, cavernous and superior petrosal sinuses. The middle
cerebral, vein after being joined by branches from the frontal
and temperosphenoidal lobes, pours its blood into the cavernous
sinus.
The sigmoid sinus is a continuation of the lateral sinus and
72 Oppeniieimer: Cranial Sinus Thrombosis in Children
is that portion which lies in the sigmoid groove. It is joined
by the inferior petrosal sinus and forms the internal jugular
vein. The sigmoid sinus receives blood from the superior
petrosal and occipital sinuses, also from the superior longitu-
dinal and straight sinuses by means of the lateral.
It is in the lateral and sigmoid sinuses, together with the
internal jugular vein, that a thrombosis is most frequently
found, when the middle ear and mastoid cells are involved,
although the other sinuses that are in communication with
Suu-LonaituJ.
Inf. Lonejitu4.
S inuk
Torculac
Uuaulaf
Suite.
Int. Jti^uloc
Fig. 2 — Sagittal Section Showing the Venous Sinuses.
them, especially the inferior and superior petrosals, are liable
to be affected.
Small veins from the mastoid cells and tympanum, also enter
the sigmoid sinus, more especially at the knee. A thrombus
formed in the sigmoid sinus may extend to the petrosals and to
the cavernous sinus as well.
There is an inconstant communication between the vessels
of the external portions of the skull and the sigmoid sinus by
means of the mastoid and posterior condylar veins. The latter
connect the sigmoid sinus with the vertebral veins and the deep
veins in the posterior part of the neck.
Oppenheimer : Cranial Sinus Thrombosis in Children 73
The lymphatics in the scalp enter the mastoid, parotid and
occipital lymphatic glands. Some of the facial lymphatics are
superficial, others deep.
The topography of the temporal bone and its landmarks vary
to a considerable extent in children from the adult temporal
bone, and it is essential to bear in mind these variations when
operating in the young, as they not only directly influence the
method of opening the mastoid but also the pathological changes
following chronic suppurative changes in the tympanic cavity.
At birth and for the first year of life, the only rudiment of
an osseous external meatus is the superficial depression situated
SPCNCt
Fig. 3 — Trans-section Showing the Relation of the Lateral Sinus to the Mastoid Cells.
in the middle of the outer and lower part of the pars squamosa
and just posterior to the root of the zygomatic process. This
depression, to which the name fossa auditoria may be appro-
priately applied, has the rudiments of the mastoid process poste-
rior to it, its surface is smoother and its substance denser. It
also contains fewer foramina for the transmission of blood ves-
sels than the surrounding bone.
At the period of birth, the portion of the bone forming the
fossa is not more than half or three-quarters of a line thick and
the membranous meatus is attached to the outer surface; the
74 Oppenheimer: Cranial Simis Thrombosis in Children
dura mater and the middle cerebral fossa to the inner surface.
Its structure is far from being compact or dense and in its sub-
stance the blood vessels from the meatus communicate with
those of the dura mater.
As the bone approaches maturity, the fossa assumes an
oblique position and forms the upper wall of the external au-
ditory meatus, while it is separated from the cavity of the middle
Fig. 4 — ^Topography of the Lateral and Sigmoid Sinuses, on the Side of the Skull.
Position Indicating Points at which Compression Plugs are to be applied,
between which the sinus wall is to be incised. (Kopetsky:
"The Surgery of the Ear.")
cerebral fossa by a dense layer of bone in which cells connect
with the tympanic cavity. In the adult, the fossa auditoria has
nearly lost its oblique direction and becomes a horizontal lamina
of bone.
While the mastoid process does not exist in the infant, it is
indicated by a small tubercle without pneumatic cells. The an-
trum lies superficially. The fissures petrosquamosal and squamoso-
Oppenheimer ; Cranial Sinus Thrombosis in Children 75
Fig. 5 — External Surface of Temporal Bone of an Infant.
Fig. 6 — Internal Surface of Temporal Bone of an Infant.
76 Oppenheimer: Cranial Sinus Thrombosis in Children
mastoideal are present. The internal auditory canal is wide
and shallow and the landmarks at the fundus of the canal are
easily discerned. The contour of the cerebral and the cerebellar
semi-circular canals are more prominent than in the adult. The
fossa subarcuata is large. Tbe sigmoid groove in children is
considerably flatter than in adults and owing to its shallowness
the lateral sinus does not project so far forward as in adults.
In adults the outer wall of the sinus on cross section is about
the form of a half circle, but in children, on the contrary, it is
shaped more like a flat arch, while the inner wall of the sinus
stretches almost straight across the sinus. In children then
the outer wall of the sinus lies considerably nearer the inner
wall than in the adult.
As with the adult, the depth of the middle cranial fossa of
course varies, but even in the child one .can always be positive
that it lies above the supra-mastoid spine. At birth, the external
wall of the epitympanic space is in the same position as occupied
by the inferior wall in the adult, the variations at this point
resulting in the changes assumed by the direction of the pars
squamosa during the developmental period. As a result of this,
the vault of the tympanic cavity is readily entered immediately
above the superior attachment of the membrana tympani, but
in making the incision through the superficial soft tissues, in
performing any postauricular operation at an early age, great
care must be taken not to make too much pressure, as the knife
may pass through the squamous suture into the cranial cavity,
as the suture is not completely closed until a later period and
simply presents a large opening in the osseous structure filled
with fibro cartilage. For the same reason care should always
be exercised even in stripping back the integument and peri-
osteum.
An infective process may extend within the temporal bone
through the smaller veins whereby the latter become involved
with septic thrombi, which gradually extend to and infect the
sinus, or the infection may extend by contiguity, directly
through the internal table to the walls of the blood-vessel, where
its further advance is characterized by sinus wall infection, and
then into the blood stream, with thrombosis resulting. Accord-
ing to Boenninghaus, thrombosis may occur from infection
located within the labyrinth. In these cases, the sinus is usually
Oppenheimer : Cranial Sinus Thrombosis in Children 77
affected below the knee, or through involvement of the superior
or inferior petrosal sinuses. In still another group of cases, in-
fection proceeds from a labyrinthine infection directly toward
the bulb through involvement of the lymph spaces of the middle
ear or through a thrombus extension from the internal auditory
vein.
From the tympanic cavity proper a thrombosis of the jugular
bulb may take place from direct infection through dehiscences
in the floor of the tympanum. In children especially, the prox-
imity of the dome of the jugular to the tympanic floor allows of
a primary thrombotic process in the jugular bulb, the infection
extending direct from the middle ear.
Many instances have been reported of primary jugular bulb
thrombosis. Boenninghaus and Korner report cases wherein
the infection entered the jugular bulb from the tympanic cavity
proper through involvement of the plexus, along the anterior
wall of the tympanic cavity.
Phillips concludes that phlebitis and thrombosis of any part
of the lateral sinus and internal jugular vein may take place as
follows: through anatomical dehiscences in the bone tissue
which covers its parietal surface, thus affording easy access to
the pathologic process ; through the direct extension into its
walls of the active purulent lesion in the bone; through involve-
ment of the smaller veins in the diseased bone, or through the
involvement of the intermediate anastomotic veins in the throm-
botic area.
With the sinus walls the seat of an inflammatory lesion and
after the process has penetrated to the inner endothelial blood-
vessel lining, a deposit of fibrin results in the lumen of the sinus
consequent upon the inflammation, the fibrin being derived from
the blood current. This deposit attaches to the vessel wall at
the site of the lesion, forming what is designated pathologically
as a "white wall thrombus."
The parietal thrombus in time enlarges with narrowing of
the lumen of the vein until finally complete occlusion may result.
The fibrin next becomes admixed with coagulated blood and
assumes the form of "red obstructive thrombus," which may
occlude the vessel's course for a variable distance. In a back-
ward direction, the thrombus may extend and involve the supe-
rior petrosal sinus, the mastoid emissary vein, the torcular
78 Oppeniieimek: Cranial Sinus Thrombosis in Children
Herophili, the longitudinal sinus and even the lateral sinus of
the opposite side ; while in the downward direction it may in-
volve the inferior petrosal and cavernous sinuses, the ophthalmic
vein, and after traversing the jugular bulb, continue throughout
the jugular vein and its tributaries.
Thrombi, both of the parietal and the obstructive types, may
be either infected or aseptic in character, the latter of more rare
occurrence by far. If the thrombus is not infected, it becomes
organized through the advent of connective tissue. On the other
hand, if it is infected, it eventually breaks down, spreading the
infection along the sinus walls to a variable extent.
Symptoms: The symptoms of lateral sinus thrombosis are
fairly constant, although in children they may be much masked
by the presence of some imderlying acute infectious diseases.
Temperature is the most important general symptom of sinus
thrombosis and young children particularly are likely to have
rises which are excessively high. A perisinus abscess may
cause a temperature of a very septic type, i. e., sudden high
rises alternating with sharp remissions ; the whole clinical pic-
ture may be such as to suggest a sinus infection, but these symp-
toms may entirely subside after the operative removal of the
diseased focus external to the sinus, i. e., a mastoiditis. The
mere presence of a high temperature in children is a less im-
portant indication for operation than in adults, but when its
presence is persistent in conjunction with an acute mastoiditis
and a pyelitis, a pneumonia or an influenza can be excluded,
operation is justified even although a blood examination fails to
show a bacteriemia. Chills are absent as a rule, although the
hands and feet are frequently found to be cold. An important
point in a case under suspicion is the taking of 2-hour tempera-
tures in order to accurately note the varying oscillations. Typ-
ical cases occasionally present themselves where the temperature
remains steadily high without much remission. In older chil-
dren, there may be headache, pains in the occipital region, and
tenderness upon palpation along the jugular vein, due to lymph
node enlargement, may be present. A diagnostic sign of im-
portance I have observed to be a unilateral enlargement of the
lymph nodes at the junction of the facial vein with the internal
jugular. The cord-like feel along the anterior border of the
Oppenheimer: Cranial Sinus Thrombosis in Children 79
sternomastoid is a symptom that I have seldom noted even in
cases where the jugular was markedly thrombosed.
Nasal hemorrhage is frequent, due to the fact that the venous
blood from the nasal passages is discharged into the superior
longitudinal sinus, and the stasis of the venous circulation in
the nose caused by obstruction of the sinus leads to hemorrhage.
From the same cause, veins passing in from the anterior fonta-
nelle to the temples and auricles may be dilated and prominent.
Drowsiness is a general accompaniment of an acute infectious
process, but the state of well being (euphoria) so frequently
seen is ofttimes very deceptive and is apt to throw one off their
guard.
Severe persistent headache may excite the suspicion of a
complicated meningitis, particularly when associated with vom-
iting, crying out in the sleep, somnolence and possible coma.
Metastasis is not uncommon. Local symptoms depend largely
upon the extent of the sinus affected. Facial cyanosis and
dilatation of the temporal and facial veins, with epistaxis, sug-
gests an involvement of the superior longitudinal sinus.
Dilatation of the cervical veins and the possible hardening
of the internal jugular vein, with or without edema behind the
mastoid process, suggest invasion of the lateral sinus. A sign
of much diagnostic significance is the presence of a postmas-
toidal edema, indicating a blocking of the mastoid emissary
vein.
A symptom which I believe I have been the first to describe
as occasionally present has been dysphagia. Upon examination
of the throat, there is found a unilateral enlargement of the
lymphoid tissue along the posterior fold of the pharynx. This
symptom, in connection with the temperature, has in its early
stages suggested a possible beginning throat infection as the
factor present, but subsequent observation has cleared up this
point. In the latter stages of the disease, edema about the orbit
and a protrusion of the eye on the affected side indicate an in-
volvement of the cavernous sinus.
It must be borne in mind these local signs cannot be relied
upon alone as a means of diagnosis, but their close association
with a more definite general symptomatology places upon them
their dependable value.
The cases presenting the greatest difficulty of diagnosis are
80 Oppenheimer: Cranial Sinus Thrombosis in Children
those where some acute infectious disease is associated with the
otitic suppuration. The temperature curve of malaria is much
akin to that of a sinus thrombosis, but in the former case a
leukopenia is present and the blood examination may disclose
the malarial parasite.
The external jugular vein on the diseased side may be less
distended than on the opposite side, since, owing to the thrombus
present in the lateral sinus the internal jugular vein is less full
than on the normal side, and the blood from the external jugular
vein can flow more easily into it. Optic neuritis is present in a
fairly large proportion of cases.
Cases of primary jugular bulb thrombosis, when occurring
in infants and young children, present typical symptoms, inas-
much as no disease of the mastoid is present and furthermore
the systemic symptoms are similar to those which accompany
pneumonia, influenza, pyelitis and affections of the gastrointes-
tinal tract. The chief symptom of thrombosis of the jugular
bulb is a sudden and rapid rise in temperature in a case of
middle ear suppuration to above 104° F., followed by an equally
precipitous decline. Thereafter the temperature curve fluctuates
after the manner of the first rise, during which time the varia-
tions in the pulse rate follow the temperature. There is usually
no distinct chill, but the hands and feet may be cold when the
temperature rises ; meanwhile during the earlier remissions the
child aippears quite normal, playing with its mates and taking
liberal nourishment. Later on, when the bacteriemia becomes
more pronounced, prostration ensues and all the symptoms of
the sepsis become apparent.
Fundus examinations may show a neuroretinitis in some
cases. Crowe of Baltimore lays some stress from the diagnostic
standpoint on being able to produce choked disc by compression
of the internal jugular vein. I have never been able to cor-
roborate this test.
In every case of mastoiditis, lateral sinus thrombosis is
always a possible complication. Its relatively high mortality,
with the absolute necessity of prompt operative intervention to
prevent a general pyemia, demands that all factors that will in
any way aid in its early recognition should receive the most
careful attention.
In establishing the diagnosis of sinus thrombosis, it is of
Oppenheimer: Cranial Sinus Thrombosis in Children 81
course essential that all other diseases which might cause a like
symptomatology should be definitely excluded. Among such
may be mentioned pneumonia, typhoid fever, acute endocard-
itis, malaria and certain cases of scarlatinal infection — their dis-
tinguishing features frequently demand the close cooperation
of the otologist and the experienced pediatrician.
In infantile hemiplegia, sinus thrombosis should be consid-
ered. In a series of 78 autopsies, reported by Starr and West-
cott in infantile hemiplegia, sinus thrombosis was found in 5.
All cases require an exhaustive consideration of the entire
symptomatology and above all taking advantage of the aid given
by blood cultural examinations.
A high temperature, continuing several days after a mastoid
operation, especially when the operative findings have disclosed
areas of necrosis of the bony covering of the lateral sinus, and
examination of the blood shows a bacteriemia. is indicative of
an infective process constituting a sinus thrombosis and demands
prompt exploration of the sigmoid sinus. An occluding throm-
bus occupying the lateral or sigmoid sinus may exist without
producing any symptoms referable to the internal jugular vein.
Blood examination furnishes reliable data in many cases.
In the early stages of thrombosis, the blood shows as a rule an
increase in the number of white cells. The increase is rarely
over 20,000. When the thrombus is infected or suppurating, a
bacteriemia may be demonstrated by blood culture, but in many
cases a clinical diagnosis may be positively made before a positive
blood culture can be obtained. Frequent reports upon the blood
examinations in these cases have proven that thrombosis may
exist without a characteristic blood picture, but a positive blood
culture is, of course, absolute evidence that the pathogenic or-
ganisms have entered the circulation and constitute an indica-
tion for immediate operation. A negative blood culture, how-
ever, does not necessarily mean that the sinus is not involved.
In studying the bacteriological flora in a large series of cases
of aural infection, which came to operation, in all the strepto-
coccus or the streptococcus mucosus was found.
In smear examinations of aural discharges, streptococcus is
probably the most frequent of the various organisms. Its dif-
- ferentiation from the pneumococcus is at times difficult, par-
82 Oppex !ii:n!KR: Cranial Sinus Thrombosis in Children
ticularly in the light of Rosenow's contention as to their trans-
mutism.
In a previous communication the conclusions reached were
that the detection of a bacteriemia should be possible in every
case of sinus thrombosis at some time during the course of the
disease, although it is possible that as the result of various
causes, such as a sterile thrombus, situated below the infected
clot, for a time at least the bacteriemia might not become evi-
dent ; or the culture may be taken before the bacteria are thrown
off into the circulation, whereas if it were taken a few hours
later the organisms would be found.
After a mastoid operation, where sinus thrombosis is sus-
pected, but where symptoms are not sufficiently definite to war-
rant opening the sinus, and a blood culture has given negative
results, it is most essential that subsequent cultures be taken.
The rule can be laid down that in the presence of streptococci
in the blood stream there is a septic focus and that further op-
erative measures are necessary.
In a case where the sigmoid sinus has been attacked but the
jugular vein has not been ligated, the persistence of a positive
blood culture is an imperative indication for ligation of the jugu-
lar vein. Should positive cultures remain after the jugular liga-
tion it would be suggestive of a bacterial infection of the endo-
cardium or a metastatic process in the lung.
In an experience dealing with approximately 150 cases of
sinus thrombosis, I have never observed an infection due to any
organism other than the streptococcus or the streptococcus mu-
cosus. This point has proven in many instances of great value
in the expression of an opinion, and shows the importance of a
culture from the pus contained in the mastoid process at the. time
of operation.
In a number of these cases, the mastoid infection was of the
pneumococcus type. After the mastoid operation, symptoms pre-
sented which were suggestive of a complicating sinus thrombosis.
Blood cultures were negative. Where operation was not advised
on the sinus in these cases, a pneumonia, erysipelas or some other
complicating condition developed which explained the symptom-
atology so much akin to that of a sinus thrombosis. One can see
therefore the diagnostic significance of a negative blood culture
in connection with a non-streptococcus type of infection.
Oppeniieimer: Cranial Sinus Thrombosis in Children 83
Prognosis: The prognosis of sinus thrombosis in children
depends upon the duration and extent of the disease and upon
the stage at which its progress is, checked by surgical interfer-
ence. The earlier the operation the lower the mortality. A
localized thrombosis of short duration, located in the sigmoid
region and therefore unaccompanied by involvement of the pet-
rosal sinuses, or the jugular bulb, when promptly operated upon,
usually results in recovery ; during the later stages after the
thrombus has invaded the tributary vessels, the torcular, the bulb
or jugular vein, the prognosis is less favorable. After metasta-
tic processes have developed in the lungs, brain, joints or heart,
the mortality is extremely high.
Treatment : The treatment of sinus thrombosis of otitic origin,
is entirely surgical, and will be touched upon only briefly in this
paper, more by way of outlining to the pediatrician the operative
procedure in a general way, rather than a detailed and technical
expose of the various steps in technic, of interest more to the aural
surgeon perhaps than to his confreres in the domain of pediatrics.
Where it has not already been done, the mastoid operation
should be performed with due regard to the differences of the
anatomy of the parts in the child as compared with that of the
adult. The sigmoid sinus should be exposed along its lateral
mastoid portion and the wall of the vessel incised, compression of
the vessel wall being made above and below the point of incision. A
wire ring curet is then passed into the lumen of the vessel through
the incision and an attempt is made to remove the clot both from
the torcular and bulbar ends. Free bleeding should be established
from both directions, after which the outer wall of the exposed
sinus should be excised and compression plugs placed above and
below to control the hemorrhage. The question as to primary
jugular ligation is an academic one and the pro and con of the
subject are hardly of interest to this audience. In general it
might be said, however, that should any difficulty be experienced
in establishing promptly a return flow from the bulbar end of the
sinus, it is advisable to cease further manipulation in this direc-
tion owing to the possibility of dislodging thrombotic material,
and promptly ligate the jugular vein in the neck. The prob-
lem of jugular ligation with or without excision of the neck vein
is one for determination by the otological surgeon. The opera-
tive procedures are attended by the cure of a great many cases
84 Oppenheimer: Cranial Sinus Thrombosis in Children
which would otherwise terminate fatally ; hence the importance
and the urgent necessity for early diagnosis, in which the pedia-
trician can co-operate to excellent advantage with the otolaryn-
gologist, to whom of necessity falls the operative treatment of
the given case.
45 East 60th Street.
I BIBLIOGRAPHY.
1. McKernon: Intracranial Complications of Acute and Chronic Middle Ear Suppura-
tion. Trans. Sect, on Laryngol. & Otol., A. M. A., 1908.
2. Blackwell: Medical 'Record, 191/.
3. Stone: Long Island Med. Jour., 1917.
4. Haeggstron>: Ilygeia, 1917.
5. McCoy: Ann. Otol., Rhinol. & Laryngol., 1917.
6. Odeneal: Ann. Otol., Rhinol. & Laryngol., 1917.
7. Lewis: Laryngoscope, 1917.
8. Ryland: Jour. Laryngol., London, 1917.
9. Oppenheimer: Ann. Otol., Rhinol. & Laryngol., 1911.
10. Oppenheimer: Archiv. Otol., Vol. 37.
11. Allport: Jour. A. M. A., April 25, 1908.
12. Bench: N. Y. Academy of Medicine, March 4, 1909.
13. Beck: 111. Medical Journal, Janury, 1915.
14. Cheatle: Surgical Anatomy of the Temporal Bone.
15. Kerrison: Diseases of the Ear.
16. Foster: Southern Med. Jour., April, 1916.
17'. Barnes: Southern Med. Jour., April, 1916.
18. Hurd: Laryngoscope, June, 1917.
19. Carter: New York Med. Jour., June 23^ 1917.
20. Todd: Diseases of the Ear.
21. Osier: Practice of Medicine, 1917.
22. Kopetzky: Surgery of the Ear.
23. Barnhill & Wales: Modern Otology.
24. Roy: Trans. A. L. R. O., 1912.
25. Holt: Diseases of Children.
26. Oppenheimer: Trans. A. L. R. O., 1903.
27. Tobey: Anns. Otol., Rhinol. & Laryngol., 1912.
28. Oppenheimer & Spencer: The Value of Laboratory Examinations in Diagnosis and
Prognosis in Otology, 1919.
29. Grossman: Medical Record, Sept. 13, 1919.
30. Day: Trans. A. L. R. O., 1903.
31. Pfingsten: Jour. Missouri State Med. Assn., June, 1915.
32. Mason: Trans. A. L. R. O., 1912.
33. Lynah: Ann. Otol., Rhinol. & Laryngol., 1912.
34. Downey: Ann. Otol., Rhinol. & Laryngol., 1912.
35. Shambaugh: Practical Medicine Series, 1918.
36. Dench: Diseases of the Ear. 1919.
37. Starr & Westcott: Diseases of Children.
38. Dunn: Pediatrics, 1917.
39. Loeb: Operative Surgery, Nose, Throat & Ear.
40. Phillips: Diseases of Ear, Nose & Throat, 1918.
41. Bacon: Manual of Otology, 1898. , ,„ ,
42. MacEwen: Pyogenic Diseases of the Brain and Spinal Cord, 1893.
43. Voss: Archiv. of Otol., 1906. _ ,^,^
44. Ballenger & Whippern: Manual of Eye, Ear, Nose & Throat, 1917.
45. Oppenheimer: Surgery of the Middle Ear and Mastoid.
SEASONAL INCIDENCE OF TETANY— A REPORT OF
47 CASES.
By Stafford McLean, M.D.,
New York.
Tetany is most commonly observed in the spring. The un-
usual number of cases seen in March and April of 1918, in the
outpatient service of the Babies' Hospital, prompted this study
with the view of finding some cause for the increase of cases in
this particular year. No definite conclusions can be drawn from
this study, but some of the data presented here may be used for
some future studies along these same lines.
fl
U.
If.
/a
%
2
5.
1.
3.
A.
Ill/
MoAfTH J4». Fe0. /U/jff. AeH. /VV^r. Uum J*", rtutr.^f- 0<.T. Nov. Dec
Fig. 1— Number of Cases per Month for Eighteen :Months. 1917-1918.
In an examination of the records of the dispensary for the
last 18 months, 47 cases of tetany are recorded — the hospital
cases were excluded as they are largely selected and the number
of admissions would have no bearing on the seasonal incidence.
Doubtless many cases, especially latent types, escaped detection
in the outpatient department. No tests were made at any time
for electrical hyper-irritability. Of these 47 cases, 12 were ad-
mitted in March, April and May, 1917, and 24 during the same
period in 1918.
The winter of 1918 was exceptionally severe, long periods of
weather below 10° F. In addition there was a serious shortage
of coal, resulting in an increased use of gas for heating among
the poorer classes. The conservation of heat led to the keeping
85
86 McLean : Seasonal Incidence of Tetany
of windows and doors tightly closed ; this resulted in a minimum
of ventilation, plus vitiated atmosphere. These periods of in-
tense cold prevented the infants and younger children from hav-
ing the customary amount of sun light and outdoor air.
Among our Italian population, particularly those who have
but recently arrived in this country, there is a dread of the cold
air of winter. Although only a small per cent of our out-
patients are Italian, of the entire number of cases, 19 or 40 per
cent occurred among this nationality. Italians of New York
are from the central and southern parts of Italy and are not
accustomed to cold weather; this accounts for their remaining
indoors so much in the winter.
Tetany is a rare disease in private practice and is infrequently
seen among the well to do. Tetany is a rare disease in our
Southern States and uncommon in California. Infants of these
localities -have the benefit of more sunlight and fresh air through-
out the year than children living in New York. Tetany is rarely
seen in the summer months in New York. In the chart illus-
trated here it will be noted that in 47 cases none were seen in
July, August, or September. Cases in the spring, as a rule,
clear up with the coming of longer days with longer periods
of out-door air and sun for the infant.
The association of rickets and tetany has always been con-
sidered a close one. Many cases of tetany are encountered which
have no evident rachitic lesions ; in these it has been assumed
that the rachitic changes were so early that they could not be
demonstrated. In only 15 cases in this study were rachitic
manifestations noted. Many of the most marked types of rickets
never show any symptoms of tetany and the most marked cases
of tetany frequently have no demonstrable rickets. There must
be other factors in the etiology as important as the rachitic
etiology.
It is to be regretted that the home conditions of these cases
were not investigated and information obtained regarding num-
ber of people per room, amount of light, whether shaft or direct,
type of heating apparatus, number of hours gas is burned and
the amount of CO2 present.
The records relating to the number of hours out of doors
each infant had per day are incomplete; this is explained by the
McLean : Seasonal Incidence of Tetany
87
fact that this information is not commonly obtained when the
history is written. In only 9 cases is there data relating to this ;
in 7 cases the infants were indoors the entire winter and in 2
all but 4 hours a week. One infant, 2 months old, was out of
doors for the first time when the visit to the dispensary was
made; this infant was breast-fed exclusively, yet had a well-
marked Chvostek's sign and laryngospasm.
The average age of the children included in this study was
10 months ; 3 of the infants were under 3 months of age ; 29 had
one or more convulsions; the majority of these 29 had had fre-
quent convulsions ; 40 had Chvostek's sign. In 22 cases the
parents had noted the presence of a crow ; in 6 cases breath
holding attacks had been observed; 16 of the cases had carpo-
pedal spasm and in one case there was carpal spasm alone.
Trousseau's sign was noted in 9 cases.
t
7.
H
3.
1.
^
.^
N\onTH>. 6- 3 3'b 4-^ ?-/a /J'/r it-H ii-%
Fig. 2 — Age Grouping of Forty-seven Cases.
Of 4t£..
Ten of the cases had been fed breast milk entirely; 8 had
had breast milk supplemented with other food. This makes a
total of 18 cases fed partially or exclusively on breast milk.
The prolonged feeding of condensed milk has a tendency' to
produce rickets. Only 6 cases of this study had been on a con-
densed milk diet ; 7 of the children were having table food when
first observed. In one of the patients, symptoms were first ob-
served following an operation for removal of adenoids and ton-
sils ; this has been frequently noted by other observers.
It is impossible to determine in a study of this limited scope
whether prolonged living in a vitiated atmosphere is the impor-
88 McLean : Seasonal Incidence of Tetany
tant etiological factor in the seasonal incidence of tetany of in-
fants or whether it is the lack of sufficient sun light. The fact
that tetany is rare in warm climates may not be due to the
amount of sunlight which the infant receives as the fact that
because of the warmth there is better ventilation of the houses.
Above the arctic circle, in Sweden and Russia, there is no sun-
light for 5 months of the year, yet I have not been able to find
any reference in the literature relating to tetany in those regions.
In this brief study it has been noted that there was an in-
crease in the number of cases of tetany seen in the dispensary
of the Babies' Hospital in the spring of 1918. This followed a
winter of unusual severity when the ventilation of dwelling
houses was necessarily bad because of the cold and a shortage
of fuel and that during the winter infants did not receive the
normal amount of outdoor air.
ly East yist Street.
Megaduodenum ; Hirschsprung's Disease (Pennsylvania
Medical Journal, Aug., 1919). W. L. Carr's patient, a girl, 6
years of age, had been constipated for five years and had vomited
for twenty-four hours before he saw her. The child was in a
condition of shock ; the skin was pale, the lips and fingers were
cyanosed and the eyes were staring. There was dyspnea with
gasping respiration. The temperature was 97.5° F. ; pulse, 120.
The abdomen was greatly distended and there was a constant
involuntary discharge of feces. The child died eleven hours after
admission. Necropsy disclosed a marked distention of the intes-
tines, which was particularly evident in the sigmoid colon, which
was bent on itself. The wall of the upper part of the rectum
and the lower part of the sigmoid colon was slightly calcified
and the lining mucous membrane was very granular. There was
hyperplasia of the mesenteric lymph nodes. A microscopic study
of the tissue from this specimen showed a complete loss of mucous
membrane, and in its place was a vascularized round cell prolifera-
tion of the submucosa. There was a corresponding hypertrophy
of the inner and outer muscular coats. — Journal A. M. A.
TETANY.
REPORT OF AN UNUSUAL CASE*
By Theodore J. Elterich, M.D.,
Professor of Pediatrics, University of Pittsburgh,
Pittsburgh.
By the term tetany is meant a spasmophilic condition, char-
acterized by prolonged contractions of the muscles of the ex-
tremities and extreme irritability of the nervous system to me-
chanical and electrical stimulation. It is closely related to other
spasmophilic conditions such as laryngismus stridulus and fre-
quent eclamptic seizures. In fact, a latent form of tetany can
usually be demonstrated in these diseases. Tetany also usually
occurs more frequently during autumn, winter and early spring
months and is rare in summer.
The underlying cause of tetany, occuring in young children,
may be safely attributed to rickets and, in older children, to a
neurotic condition. In both instances, absorption of toxins from
the alimentary' tract is probably the active cause. As in rickets,
changes in the calcium metabolism occur in this disease — more
calcium is eliminated than is ingested with the food. Calcium
absorption depends to a great extent upon the amount of fat in
the food. In the economy of the infant, one of the most impor-
tant functions of the fat is to facilitate the absorption of the
calcium salts from the intestinal tract. In rickets, there is not
only a lack of deposition of these salts, but also absorption of
those already deposited due to hyperemia, or as expressed by
Virchow, a process closely akin to inflammation. This may to
some extent explain the negative calcium balance observed in
rickets and tetany.
In older children tetany occurs in individuals of a decided
neurotic type. In all classes of cases that marked and often se-
rious gastrointestittal disturbances have either preceded or ac-
companied attacks of tetany is the experience of the writer.
The relationship between the absence or disease of the para-
thyroids and tetany in children has not been proven. It has
been shown that these alterations have occurred in children who
have shown no evidence of tetany and the disease occurs in chil-
* Read before the Pittsburgh Academy of Medicine, October 28, 1919.
89
90 Elterich : An Unusual Case of Tetany
dren with perfect parathyroid glands. The following rather un-
usual case is of more than passing interest:
Bertha M. S., 4 years old, admitted to the Pediatric Service
of the Allegheny General Hospital, August 29, 1918, with a pre-
vious diagnosis of meningitis. On admission, the general ap-
pearance of the patient was strongly suggestive of an advanced
case of this disease. Physical examination, however, failed to
corroborate the presence of a true meningeal condition. The re-
flexes were unimpaired and there was absence of Kernig and
Brudzinski signs. Lumbar puncture was also negative. The
temperature was 99° F., pulse 120, respirations 23, heart and
lungs negative. The urine contained a slight trace of albumin,
a few red and white blood cells. The patient was in a deep
stupor and could be aroused only with difficulty. Urine and
feces passed involuntarily.
The onset of her illness was somewhat sudden. About a
week previous to her admission to the hospital, she complained
of headache which was followed by a rather severe diarrhea. The
bowel movements were frequent in number, very offensive, green
in color and contained much mucus. She did not vomit. On the
third day she became somnolent but could be aroused without
difficulty.
Her previous history was good. She was of normal weight
and height at birth, was breast-fed and partly raised on malted
milk. She thrived and seemed not to have had any symptoms
suggestive of rickets. She was shy and had a highly nervous
disposition. With the exception of pneumonia, in her third year,
she had escaped all contagious and infectious diseases. The
family history as to tuberculosis, alcoholism or lues is negative.
On the day following her admission, she developed a tonic
contraction of the muscles of the upper and lower extremities
with occasional rigidity of the muscles of the back and of the
face. The hands were flexed on the wrists and the feet were
in the talipes equinus position. Any attempt to straighten the
limbs caused severe pain and produced violent tremblings of the
hands. The patient moaned constantly in her sleep and at times
seemed to suffer severe pains.
This condition persisted for several weeks. During the fourth
week she commenced to show signs of improvement and within
a few days returned to full consciousness. Her general physical
Elterich : An Unusual Case of Tetany 91
condition improved very slowly, but she finally recovered fully.
During her entire illness, the temperature remained imi-
formly at about 99° F., with the exception of a flare up to 103°
F. or 104° F. on 1 or 2 occasions, caused by the formation of
several superficial abscesses in her right thigh. The pus con-
tained staphylococci (albus).
The treatment consisted in the correction of the digestive dis-
turbance by the usual methods, dietary and eliminative, and the
administration of sedatives, bromid, chloral hydrate, codein and
belladonna. The best results were obtained from the bromid and
chloral. Tepid baths also afiforded some relief.
The diagnosis is somewhat open to criticism. In tetany the
muscles of the back and face are not usually involved nor does
the patient lose consciousness. The condition was undoubtedly
due to an intestinal toxemia and may be classified as an atypical
form of tetany.
Escherich describes a somewhat similar condition which he
calls pseudotetanus (Pfaundler and Schlossmann, Vol. IV, page
296). The clinical picture of this case corresponds to that of
pseudotetanus, except that the arms and legs were affected, and
very markedly so, which he states is absent in this condition.
The nature of this disease has never been fully explained. Esch-
erich called his cases tetany in spite of the absence of the char-
acteristic over-excitability of the muscles, but Pfaundler, who
made an exhaustive study of a new case, rejects Escherich's
view for this very reason.
Pseudotetanus begins a few days after the onset of the dis-
ease and persists for from 3 to 6 weeks, when the contractures
gradually relax.
The prognosis is good and the treatment consists in the
administration of chloral and bromid or, if necessary, injections
of morphine.
The diagnosis of tetany rests upon the presence of carpo-
pedal spasm, Chvostek and Trousseau phenomena, and the over-
excitability of the nerves to mechanical and electrical irritation.
The peculiar position of the hands flexed on the wrists and the
feet in the talipes equinus position, when once seen is a clinical
picture not easily forgotten.
The Chvostek sign consists in tapping the facial muscles over
92 Eltericii : An Umtsual Case of Tetany
the exit of the facial nerve producing twitching of the muscles
of the corresponding side of the face.
Trousseau's sign consists in the fact that pressure on the
nerve trunks in the internal bicipital groove produces the peculiar
tetanic position of the hand.
The prognosis in tetany is fairly good and the duration of
an attack may vary from a few hours to several weeks. It must
always be regarded as a grave condition. The treatment con-
sists in correcting by proper diet the digestive disturbances
which are invariably present, thorough cleansing of the ali-
mentary tract, administration of sedatives and treating the un-
derlying conditions which may be present.
As previously stated, rickets is the chief factor in the pro-
duction of tetany, in children under 3 years of age. The admin-
istration of phosphorus and cod liver oil in these cases will
usually prevent a recurrence of the attack.
In older children, the ever-present neurosis should be treated
by proper regime, diet and tonics.
In conclusion, the writer is of the opinion that tetany is
merely a symptom complex due to the absorption of toxins from
the digestive tract, the underlying causes being rickets in the
young and a neuropathic diathesis in the older children.
Care of New-Born (Northwest Medicine, Aug., 1919). E.
J. Huenekens has collected 70 cases of premature infants coming
under his personal observation ; of these 58 developed definite signs
of rickets. Of the 12 who did not develop rickets, 3 were under
observation too short a time and 4 were 2 to 3 weeks premature,
leaving only 5 definitely premature infants that did not develop
rickets. Therefore, 58 out of 63, or 92 per cent, of premature and
twin infants were found definitely rachitic. The time of occur-
rence is of great interest, because rickets usually does not begin
before the sixth month. Of 33 cases seen for the first time at or
before four months, 27, or 81 per cent, showed evidence of rickets
at that time. It is, therefore, evident that in the treatment of the
special form of rickets in premature infants the deficiency of
calcium must be made up. Based on the experimental work of
Schloss, Huenekens has been using tricalcium phosphate and cod
liver oil with very good results. — Journal A. M. A.
A MODEL PEDIATRIC SERVICE FOR THE MODERN
GENERAL HOSPITAL
By Frank Howard Richardson, M.D.,
Assistant Pediatrist and Chief of Children's Clinic, Brooklyn Hospital.
Brooklyn, N. Y.
In a recent issue of a journal devoted to the problems of his
specialty, a colleague has discussed a model organization for a
gynecological and obstetrical service, using as a model or point
of departure service already existing in one of the best of our
large general hospitals. This actual fabric of fact he has em-
broidered v^ith colors supplied by a rich imagination, and has
created what he considers an ideal service for his branch of sur-
gery.
It has seemed to the present writer that something of a similar
nature was called for in the realm of pediatrics, if this specialty
is to be taken seriously, and given a dignified status in the cosmos
of the twentieth century hospital. The usual tendency seems
to be to tag a children's ward and a children's service to the tail
end of the general medical, fill the ward with a general hodge
podge of surgical, medical, and orthopedic cases, which have
nothing in common but a relative similarity of ages, and let each
attending treat there all of his cases who happen to be under 12
years of age. Naturally, such a ward has, and can have no settled
policy and no coherent plan, except such as is carried in the head
of the actual pediatrist, and head of the ward, the head nurse.
The chief of the children's service can of course order nothing
for the patients of the other men who chance to be in the ward.
Even though the general surgeon is quite willing, as a rule, to
confess to a complete ignorance of the intricacies of infant feed-
ing, he and the nurse must battle through the alimentation of
the surgical children, until nature rallies to their aid and cures
them, in spite of faulty feeding, or they become so frankly cases
of malnutrition that he washes his hands of them, and turns them
over in desperation to the pediatric service. This procedure will
take perhaps a week, but more likely a month, too late for the best
interests of the patients, and for the peace of mind of the man who
has to try to regain the unnecessarily lost ground in feeding them.
93
94 Richardson : A Model Pediatric Service
Our feeling-, then, is decidedly to the effect that all children
in a hospital should rightly be in the Children's Service, which
is organized under one head, a pediatrist. Whether or not he
shall be considered, for administrative purposes, as under the
medical chief (just as, for instance, in the hospital which we shall
use as our text, the orthopedist and the otolaryngologist owe al-
legiance technically to the surgical chief), is a matter of minor im-
portance. The main point is, that if a medically sick child or a
well child is such a different being from an adult that he requires
the trained services of an expert in order to properly nourish and
guide him, still more is this expert knowledge and attention of
right his, when surgical risks are superimposed upon medical, or
when he is trembling on the verge of a tonsillectomy for which
his general condition at the moment may be totally unfit. In our
ideal service, then, all others treating children in the hospital
should do so under the direction of the pediatrist; who then
would not transfer his little patients to the surgeon, the ortho-
pedist, or the nose and throat man, for their respective services,
any more than he now transfers them to the radiologist or the
pathologist, when he desires an x-ray or a blood culture. To
paraphrase a remark made about the relationship that should exist
between the physician and the surgeon in this regard, we might
be permitted to^ask that the other services act in this particular
as the handmaidens of the pediatric. I remember a case in point
recently seen, in which a baby with bronchopneumonia and ery-
sipelas was having a sore over the sacrum dressed by the sur-
geons. A careful consideration of the case in the light of its
whole picture, rather than as the work of 2 departments, brought
out the fact that, in all probability, the offending organism caus-
ing all the trouble was a streptococcus which had entered via
the sacral lesion.
If authority or reference be asked for, for this conception of
the best organization for the ideal functioning of a children's
ward, we may be pardoned for indulging in a personal allusion,
and pointing to the plan of the Babies' Hospital in New York
City as a model that may well be set before any children's ward.
Perhaps no better effort could be made by any pediatric ward
than to endeavor to approximate as closely as possible to this
model. The hospitals that have done the best work, like the
Richardson : A Model Pediatric Service 95
armies that have consummated the greatest campaigns, have been
those in which there was a centering of authority and responsi-
bility in one head. The commission .form of government, while
admirable for a city democracy, is not an ideal solution of the
problem of a hospital service.
In a discussion of this sort, it is perhaps as well, before going
further, to postulate certain things as being granted by us all.
If these are not taken as axioms, then the conclusions that we
draw will not be binding. We shall assume, then, throughout
this paper, that the mission of the modern hospital is threefold :
first, comes the ministering to the sick within its doors ; second,
the instruction of the medical fraternity of the community, both
within its staff and without — the hospital that fails in this second
duty, of course, thereby confesses to its failure in the first, as we
nowadays believe; third, the duty of educating the lay portion
of the community in all matters pertaining to its health, individual
or collective. All these functions we must bear in mind, in plan-
ning our pediatric service, if we are to secure the best results.
Let us enumerate the various positions that should be com-
prised in the ideal staff, and then go on to map out their duties
and scope. We might name the following: a consulting pedia-
trist ; an active attending, or pediatrist in chief ; 2 associate pedia-
trists; 2 senior clinical assistants; and adjunct clinical assistants,
to the number justified by the size of the clinic connected with the
service.
Considering these functionaries in the order of their rank, we
find first, the permanent consulting behind the permanent chief —
permanent, that is, in the sense of having a continuous service.
The consulting should be considered not in any sense as an
emeritus, whose worth and usefulness are things of the past, but
should be available, and constantly and freely used by the chief,
for counsel as to the policy of the service, as well as for consul-
tation over individual cases. From his riper experience, he
should be a source of inspiration, as well as a rich mentor, for
the teaching part of the' work.
The permanent attending pediatrist, or chief, is the man on
whose ability and personality the success or failure of the whole
service depends. As the whole machine is dependent upon him,
and he is answerable for its performance, he should of course in-
itiate the nomination of his subordinates, who will be appointed
96 Richardson : A Model Pediatric Service
by and with the advice and consent of the board of trustees, man-
agers, or governors, who, of course, hold the official appointing
power. Their period of service should be co-terminous with
their chief's.
In addition to the duties and privileges naturally inhering in
such a position, the following special points ought to be men-
tioned. It goes without saying that a man who accepts an ap-
pointment to the headship of a service in this day and generation,
will take his appointment not as a sort of Croix de Guerre, or
benediction for work well done in the past ; but rather as a com-
mission, which invests him with the obligation to perform yeoman
service in the future. Like the head of a large going business
concern, he will keep in touch with every phase of his department,
from the diet kitchen to the O. P. D. The part of his work which
is, and of right ought to be, the most prominent in his mind, is
the making of his daily rounds, on which as many of the asso-
ciates and clinical assistants as possible should be not only invited,
but expected, to be present. One of the first things necessary,
in order to invest this function with its proper importance, is to
set, and adhere to, a fixed hour. Without this, it is of course im-
possible to give the rest of the staff the ward privileges to which
their work in the clinic entitles them. An attending, who is too
busy to keep faithfully to this appointment, except in rare emer-
gencies, is too busy to undertake the confining duties of the head-
ship of an important department in a modern hospital. It has
seemed advisable, in view of the teaching feature of our model
service, without which we have agreed that our hospital is shirk-
ing one of its prime reasons for being, to have these rounds deal
with but a selected number of cases on any one day, rather than
to feel that every case should be seen by the chief on rounds every
day. In this way, while it will not take many days for the com-
plete circuit to be made, enough time may be devoted to each case
considered to make the hour one of very real instruction to the
practitioners on the staff who are taking time out of their busy
days to attend, and who are justified in expecting the profit they
obtain from these rounds to compensate them for much of the
routine work that they devote to the clinic. The writer ventures
to say that such rounds, as given at a hospital not a thousand
miles from here, are well worth the time of any man in this city,
Richardson : A Model Pediatric Service . 97
giving, as they do, to the half dozen men who attend them, a veri-
table post-graduate course in pediatrics, which greatly sweetens
the necessarily wearisome grind that is inseparable from the main-
tenance of an outpatient department. The quizzing done by the
chief, addressed in turn to each man present, regardless of age or
rank, proves a most valuable and stimulating exercise. The 2,
3, or at most 4 cases seen during the hour are not too many to be
read up by the men the same day; and it is surprising to find
what a range of pediatric reading will be covered by such a daily
stint. Guests should be welcomed ; nothing keeps up the tone of
this function like the feeling of being under outside observation.
Such rounds may well either begin or end at the dispensary,
where there is always some material which may well be drawn
upon to point a pediatric moral or adorn a children's tale. Such
a daily visit to the clinic has several very good effects. It gives
the patients a comforting sense of the importance placed by the
hospital authorities upon this part of the work. It shows clinical
assistants, nurses, and everyone else in the dispensary building
that the hospital considers them, not as a body apart (which, un-
fortunately, is so often the case), but as a very real, vital part of
the institution. It gives the chief an idea of the sort of attendance
record the clinical assitants are making, and gives them, by the
same token, some incentive toward a faithful attendance, when
they see that this is seen and appreciated.
While we are speaking of rounds, we may logically take up
2 other matters which we have considered almost essential to the
building up of the esprit that will make possible such a service as
we have been considering. One is a weekly period, somewhat
longer than the daily rounds, which has been humorously referred
to as ''Grand Rounds." At this time, there should be a formal
medical taking of stock, when each case on the service, properly
briefed and brought down to date by the clinical assistant charged
with its conduct, is presented, and the events of the week gone
over by the whole staff in the light of any new developments that
have taken place. Assignment of special topics for preparation
outside may be made at this time.
Some services have dignified some of the points mentioned in
<he last paragraph to the extent of forming a clinical society for
their consideration. The very intimacy of the workers with each
98 Richardson : A Model Pediatric Service
other, and the possibility of verifying disputed points at the bed-
side, make such a society one of the most valuable that one can
well imagine. This proves an excellent place to try out the re-
action produced by any papers the members expect to present else-
where.
The other matter, which may either be made a part of "Grand
Rounds," or else grow out of it into a separate function, consists
in the establishment of a weekly didactic clinic, such as was de-
veloped to a high degree in pre-war days in a hospital in this city,
not connected with any teaching institution proper. To this were
invited the members of the entire hospital staff (including the
O. P. D.), as well as physicians throughout the city who had sig-
nified a desire to take advantage of the privilege. Such a dem-
onstration clinic proves a wonderful stimulus to the men of the
department that puts it on, making the working up of cases for
this definite purpose a matter of vital interest.
There should be 2 associate attendings, on continuous service,
but alternating as to their functions. Of these, one is in direct
charge of the ward work; the other is chief of the clinic. The
duties of the associate on the ward approximate those of the resi-
dent, in hospitals where there is such a functionary. His most
important duties consist in: (a) acting as attending in the absence
of his chief; and (b) seeing and treating daily all cases in the
house, with the exception of those dealt with more exhaustively
by the chief, on his didactic rounds. In addition to these func-
tions (which, it will be seen, make his position on the staff one
of great importance and responsibility, far greater than is or-
dinarily understood by the term "associate"), he should know,
and should frequently be called upon to demonstrate, that he
knows, intimately and at first hand, just what is going on in the
diet kitchen. He should be familiar with the minutiae of the
preparation of the infants' formulas, as well as with the varying
daily content of the diets for the runabouts. Calories, as applied
to hospital dietaries, should have for him none of the terrors of
the unknown. He should synthetize and coordinate the work of
the various specialists, and arrange the delicate formalities of
calling in the handmaidens of the pediatrist, — orthopedist, sur-
geon, otolaryngologist, and, quite as freely and as frequently, the
internist. He must be equipped with a knowledge of all the
bothersome minutiae about which any blundering inquirer may
Richardson : A Model Pediatric Service 99
ask, and all about which the chief should know, but probably
doesn't. He should act as a sort of ex-officio inspector-general,
to use the military name of a certain unpopular but necessary
functionary, whose business it is to know whatever is going on,
and to report back to his chief, on needed changes. He should
make it his business to drop into the ward at any and all times
of the day, and, with or without the assistance of the interne,
delve into things that will make the presentation of the cases by
the chief more valuable.
The chief of the clinic, our other associate attending, should
be, in addition to all that the name implies, a teacher of the clinical
assistants. Not only is he held responsible for the actual attend-
ance of a sufificient number of them to cover the cases, but he must
so marshal his forces that the newer men are given the instruction
so necessary to their advancement and so essential to the vital
interests of the patients, and yet so seldom vouchsafed to the
entering dispensary man. How well we know the usual formula
used in introducing a new man into a dispensary room: "Go
right ahead. Doctor, we have lots of material. Just go ahead and
treat your cases as you see fit." The chief of the clinic should
oversee the work of the new man for a time, and from time to
time, so that it may conform to the policy of the service. It is
most essential, for instance, that some uniform plan of procedure
with regard to infant feeding be understood and employed
throughout the clinic. He must so arrange the schedule of the
men that the clinic is always at least partially manned, in case
daily rounds are made during dispensary hours, as seems wisest,
in order that a second trip to the hospital in one day may not be
required of the clinical assistants, who are as a rule men in gen-
eral practise. He should see to it that each man has an oppor-
tunity, as occasion may arise from time to time, to be excused
from the routine work of the day, in order properly to work up
a dispensary case for admission to the ward, or to do some special
further outpatient treatment or test, such as lumbar puncture,
protein sensitization test, etc. Without some such provision as
this, it is quite impossible for the available diagnostic sources of
a case to be exhausted before its admission to the hospital, and thus
much valuable light may be lost, that might otherwise be brought
to bear on the case. Without such opportunity to do something
out of the ordinary occasionally, dispensary work quickly degen-
100 Richardson : A Model Pediatric Service
erates into an uninspiring- routine, which soon loses its charm to
the busy practitioner, and is endured by the serious minded, am-
bitious student of a specialty simply as an unavoidable stepping
stone to the preferment that he hopes for, inside the house. The
result of this belittling of the importance and interest of the dis-
pensary is being seen these days in a situation strikingly like that
so dreaded by the business man of yesterday, and only just
beginning to be seriously combatted by the business man of today,
namely, the unnecessary "turnover" of new employes constantly
coming in to replace dissatisfied old ones who have lost interest
in their job. This, of course, results in a constantly repeated
training, never completed because the new men in turn drop out
before they become really efficient. In the very nature of things,
not more than 2 or 3 clinical assistants can reasonably aspire to
places on the attending staff; but every one of them can demand,
and should receive, an invaluable postgraduate course in his
specialty, and those allied to it, if only some such enlightened
policy is put in force and carried out. The reflex eflfect of such a
policy upon the ward service, both as to the character of its
conduct and the cases sent in, is wonderfully stimulating. And so
the post of chief of clinic has proved to be one of the most im-
portant, as well as fascinating and exacting, on the whole staff,
in hospitals where the dispensary has at last come into its own.
At last, after skirting all round them throughout this dis-
cussion, we come to a consideration of the foundation stones of
our edifice, the clinical assistants, whom, as Lincoln once said
of the common people, the Lord must love, for he made so many
of them. They fall into 3 classes : ( 1 ) the man who plans to do
pediatric work exclusively, in time if not right away, and so
aspires to a place on the hospital staff; (2) the general practi-
tioner who wants to be able to say that he is connected with such
and such an institution, and perhaps have the privilege of using
its private rooms for his patients; (3) the physician, young or
old, who genuinely desires instruction, and who, if the scheme
outlined herein, or some other with a similar purpose, is adopted,
will get it. For it goes without saying, that the most valuable
thing about a clinical assistantship is the instruction gained — valu-
able, that is, from the point of the patient treated as well as from
that of the doctor. Not only is it a fact that that is virtually the
'nly coin with which his services can be paid, but it is equally
Richardson : A Model Pediatric Service 101
a fact that, if there be any virtue or if there be any praise in spe-
cial departments and special rooms, the mere appointing of a man
to a dispensary service does not, ipso facto, invest him with the
necessary knowledge and experience successfully to perform his
duties. It should, therefore, be evident that that hospital is fail-
ing in its duties, in both directions, which does not educate its
clinical assistants to the best of its ability (which means in the
.wards as well as in the dispensary) in the discharge of their
duties, in other words, in pediatrics.
If some such privileges are extended, certain requirements
may fairly be demanded. A reasonably faithful attendance is,
of course, taken for granted ; the popularity of such a service, as
soon as its advantages become at all widely realized, will produce
this almost automatically. Each man should be required to read
or publish something, as from the service, at least 3 times a year.
A report of a case is surely not such a difficult matter that it could
not be accomplished by any man as often as this. A piece of real
research work, alone or in partnership with some one else, ought
to be done once a year by every man on the staff ; a yearbook by
one hospital department would be an innovation, but surely not
an impossibility ! Attendance at rounds is, of course, a privilege,
providing rounds are made as interesting as we have a right to
demand that they should be made.
I venture to predict that some such plan as the one we have
mapped out will have to be adopted sooner or later, if we are to
solve the vexing problem of keeping our dispensaries efficiently
staffed. The hospital, whose clinical assistants are thus given a
continuous postgraduate course in their specialty, inside the hos-
pital and out, and are taught to present the results of the work
that they have done and the studies that they have accomplished,
will soon cease having to beg men to serve its rooms. Instead,
it will have to establish (mirabile dictu, can one imagine it?) a
dispensary staff waiting list.
A logical way to bring this paper to a close would be to dis-
cuss the dispensary in which so many of the activities referred
to above are to be carried on. But this, though perhaps the crux
of the whole situation, must be taken up in a separate paper ; space
forbids considering it here. Suffice it to say that a large, enthu-
siastic, faithful dispensary staff always means a wealth of patients,
who soon flock to the place where they get the best treatment.
102 Richardson : A Model Pediatric Service
The effect of this on the ward, if only there is the teamwork
that we have tried to develop, is self evident. Only with such a
close, organic connection between inpatient and outpatient de-
partments can the true hospital service of highest efficiency ever
be reached. The hospital service that fulfills our 3 postulates and
best serves the patient, educates the physician, and teaches the
laity, to the fullest extent of the possibilities that in it lie.
Toxic Action from Intestinal Flora (Riforma Medica,
Naples, Aug. 16, 1919). N. Pane is director of the Istituto di
Batteriologia of the University of Naples, and he here presents
comprehensive data confirming the presence in the intestines of
toxic facultative anaerobic and aerobic bacteria which by their
products may gradually in time thoroughly intoxicate the organ-
ism. This is especially liable when much meat is eaten. By modi-
fying the diet, conditions may be so changed that the toxic bac-
teria no longer find the environment favorable for their prolifera-
tion, and the production of their toxic products ceases. This is
the explanation, he continues, of the benefit from restriction to
milk in chronic intestinal and liver disease. The milk in the diet
favors the proliferation of the bacteria of acid fermentation, and
these crowd out the toxic bacteria. Milk in itself does not seem
to have any antitoxic action. He cultivated in milk some of the
toxic bacteria and their virulence seemed to be permanently in-
creased. All his patients were between 50 and 60 and all had
indican in the urine. He does not place any reliance on yoghurt
as, although this answers the purpose while the yoghurt is being
taken, yet as the lactic acid bacilli do not form part of the cus-
tomary flora of the adult intestine, they soon die out when the
yoghurt is discontinued. The acidophilus and the bifidus, on the
other hand, are encountered regularly in human stools. — Jour.
A. M. A.
SOCIETY REPORT
THE NEW YORK ACADEMY OF MEDICINE— SECTION
ON PEDIATRICS.
Stated Meeting, Held January 8, 1920.
Charle.s Hendee Smith^ M.D., in the Chair.
A CASE OF COMPLETE HEART BLOCK.
Dr. William Rosenson presented this patient, a girl ten
years of age, who first came under observation at the cardiac
clinic of the Mount Sinai Hospital 2 years ago. At that time
she had a pulse of 44, but was perfectly comfortable, her only
complaint being slight pain and distress over the precordium on
considerable exertion.
Her family history had no bearing on the condition with the
exception of the fact that she had a sister who had mitral regur-
gitation.
The patient's personal history showed that labor had occurred
at full term, was tedious and difficult, and she had been blue for
several hours after birth. She had had pneumonia, diphtheria
and whooping cough, but no chorea, acute rheumatism, or pains
in the joints. Until she was seven years of age she showed
absolutely no symptoms of heart trouble. At this time the pain
and distress over the precordium was first noticed, but there
were never any signs or symptoms of decompensation.
Physical examination revealed a definite apical impulse in the
fifth interspace somewhat outside the midclavicular line. Per-
cussion showed the right border of the heart 5 cm. to the right,
and the apex 9^ cm. to the left of the midsternal line. There
was a long sawing diastolic murmur transmitted over the pre-
cordium, best heard in the second left interspace. The pulse was
always between 40 and 50. The electrocardiograph showed a
complete heart block. The heart was enlarged both to the right
and to the left. The heart function, however, was quite normal.
There was absolutely no cyanosis, but slight dyspnea after
hopping 150 times. The blood count and urine were normal.
The fluoroscopic examination showed a typical condition which
the roentgenologist stated was characteristic of heart block.
103
104 New York Academy of Medicine — Section on Pediatrics
There was a coincident contraction of the right and left sides of
the heart. He thought the murmur was congenital on account
of its character and the history of the case. The defect, though
impossible to localize definitely, seemed to be a direct communi-
cation between the aorta and pulmonary artery, just above the
aortic valves.
Dr. Rosenson said he had been able to find only 6 cases of
congenital and 20 cases in all of heart block in childhood de-
scribed in the literature. Some of the reported cases were due
to diphtheria and rheumatism.
A CASE OF AURICULAR FIBRILLATION IN A YOUNG GIRL.
Dr. William Rosenson presented this patient, a girl 15
years of age, who gave a history of having had pneumonia twice
and frequent attacks of tonsillitis. She gave no history of rheu-
matic pains or joint involvement. Seven years ago she was in
the wards of Mount Sinai Hospital 3 times within 1 year suffer-
ing from symptoms of decompensation, dyspnea and palpitation.
During the last 5 years she had attended school regularly and
was comfortable all the time, never having been compelled to
take to her bed.
About 1 month ago she had slight pain over the precordium
and considerable dyspnea in walking up stairs and passing into
the different class rooms at school. She had an absolutely ir-
regular pulse, the rate being 120. A definite impulse could be
seen in the midclavicular line. On auscultation, a blowing sys-
tolic murmur at the apex could be detected. About 7 years ago
a note was made on her history sheet at the hospital stating that
she had a presystolic murmur. She was in bed for 10 days on
large doses of the infusion of digitalis, 2 drams every 4 hours.
She has had an irregular pulse only during the past month.
There was evidence that she had had heart disease for 10 years.
The electrocardiograph showed auricular fibrillation and the
X-ray showed the heart to be enlarged.
specimen of congenital heart malformation.
Dr. Walter Lester Carr presented this specimen. He
stated that the boy from whom it was taken was 12 years of age,
underdeveloped and poorly nourished, and both skin and mucous
membranes were markedly cyanosed. The fingers and toes were
clubbed with capillary pulsation. Venous pulsation was seen on
Nezv York Academy of Medicine — Section on Pediatrics 105
both sides of the neck. The chest was not rachitic, but there
was a flare in the costal cartilages from the 7th to the 10th ribs
on both sides. The heart showed a diffuse heaving without a
distinct apex area. Palpation gave a thrill over the entire pre-
cordium. Auscultation revealed an intense systolic murmur with
the first sound, heard with great intensity at the second left inter-
space and with diminished intensity in the back. The difficulty
was to determine the relationship of the murmurs, but finally the
diagnosis was made that there was a patent foramen and an
obstructed pulmonic valve. The heart was hypertrophied.
Changes were detected in the lungs. This was confirmed by the
X-ray, which showed the heart enlarged and the lungs infiltrated.
The child had no edema and the urine was negative. The tem-
perature was irregular owing to the lung condition. The blood
showed an increase in the red cells to 6,900,000. The child was
allowed around the ward but gradually grew worse, the tuber-
culous process in the lung increased, until he had to be kept in
bed and finally died on November 30, 1919. In showing a speci-
men of congenital heart malformation it was well to appreciate
that there might be a defect in development that gave congenital
heart disease or there might be heart disease, as endocarditis,
developing in intrauterine life. This specimen belonged to the
type of defective development. Clinically one had to consider ( 1 )
the character of the lesion, (2) the prognosis, and (3) the likeli-
hood of intercurrent disease. First, as to the character of the
lesion, when a patent foramen or an obstructed pulmonary artery
might usually be detected without difficulty, but in the malforma-
tion shown a decision as to the complete lesion was difficult.
Second, the prognosis was always bad, as the child could not de-
velop and grow since the heart was not able to carry on the
circulation. Third, pulmonary tuberculosis was likely to occur.
Drs. Cornwall and Weiss had performed the autopsy • under
the direction of Dr. Harkin of Streckler Memorial L,aboratory.
The report showed that the heart was considerably enlarged.
The myocardium was beef red in color and presented no evidence
of interstitial fibrosis. The valvular arrangements in the heart
were of a very peculiar nature. The pulmonic orifice was con-
siderably narrowed. The semilunar cusps of the valve were mis-
placed, being about an inch and a quarter above their normal
level. There were several redundant folds of intimal endothelium
106 New York Academy of Medicine — Section on Pediatrics
between the conus arteriosus of the right ventricle and the true
semilunar valves of the pulmonic. These intimal folds were
arranged in the form of pseudo valves. The left ventricle was
considerably widened and into it showed 3 sets of valves, those
from the right heart, namely, the tricuspid, and those from the
left heart, namely, the mitral and the aortic valve. The mitral
valve was posterior to the tricuspid and somewhat to the left.
This arrangement was made possible by the absence of a portion
of the intraventricular septum. The foramen ovale was widely
open. The aorta presented no anomalies. The ductus Botalli
was patent half way across. A probe could be passed only one-
half way across from the aorta to the pulmonic artery, but not
straight through. The conditions in the heart were pulmonary
stenosis; patent foramen ovale; patent intraventricular septum;
eccentric hypertrophy of the left heart, and slight concentric
hypertrophy of the right heart. The circulation then would per-
mit of a three-fold distribution of the right auricular blood,
namely: most of it would enter the left ventricle, and lesser
amounts would enter the right ventricle and left auricle. The
absence of a marked hypertrophy of the right ventricle in the
face of pulmonic obstruction was to be explained, it seemed, on
the basis of a great percentage of the blood passing in 2 directions
in addition to the normal. Incidentally it might be noted that
this might account in no small measure for the intense cyanosis
observed during life. In addition to the heart defects, the autopsy
revealed a diffuse -miliary tuberculosis and amyloidosis of the
liver, spleen and kidneys.
Discussion — Dr. William I. Reardon said there was really
nothing to be added to what Dr. Carr had said. In connection
with the left ventricle, there were 3 valves, the tricuspid, aortic
and mitral, while with the right ventricle there was only one, the
pulmonic valve, which was markedly stenosed. There were 2
patent areas in the interventricular septum. The circulatory
feature of interest was that the right ventricle received its blood
for the pulmonary circulation by an overflow from the left ven-
tricle through the patencies in the septum. There was an abor-
tive attempt at a patent ductus arteriosus Botalli, a small sac-like
depression being present in the pulmonary artery and also in the
New York Academy of Medicine — Section on Pediatrics 107
aorta, but a probe could not be passed through connecting these
up. The foramen ovale showed a small patency.
SINUS ARRHYTHMIA.
Dr. Murray H. Bass read this paper, in which he stated that
the development of the electrocardiograph had opened up a vast
field for exploration of both normal and pathological conditions
of the heart, and by means of this information they were able to
group the various cardiac irregularities in a much more scientific
manner than formerly, and had brought out the fact that cardiac
arrhythmias were really not as rare as had previously been sup-
posed. In this paper he briefly reviewed the various types of
arrhythmia which were met with in childhood, laying special
stress on the prognosis connected with each variety. These types
were: 1. Sinus arrhythmia. 2, Simple tachycardia. 3. Paroxys-
mal tachycardia. 4. Auricular fibrillation. 5. Heart block. 6.
Premature beats.
Sinus arrhythmia was by far the commonest form of juvenile
irregularity. This condition rose from changes in the vagus
impulse which resulted in the heart, as a whole, beating at dif-
ferent rates at dififerent times. Very marked varieties of sinus
arrhythmia might perhaps be considered as bordering on the
pathological, but this type of irregularity was found in practically
all children so that it was spoken of as a physiological irregu-
larity. It was very important to bear this fact in mind since
many parents had been unduly alarmed by being told that their
children were sufifering from heart disease when in reality the
condition present was only sinus arrhythmia. In diagnosing this
condition the child should be asked to take deep breaths, when the
irregularity at the pulse would be brought out more clearly.
Following this, the child should be asked to take some rapid
exercise, when the irregularity, if due to sinus arrhythmia, would
diminish or entirely disappear. As a final test, though this was
rarely necessary, atropine might be administered, following
which the irregularity would disappear owing to the blocking of
the vagus impulses. This condition needed no treatment per se,
though when present in high-strung neurotic children it should
be regarded as one of the evidences of nervousness, and the aj>-
propriate treatment of the condition instituted. Under no cir-
cumstances should exercise be forbidden on account of the heart
irregularity alone.
108 New York Academy of Medicine — Section on Pediatrics
Under the head of simple tachycardia were included all those
cases of rapid heart in which the pulse tracings or electrocardio-
gram revealed no abnormality of the heart mechanism except
increased frequency of the beat. These cases differed from
paroxysmal tachycardia in that the electrocardiogram showed the
impulse in the heart to rise at its normal site of origin, whereas
in paroxysmal tachycardia the impulse arose elsewhere. Simple
tachycardia might result from nervousness, hyperthyroidism, or
from conditions in the heart muscle itself making increased de-
mands on the circulation. It was associated with fever and cer-
tain disturbances of nutrition, such as scurvy. In rare instances
tetany might be the cause of tachycardia.
Paroxysmal tachycardia was a condition characterized by
sudden attacks of very rapid heart action in which the electro-
cardiogram showed that the impulse during the attack failed to
arise in the sinus node, but originated in some other portion of
the heart tissue. The cause of these attacks was not at all clear.
Some of the cases occurred in previously healthy children ; others
were found in children suffering from rheumatic carditis or diph-
theritic myocarditis. Contrary to the condition in adults, the
great majority of cases in children occurred in individuals free
from valvular disease. It might occur at any age, the youngest
reported case being 28 months old. The attack started very sud-
denly accompanied by an abnormal sensation in the heart region,
occasionally by vomiting and depression. It was quite remark-
able to see how comparatively comfortable these children were
even when the pulse rate lay between 2CX) and 300. In addition
to the rapid pulse there was excessively rapid pulsation at the
wrist. The duration of an attack might vary from a few hours
to several weeks. Not enough cases of tachysystole had been
carefully observed to permit one to speak with any degree of posi-
tiveness as to the prognosis. If the attacks did not occur with
great frequency and if the heart muscle did not seem much
affected, the outlook as to life was apparently good, since many
of the cases were reported in adults who had survived, though
their attacks began in childhood.
Auricular fibrillation was infrequent in childhood and its
characteristics when present in early life did not differ in any
way from those found in adults. The reason it was rare in
New York Academy of Medicine — Section on Pediatrics 109
childhood was because it almost never occurred in a heart pre-
viously healthy.
Heart block in children, contrary to the condition in adults,
was due to the acute, rather than to the chronic, cardiac diseases.
Whereas the common causes in adults were syphilis and arterio-
sclerosis, in children acute rheumatism, diphtheria and less often
pneumonia were the chief etiological factors, though it might
less commonly be due to congenital malformation. Too few
examples of heart block had been examined and followed up
for one to be able to say much in regard to their prognosis.
They undoubtedly must be looked upon as very serious cases,
and, especially when accompanied by defective cardiac develop-
ment, should call for a very guarded prognosis.
Premature beats were not a very frequent finding in child-
hood. While in adults they were of no very harmful portent,
in childhood they were often an indication of severe damage to
the heart muscle. There was considerable difference of opinion
as to the prognostic significance of extrasystoles. Personally,
he could truthfully say that he had never observed extrasystoles
in children except in cases in which he could put his finger on a
real cause for serious heart damage. Thus he had seen them
in the course of diphtheria and had seen them persist for several
years after an acute illness.
In summing up. Dr. Bass said the fact should be emphasized
that, contrary to the views entertained 5 or 10 years ago, the
cardiac arrhythmias were not confined to adult life. Moreover,
practically all the various forms of irregularity were represented
in early life. It was also of considerable interest to note that
the same clinical conditions might have an entirely different
etiology in childhood and in adult life. On the other hand, he
did not wish to convey the idea that arrhythmias were com-
monly encountered during childhood; he believed, however, that
they were of frequent enough occurrence to be of considerable
clinical importance. Now that most of the larger hospitals were
equipped with electrocardiographs, he thought that pediatricians
should make an effort to examine all cases of cardiac arrhythmia
cardiographically in order that their knowledge of this rela-
tively new and unexplored field might be rapidly increased.
Discussion — Dr. Louis Faugeres Bishop spoke of the prog-
nosis in congenital heart block. He said he had had the privi-
110 New York Academy of Medicine — Section on Pediatrics
lege of following one of these examples of heart trouble for
quite a number of years. Ihe patient was a young woman who
came to him about 10 years ago from Washington. She had
had a very slow heart from birth, and, her father being an army
surgeon, she had been kept under quite close observation. At
one time her condition underwent a sudden deterioration and
for that reason she had consulted him. At that time she had
a heart rate of about 40. The Mackenzie polygraph (since they
did not have the electrocardiograph at that time) showed evi-
dence of auricular flutter superimposed on the congenital heart
block and that explained why she was not in as good physical
condition as ordinarily. The auricular flutter subsided and she
regained her normal health. About 3 or 4 years ago she con-
sulted him again, this time to know whether she should get
married. Knowing that having decided to get married remon-
strance would be useless, he gave his consent. She had since
gone through a confinement safely and was enjoying a fair
degree of health. Though she had had this heart block from
birth, so far as he could see she was getting on well and was a
happy mother.
Dr. Herman Sciiwarz stated that he had followed up the
cases of 3 children who had presented extrasystoles. One was
a child 4 years old, whom he only saw for a few months. The
second child was 9 years old when Dr. Schwarz first saw him 4
years ago. The third was 7 years old 2 years ago. The second
case had these extrasystoles fairly constantly until a month ago.
There had never been any acute disease, and there was no eti-
ological factor obtainable. These cases were not sick and did
not show any signs of cardiac distress. It would seem that
extrasystoles associated with other heart lesions might mean a
diseased ventricular wall. Perhaps that was also the case where
there are no other lesions. However, the same care should be
taken at the start in these cases as if they were cases of straight-
forward valvular disease of the heart.
Dr. Walter Lester Carr said he wished to speak of tachy-
cardia. Recently he had seen a nervous boy who was away at
boarding school and often took more than ordinary exercise.
He had examined the boy several times and concluded that the
tachycardia was a nervous manifestation. During the Christ-
mas holidays the boy was examined by 3 physicians, one of
New York Academy of Medicine — Section on Pediatrics 111
whom thought it was wrong to allow the boy to take exercise.
An X-ray showed the heart of normal outline, and after exercise
the heart rate was regular and steady. An irregular, rapid
heart during the time of development and growth was not at
all unusual. It was unfortunate that terms were used that gave
the impression that these heart conditions were organic. Physi-
cians were responsible for insisting that rapid and irregular
hearts should be cared for as serious lesions, whereas regulated
exercise lessened the rapidity and irregular action. With refer-
ence to the rapid action of the heart seen in some children and
babies, he had such cases with acidosis. One baby was a year
old and had a pulse rate of 190 and a decided acidosis, without
organic changes.
Dr. William Rosenson said he did not think it was possible
to say anything definite in regard to the prognosis of extra-
systole. In some cases of extrasystole there was serious dam-
age to the heart, while in others there were neither symptoms
nor signs of cardiac disease. In two such cases coming under
his observation there were no signs or symptoms of heart dis-
ease and the extrasystoles disappeared from time to time; then
again they would appear. The cardiac function was good and
sometimes the systolic murmur was heard only over the pul-
monic area. In neither case could he say anything in reference
to prognosis from the extrasystole alone.
Dr. Dever S. Byard said he would like to acknowledge his
appreciation of Dr. Bass' paper, and his interest in the open
discussion which it had provoked. His own impression was,
generally speaking, that extrasystole did not necessarily express
a serious cardiac condition, although he could not assume to
have noted it very frequently in children.
He recalls recently extrasystole in 2 brothers in immediate
convalescence from severe measles. One boy was really very
ill, his measles being complicated by double otitis media and
acute endocarditis. Pie showed extrasystoles on the 12th day
following the appearance of the rash. The younger boy had
also a severe type of measles with no apparent complication.
On the 10th day following the appearance of his rash, he, too,
showed the extrasystole. The symptom in the case having
endocarditis persisted nearly 4 weeks, but disappeared in the
112 Neiv York Academy of Medicine — Section on Pediatrics
second case after 3 weeks. Both subjects had some circulatory
embarrassment in the first week. This sign was noted. Elec-
trocardiograms gave no other evidence of cardiac disease. In
the one child evidences of the endocarditis persisted nearly 3
months. In the other, after the first week, the extrasystole was
the only noted abnormality. Both boys are now absolutely free
from evidence of cardiac disease.
These probably instance cases presenting extrasystole in
toxemias, in some of which, at least, the symptom need not be
regarded as particularly unfavorable.
Dr. Robert H. Halsey called attention to several outstand-
ing facts in the history of the introduction and use of medical
instruments. First, the introduction of the clinical thermom-
eter brought out a good deal in reference to the occurrence of
temperature which had not been thought of before; but most
important, temperature was only a symptom, especially in infec-
tious diseases. When the sphygmomanometer was introduced,
trouble began in the effort to understand what high or low blood
pressure meant. Even now many fail to realize that it is only a
symptom. So, too, with the introduction of the electrocardio-
graph, there are a number of things which are not yet fully un-
derstood, and one of these is the extrasystole. One interpreta-
tion is that the extrasystole indicates an irritable state of the
heart muscle and depends upon a condition which may be tem-
porary or progressive and permanent. Other signs must be con-
sidered with the extrasystole, and thus together they may indi-
cate slight or serious changes taking place.
Dr. L. T. Le Wald said that during a discussion before the
Section on Medicine a few months ag'o, the X-ray was referred
to as one of the "older methods," like auscultation, so perhaps
he was a little out of date in speaking of the X-ray, though the
X-ray was only 25 years old. However, though the electrocar-
diograph had come largely into use in the diagnosis of heart
conditions, the X-ray evidence was still of extreme value. He
had known such a gross lesion as dextrocardia missed by electro-
cardiograph examination in the absence of X-ray examination.
He wished therefore to enter a plea in regard to the interpreta-
tion given as to the size of the heart, since a slight alteration in
the position of the patient might materially alter the diameters
<?f the heart. He had seen such gross errors with plates taken
New York Academy of Medicine — Section on Pediatrics 113
on the back of the patient, and in children who were ill that was
apt to be the case, as it was easier to take the plate that way.
Unless one realized the possibility of gross deformities in the
shape of the heart when the plate was taken on the back one
might be led into error. It was a difficult problem to establish
a standard for the normal size of the heart at dififerent ages and
particularly was that true in children. The eftect of the respira-
tory phase on the size of the heart was very marked and the dif-
ference between a plate taken in the upright and one taken in
the prone position was 10 or 15 per cent. There was also diffi-
culty at times in distinguishing between right and left side en-
largements. To obviate the possibility of error, due to these
different positions, one should put markers on the front and back
of the chest to make sure that there was no rotation at the time
of the exposure. Another very important point, especially ap-
plicable to difficult cases in which one was trying to discover
minute changes, was the advisability of making a series of shad-
ows at long distance and then averaging the results. The civil
engineer employed this method of taking averages when he was
endeavoring to make accurate calculations, and it was certainly
wise to use such a method in our work.
Dr. Charles Hendee Smith said he was interested in the
remark that mothers ought to be taught not to worry about these
irregular hearts and also felt that too few doctors realized that
these irregularities were not of serious significance. Nurses are
perhaps in greatest need of education on this subject. He said
that if a child had an irregular heart and one left stimulants
about, the nurse was sure to give them. He cited a case of that
kind in which a child with pneumonia had perhaps been given
a little too much digitalis and the pulse slowed down. During
convalescence the child was in perfectly good condition with a
physiological sinus arrhythmia, but the nurse, not understanding
this, had given all the caffeine and camphor that was available.
Premature systoles in his experience were very rare ; he re-
membered having seen only 3 or 4 cases of premature systole.
He recalled one child, otherwise normal, who from time to time
came with fairly frequent premature systoles. The other cases
that he had seen had a moderately severe heart lesion and had
all done perfectly well. It certainly is a rather rare condition in
114 Nezv York Academy of Medicine — Section on Pediatrics
children whose hearts were found damaged and decompensated.
He was surprised to hear that Dr. Bass had found it to be con-
sidered more serious in children than in adults.
Dr. Bass, in closing, said he was glad his paper had pro-
voked some discussion about extrasystole, because in looking
up the subject in the literature he had found so many different
opinions expressed. He had not seen a great many cases and
those that he had seen seemed to be following serious conditions.
In 2 cases, in which extrasystole had followed diphtheria, it had
persisted, but the children did not seem sick, though their hearts
were damaged in some way.
The statement about extrasystole being more serious in chil-
dren than in adults Dr. Bass said was quoted, the statement
having been made by Dr. Wilson in an article in the American
Journal of Diseases of Children, published 2 or 3 years ago.
From the standpoint Dr. Halsey had taken he must be correct.
These cases should be kept under observation and reported on
from time to time. Dr. Bass said he had gone through the lit-
erature and the statements made in regard to extrasystole were
very vague and misleading.
Dr. Rosenson's child was 10 years old and did not look more
than 6 and was 20 pounds below the average in weight. The
boy of 15, whose case he had reported, was the size of a child
11 years old. Most of these cases were reported as cases of
patent ventricular septum and he had thought that his case might
be explained on that basis. The condition under the X-ray was
of considerable interest. Cases of patent ventricular septum
when examined by means of the fluoroscope showed the heart
shadow to be circular in outline. The contractions of both the
right and left heart borders occurred synchronously, so that the
shadow appeared suddenly to diminish in size with each systole.
This was probably explained by the fact that there was some
rotation of the heart, resulting in the right border being formed
by the right ventricle (instead of the auricle) and the left border
of the left ventricle.
Dr. Smith asked whether in paroxysmal tachycardia any-
body had tried vagus pressure. He said he had seen one elderly
person and one adult in whom, by pressing on the transverse
process of the cervical vertebra, one could control the paroxysmal
tachycardia. _ .^
New York Academy of Medicine — Section on Pediatrics 115
Dr. Herman Schwarz said in reply to Dr. Smith's question
regarding the control of paroxysmal tachycardia by pressure on
the vagus that Dr. Koplik had observed such a case for many
months in the wards of Mt. Sinai, and that pressure on the vagus
did not cause any change in the rhythm.
FLUID INJECTIONS IN DEHYDRATED INFANTS.
Dr. Stafford McLean described experiments made during
the summer of 1918 for the purpose of securing some exact data
on the effects of the introduction of fluids in dehydrated infants.
After a series of experiments in rabbits, using 4 and 6 per cent,
sodium bicarbonate injections intraperitoneally, and also injec-
tions of 6 per cent, dextrose, they decided that similar injections
could be given to infants without causing either injury or dis-
comfort. A special chart was kept in each ward where the
fluids were administered, and in conjunction with the ordinary
ward records data relating to the immediate effects of fluids
injected were also recorded; these included weight taken before
injection and 24 hours later, and records of pulse, temperature
and respiration ^ hour before and 1 hour after treatment. Only
infants showing signs of dehydration were treated. There were
76 infants who received in all 269 injections of fluid. Of these
injections 155 were hypodermoclyses, 92 were intraperitoneal in-
jections and 22 were sinus injections. The mortality in these
76 cases was 56.5 per cent. The amount of the clyses varied
between 90 and 150 c.c, depending upon the size and condition
of the child. The following different solutions were used : 6 per
cent dextrose in normal saline, 6 per cent dextrose in distilled
water, normal saline solution, 2 per cent sodium bicarbonate with
2 per cent dextrose solution and 1 per cent dextrose with 1 per
cent sodium bicarbonate. No bad results had been noted from
the intraperitoneal injections except discomfort in a few in-
stances. An analysis of the 76 cases showed that there were 26
cases of acute intestinal intoxication, or 34.2 per cent; of all
other diseases there were 50 cases. The mortality in the intes-
tinal intoxication cases was 76.9 per cent as contrasted with 52
per cent in the other diseases. In going over the record they
had been impressed by the bad results in those infants who
received 3 or more injections as compared with those who re-
ceived less than 3. In spite of these results noted in the table
116 Neiv York Academy of Medicine — Section on Pediatrics
it was found that repeated injections did no harm. One of the
cases received as many as 13 injections. After going- into a de-
tailed analysis of the eflects of these injections on weight, tem-
perature, respiration in the different groups of children in the
series and studying the effects in infants at different ages, Dr.
McLean summarized the results as follows: Injection of fluid
into the peritoneal cavity in dehydrated infants is a simple
method of procedure and in our hands has had no undesirable
eft"ects. The size of the infant is no bar to his ability to utilize
the fluids injected. From the results of injections in very small
infants, under 3,000 grams, we are led to believe that larger
infants might utihze larger amounts than have been given the
infants in this study. Age has no bearing on an infant's ability
to utilize injected fluids. The pulse is more frequently affected
after sinus and intraperitoneal injections than after hypoder-
moclyses. The respiratory rate is more frequently affected in
peritoneal injections than in sinus and hypodermoclyses. The
temperature is more frequently elevated in sinus injections than
in intraperitoneal or hypodermoclyses. Weight gains were more
frequently noted following intraperitoneal injections than after
sinus injections or clyses. Certain infants do not show any im-
provement until they have had repeated injections of fluid. The
shorter the interval between the onset of symptoms and the be-
ginning of treatment the greater is the response.
Discussion. — Dr. Herman Schwarz said this was a very in-
teresting and important contribution to the study of water bal-
ance in infants and children. This question was gaining more
and more importance, and rightly so. Through an understand-
ing of the water balance the increased infant mortaHty might
be explained and also the occurrence of acidosis in gastrointe,,-
tinal and other diseases. It was also important in regard to the
fever itself. In the new-born infants, fever had been thought
to be due to lack of food, but the late Dr. Crandall showed that
it was due to lack of water and not lack of food. Other experi-
ments have been conducted for the purpose of observing and
studying the water balance. Meyer took 3 groups of children
and gave them a protein milk of high concentration, containing
about 1200 calories per liter. The water intake was very much
reduced. The first group lost weight; the second group held its
weight, and the third group gained for a little while. The first
New York Academy of Medicine — Section on Pediatrics 117
group, that which lost weight, also regularly showed a rising
temperature. This fever could be made to disappear by giviii;^
the children water, and they could also be made to gain merelv
by the addition of water. The nitrogen balance was positive,
but the sodium chloride balance was negative. J. O. Balcar's
experiments (Archives of Internal Medicine, Volume 24, No.
1, p. 116) also showed that if animals were given large doses of
sugar, temperature could be produced, but if large doses of water
were given in addition, the temperature could be brought down
We know that many children have increased temperature during
the summer, without anything accountable for it. These ten.
peratures may go up as high as 101° and 101.5° F. and can be
made to disappear by absolutely no other procedure than the giv-
ing of fluid. The amount of fluid excreted by a child in hot weather
is about 6 times as much as in cool weather. In sick infants,
especially those with gastrointestinal conditions, acidosis and the
like, it is important above everything- else to see that the water
balance is covered with a normal or even more than normal
amount of water, apart from the amount of calories ingested.
Dr. Smith said that those who attended the joint meeting
of the Pediatric Societies in Philadelphia would remember that
st the Children's Hospital they gave fluid by mouth in the long
intervals between feeding and they had been trying it at Bclle-
vue. The fluid was administered by using a catheter and a
funnel and was given during the long interval between feed-
ings at night. By this method one could give a good many
ounces of fluid in 24 hours. It was interesting that in the case
of 1 or 2 children who were being fed on thick gruel, because
they did not retain liquid food, the water administered in this way
stayed down, better at night. Giving water by gavage had the
advantage that it did not require sterilization of water and ap-
paratus as it did in the other complicated methods of administra-
tion, A child would often retain water given by gavage when
it could not retain it if it was given with the food.
Dr. Harold R. Mixsell called attention to one point not
emphasized. He said that at the Nursery and Child's Hospital
they had combined 2 methods of giving fluids : giving normal
sahne by the intraperitoneal route, and using 10 per cent glucose
solution intravenously. Although he had not the exact figures
at hand, he was under the impression that their mortality at the
118 New York Academy of Medicine — Section on Pediatrics
Nursery and Child's- Hospital in cases of extreme dehydration
had been decreased to at least 10 per cent lower than Dr. Mc-
Lean's figures. At any event, the results had been most grati-
fying and he felt that it should be mentioned. Dr. Marriott of
St. Louis had suggested it, and had reported equally good results.
Dr. L. T. Le Wald said that in connection with the new
method of X-ray examinations after injecting oxygen into the
peritoneal cavity for diagnostic purposes certain points in the
technic had been brought up because of the possibility of unto-
ward consequences. Dr. McLean had used such a large series
of children, injecting fluid into the peritoneal cavity, that his
experiments were very valuable as showing that this procedure
was devoid of danger. Owing to the fact that the injection of
air into the peritoneal cavity was of such great diagnostic value
a contribution that went to show that the procedure was devoid
of danger was most welcome.
Dr. McLean in closing said that in the study just reported
he had been careful to avoid conclusions.
In reply to Dr. Mixsell, Dr. McLean said that he knew the
method of Dr. Marriott, but that it had not been done at the
Babies' Hospital in connection with this work. «
Dr. Le Wald had asked if the technic was not difficult and
were one not likely to puncture the intestines. In reply Dr.
McLean stated that it was an extremely difficult matter to punc-
ture the intestine when one desired to do so. He said that he
had had no accidents. In a couple of Dr. Blackfan's cases, where
this method had been used, just prior to the infants' death, a
small hemorrhagic area had been found about the site of the
puncture and in other cases under the same conditions some
fluid had been found in the peritoneal cavity. Although this
method was used successfully in a number of cases by Blackfan,
he had stated in his article that Dr. Howland had brought the
method back from London, where he had seen it used in one
of the hospitals.
DEPARTMENT OF ABSTRACTS
Cautley^ Edmund: Duodenal Stenosis. (British Journal
of Children's Diseases, April-June, 1919, p. 65.)
Edmund Cautley reports a case of duodenal stenosis, where
the child lived for over 13 months, although the degree of stenosis
was so great that it would only admit the passage of a small probe.
A male infant, aged 12 months, was first seen on account of
attacks of fever and vomiting. He was a full term child, weigh-
ing 6 pounds at birth. Icterus neonatorum persisted for about
2 weeks. At 10 days of age he had a convulsion while nursing,
but had no subsequent attacks. He was breast fed for 5 months,
with the addition of one bottle daily of milk and water at 4 months
of age. He was then weaned, and, not being able to retain milk
and barley water or glaxo, was fed on peptonised milk for sev-
eral months and, later, on Allenbury's foods, meat juice and
Scott's emulsion. All his life he had been subject to feverish
attacks, temperature 101° F.-104° F., with vomiting and loose
green stools containing considerable mucus. These attacks had
become worse since the age of 4 months. His weight was 1 ounce
less than at the age of 5 months. On examination, the child was
wasted and weak, but could hold his head up and sit up with a
little assistance. He had no teeth, a small head (16^ inches in
circumference), a slight degree of hypotonia and was said to be
Mongolian, though the evidence thereof seemed insufficient. The
stomach was considerably dilated and gastric peristalsis was very
marked with a doubtful swelling felt in the pyloric region. The
diagnosis was suggestive of moderate pyloric stenosis, with sec-
ondary attacks of increase in the obstruction from spasm or swell-
ing of the mucous membrane — on exploration 3 days later the
pylorus was found widely dilated, and the obstruction was un-
doubtedly situated lower down, but the state of the child did not
warrant further exploration or gastro-enterostomy. During the
next 5 days he was free from vomiting and gained weight. At
the end of another week he was not so well, having vomited con-
siderable greenish fluid the previous night, and gastric peristalsis
was marked. He was treated by lavage. On the next day he
collapsed, the temperature rose to 104° F, and he died a few hours
later.
119
120 Department of Abstracts
At autopsy the stomach was found dilated and hypertrophicd ;
pylorus widely dilated, admitting the first finger. The first part
of the duodenum was dilated into a more or less spherical sac over
2 inches in diameter. The second part, for a distance of an inch,
was extremely stenosed, merely admitting the passage of a probe ;
and the duct entered about the middle of the stenosed portion.
There were no other abnormalities. C. A. Lang.
BoEHME, GusTAV F. : Fatal Case of Aspiration Pneu-
monia Caused by the Ingestion of Zinc Stearate. (Medical
Record, August 30, 1919, p. 364).
The author reports the case of a child, aged 15 months, who
swallowed at least 1 ounce of stearate of zinc powder. When first
seen by the mother, the mouth and throat were filled with the
powder, which also came from the nostrils with each respiratory
movement. The child immediately became somewhat dyspneic and
the abdomen was distended. When seen by the writer the child
was resting quietly, but with inspiratory and expiratory dyspnea.
There was marked lateral movement of the chest, the abdomen
was distended and tympanitic, and a mild degree of cyanosis was
present. Pulmonary examination revealed fine rales over the
whole chest. Temperature, 99° l\ Twelve hours later the child was
more markedly cyanosed, the respirations were dyspneic, with a
reversal of the pause and a slight expiratory grunt. The abdo-
men was less distended, having been relieved by enema and
catharsis. The rales were coarser and more bubbling in char-
acter, the left base showing some dullness and evidences of a
beginning consolidation; temperature, 99°F; pulse, 150. The
child had had a slight cold for 4 or 5 days previous to the inges-
tion of the powder, so it was presumed that it had a mild bron-
chitis, which, due to the aspiration of the zinc stearate, was con-
verted into a bronchopneumonia, with acute edema. The child
died of acute edema and cardiac distention within 36 hours of the
inhalation of the powder. The temperature just before death rose
suddenly to 102° F., and the respirations. rose to 80, were shallow
and markedly obstructed. The conclusion was that the child died
from an aspiration bronchopneumonia, due to the aspiration of
zinc stearate. C. A. Lang.
Department of Abstracts 121
Fischer, Louis: The Abuse of Catharsis and Laxatives
IN Infancy and Childhood. (Medical Record, August 16,
1919, p. 275.)
The daily administration of laxatives and correctives to in-
fants and children is a common practice amongst many mothers
and nurses. The author states that while the daily use of drugs
may be required for a short time to stimulate the secretions and
cleanse the gastrointestinal tract, it is unnecessary to continue this
practice over a period of many months. In acute febrile manifes-
tations or in toxic and septic conditions, where sluggish or pseudo-
paralytic functions exist, laxatives are indicated, and are urgently
required to eliminate stagnant residue and fermenting particles
of food and their toxins, which might be absorbed into the circu-
lation. This is especially true in intestinal intoxication, accom-
panied by fever, caused by excessive fat or protein feeding. The
pernicious habit, however, of giving a daily laxative lessens the
functional activity and weakens the intestinal mucosa. This will
in time result in a total loss of the peristaltic waves that coarse
food will produce if regularly fed. While we attain the object of
cleansing and eliminating fecal particles, we frequently interfere
with the normal process of digestion and assimilation and deprive
the system of nutrition intended for growth. He condemns the
use of warm soap-water enemas, as well as the habit of adding
correctives to the infant's milk daily. He emphasizes the impor-
tance of giving pure filtered cool water between meals, several
times daily. In older children, the mechanical stimulus in the
atonic gut can be given to food by the addition of bran to cereals
or by the use of figs, raisins, whole wheat bread, and the coarse
cereals, such as oatmeal ; also the green vegetables, such as
chopped spinach and string beans. Deficient peristalsis can be
stimulated by colon massage, gymnastics, or calisthenics. In
some instances gentle faradization, or the high-frequency current,
applied in 2-day intervals, will aid in stimulating the internal
functions and in promoting peristalsis. In subnormal nutrition,
where rachitic atonies of the intestine exists, there is no drug that
will aid nutrition and modify constipation better than cod-liver
oil. Olive oil enemas in infants are valuable, but should not be
used more frequently than every other day. The use of thyroid
extract and pituitrin he has found successful in a moderate num-
ber of cases. . C. A. Lang.
122 Department of Abstracts
Moody, Ellsworth : Recurrent Vomiting in Young
Children. (Journal of the Missouri State Medical Association,
August, 1919, p. 257.)
The author gives a short review of the literature on recurrent
vomiting in young children and describes briefly the 4 cases which
have come under his observation and have been apparently bene-
fited by preventative treatment. All 4 cases were girls between
3 and 5 years of age; all had been subject to these attacks for a
year or more, which came on without premonitory symptoms or
demonstrable cause, and occurred once every 3 or 4 weeks. All
4 children had had their tonsils removed; none showed evidence
of diseased teeth and all showed pus cells, acetone and diacetic
acid in the urine. In two of the children the vomiting was usually
followed by loose stoqls for 3 or 4 days, but without other evidence
of gastrointestinal pathology. Treatment did not seem to afifect
any of the cases during an attack; alkalies by mouth, even in
minute doses, were always vomited and the feeding of 5 per cent
glucose by rectum, in alkaline solution, did not seem to be bene-
ficial. After all cases had been seen in one or two attacks the
following procedure was outlined : Sodium bicarbonate 0.6, with
brandy 0.18 in a tablespoonful of water, were given 3 times a day
as routine. When the child showed the slightest evidence of a
possible impending attack, sodium bicarbonate 0.9 with brandy
0.3 was given every hour for 7 doses and followed by a phenol-
phthalein cathartic. Since this treatment was started, more than
3 years ago, one child has been absolutely free from the attacks ;
one has had 2 attacks and two have had 1. The parents have
decreased the dosage for all of the children so that now 2 are
receiving sodium bicarbonate 0.3 once daily and the other two
only occasionally. C. A. Lang.
Marriott, W. McKim : The Artificial Feeding of Ath-
reptic Infants. (Journal of the American Medical Association,
October 18, 1919, p. 1173.)
Marriott uses the term "athrepsia"in referring to the condition
of extreme malnutrition of infants, otherwise known as "maras-
mus," "infantile atrophy," or "decomposition." In regard to its
pathogenesis it may be considered as the end result of an insuf-
ficient intake, or of a failure to utilize food in sufficient amount
to supply the demands of the body ; in other words, a condition of
Department of Abstracts 123
virtual starvation. In this condition the volume flow of the blood
is diminished. This diminished volume flow, it has been shown, is
dependent, in part at least, on a decreased blood volume seemingly
the result of a decreased protein content of the plasma, and conse-
quent inability of the blood to maintain its water content. There
is, therefore, an atrophy of the blood as well as of the rest of the
body. The obvious remedy being food, and the intestinal tract of
these infants being weak, one is confronted with the problem of
feeding a large amount of food to an infant who is incapable of
taking care of even small amounts of ordinary food. Glucose
injected parenterally has distinct limitations and is only a tempo-
rary expedient. Transfusions and intravenous gum acacia saline
mixtures fall under the same class. Breast milk might meet the
needs of the child, but it is not always available.
It has long been a matter of common knowledge that infants,
suffering from gastrointestinal disturbances, are able to take
larger amounts of milk artificially soured by lactic acid organism
than they can of sweet milk. The author, therefore, determined
on a lactic acid milk as a basis in feeding athreptic infants on the
assumption that a certain amount of fat can be tolerated, especially
in lactic acid milk, and remembering that the 2.5 per cent of fat
in protein milk, and the fat in buttermilk is well taken care of,
he used undiluted lactic acid milk containing amounts of fat up
to the amount contained in whole milk. To this was cautiously
added carbohydrate to increase the caloric value. A non-readily
fermentable sugar was selected and corn syrup, otherwise com-
mercial glucose, a mixture of dextrin, glucose and maltose, was the
sugar of choice. This mixture was added up to 10 per cent with
little or no tendency to diarrhea. In addition, corn syrup in a 5
per cent solution was given almost ad libitum between feedings
to supply further calories.
The preparation of the mixture is as follows : whole milk is
sterilized by boiling, cooled to room temperature, inoculated with
a culture of Bulgarian bacillus or other lactic acid producing
organisms, and incubated over night. This should be a thick,
creamy, homogeneous mixture. The usual commercial corn syrup
in a 50 per cent solution is then added. Care should be taken not
to agitate the mixture sufficiently to separate the fat as butter.
This is kept in a refrigerator until used. As it is very thick, a
nipple with a large hole must be used in feeding.
124 Department of Abstracts
It is advisable to begin with a mixture of equal parts of whole
lactic acid milk and buttermilk. The buttermilk is gradually taken
away until whole lactic acid milk is used entirely. The syrup is
then added, 3 per cent as a starter, and is gradually increased
according to the infant's tolerance and the amount of food neces-
sary to cause a gain in weight, sometimes the sugar content being
as high as 15 per cent.
Forty infants were fed by the author, the majority being be-
tween 2 and 5 months of age. Eight weeks was the longest time
any of them were kept on the formula. He feels from the results
obtained, that although this type of feeding is not a panacea, yet
we have a formula which enables one to administer a considerable
amount of nourishment in an easily assimilable form to infants
needing a large amount of food but having an intolerant gastro-
intestinal tract. Harold R. Mixsell.
Guthrie, Douglas : Aural Suppuration in Early Child-
hood: Its Prevention and Treatment. (The Lancet, Septem-
ber 6, 1919.)
Because 90 per cent of the work at ear and throat clinics is
either for tonsil-adenoid disease or aural suppuration, and because
of their serious results, the author feels more attention is due
these conditions. Ill health from swallowing septic material,
enteritis, or even meningitis are not unusual complications, and
deafness is a frequent result.
Anatomically, the mastoid process is not developed in infancy
nor until the second year, but the antrum is relatively larger, well
drained and close to the surface of the skull. It lies higher in
reference to the middle ear than in the adult. The Eustachian
tube is relatively shorter, wider and more horizontal, therefore
draining better but being more open to infection than in the adult.
Eight observers at post-mortem examination found 82 per
cent of the middle ears involved, pneumococcus and streptococcus
being the organisms usually found. The commonest cause in
infancy is the ordinary cold.
The temperature may be high, or not over 100° F, at which
level it may persist for some time after subsidence of inflamma-
tion. Pain, as shown by crying, sleeplessness and boring of head
in the pillow, is frequently present, though it may not be constant
Department of Abstracts 125
and may'even be absent. Sometimes there are symptoms sug-
gesting meningitis. Generally the drum perforates in 3 or 4 days
and the ear is dry in 2 or 3 weeks.
If the seat of infection is elsewhere in the middle ear, the drum
may appear normal. Also when a child cries the drum is red.
Both of these facts make diagnosis difficult from direct examina-
tion of the ear drum alone.
Mastoiditis is not common considering the frequency of otitis
in children.
The treatment of the otitis includes the use of cocaine, carbolic
and glycerine drop and a free myringotomy under general anes-
thesia. The small clot forming over the incision should be
syringed away a moment or so after opening. Pus may not
appear at once, but a couple of days later.
Tuberculosis, as a cause of persistent aural suppuration, not
uncommon in infancy, becomes less frequent as age advances.
Thirteen out of 150 cases of chronic aural sepsis were tubercular.
In 12 the disease commenced during the first year of life, had a
painless onset, showed enlarged glands around the ear, had pro-
duced a facial paralysis in 7 cases, and a mastoid abscess with
fistula in 3. Ten of the 13 cases were bottle fed and in only 1 of
these cases was the milk boiled. It would seem, therefore, that
the infection was milk born. A very radical mastoid operation
was done in 9 cases, 6 doing well as a result, 3 dying.
Therefore, the author offers briefly the following scheme of
procedure in handling persistent aural suppuration: (1)
cleansing and antisepsis of the ear by swabbing out with peroxide
on cotton and later dropping in alcohol (only by the expert is
syringing successful and advised) ; (2) removal of adenoids, in-
cluding not only the large, firm growths, but the smaller, softer
and more generally scattered and considerably diseased lymphoid
tissue; (3) conservative operation, and (4) radical operation.
The latter is seldom indicated in children. Therefore, the con-
servative mastoid operation in cases where (1) and (2) have not
been successful in curing the condition in 2 or 3 months should
be chosen. The antrum is opened, the greater part of the pos-.
terior wall of the bony meatus is removed, the aditus cleared, a
wide meafal flap constructed and the bone cavity treated with
bipp. Therefore drainage is provided while the drum and ossicles
are left untouched. Hugh Chaplin.
126 Department of Abstracts
Spohr, C. L. : The Results of Routine Wassermann
Tests in Children. (The Ohio State Medical Journal, January,
1920, p. 21).
Using the Craig modification of the Wassermann test, speci-
mens of blood were taken from 1,840 children at the Children's
Hospital, Columbus, Ohio, with the following results : total posi-
tives, 9.39 per cent; negatives, 90.61 per cent. In only one of
the cases was the disease acquired after birth.
The author reviews the literature of the Wassermann test
in cases of hereditary syphilis as follows : Epstein at Prague, 33
per cent of 235 new born infants; Blackfan, Nickolson and White,
2 per cent of 101 patients; Holt, 6 per cent of 178 hospital chil-
dren; Children's Clinic at Prague, 5.7 per cent of 2,533 infants;
Elliot of Glasgow, 10 per cent of 130 children; Whitney, San
Francisco Hospital, 2.9 per cent of 915 children; Churchill and
Austin, Children's Alemorial Hospital, Chicago, 3.3 per cent of
695 cases. L. L. Shapiro.
Brooks, Ernest R. : Enlarged Thymus, Symptoms and
Treatment. (The Ohio State Medical Journal, January, 1920,
p. 23.)
The author makes the diagnosis of enlarged thymus, first, by
the history and usual objective symptoms of pressure upon the
upper respiratory tract ; second, by percussion, using the so-called
threshold method of percussion, third, the x-ray, which gives the
most valuable information.
Two interesting cases are presented, showing very satisfactory
results with x-ray therapy. This consists in from 3 to 6 treatments
at intervals of a week for mild cases, and full doses repeated in
3 or 4 days for urgent cases. The therapeutic test of x-ray
treatment in asthmatic cases, with no demonstrable enlargement
of the gland, is advocated with gratifying results.
L. L. Shapiro.
Mussio-Fournier, J. C. : Paraplegia from Idatid Cyst of
the Cord. (^Archives de Medecine des Enfants, No. 2, 1919.)
Boy of 12, no history whatever, no hereditary stygmata. For
3 years had been suffering intermittently from severe pain in
the upper spine, with some rigidity. These symptoms disap-
Department of Abstracts 127
peared usually after 2 weeks of rheumatic medication. Two
weeks before entering the hospital the pain had been more severe,
descending along the sciatic nerve and preventing the boy from
walking. Loss of sensibility to heat or pain was noticed along
the territory of the eighth dorsal nerve, extending in lesser degree
to that of the third and fourth sacral. All movements of the
lower limbs were possible, although in lesser degree than nor-
mally. Exaggerated reflexes. Walk resembled that of a paretic,
with great incoordination of movements.
Examination of the spine showed a painful spot at the fifth
dorsal and at the posterior quarter of the sixth right rib. X-ray
showed a process of osteitis. Normal spinal fluid, negative Was-
sermann and von Pirquet. As the patient was rapidly becoming
worse surgical means were resorted to to determine the cause of
spinal compression. During laminectomy a large number of
idatid cysts were found in the perivertebral muscles of the region
affected and also in the posterior perimeningeal space of the cord.
What appeared to be the primary source of the affection was
found in the right subpleuric region. C. D. Martinetti.
Gaing, E. : Pylorospasm Successfully Treated. (Archi-
vos Latinos Americanos de Pediatria, September, 1917.)
The case in question was a girl born at term in good state of
nutrition. Mother was able to nurse abundantly. After 19 days
vomiting began, followed by exaggerated peristalsis. Vomiting
continued incessantly in spite of changes of diet and even actual
starvation. Weight decreased rapidly. After 12 days of sick-
ness weight had decreased 1 kilogram, a pyloric tumor, con-
tactile on percussion, had appeared. Percussion caused pain.
After 26 days, feeding according to the Jbrahim formula was
commenced, giving 5 c.c. every ten minutes. There was a slight
improvement. Then as the maternal milk appeared to contain
much fat this was carefully removed. Very decided improve-
ment then set in. The quantity of milk was increased to 10 c.c.
and then to 20 c.c. After 6 weeks the baby was able to nurse
from the breast with very little vomiting. After 54 days exactly,
she was entirely normal and continued to be so. The child
was 5 years of age at the time of writing and had never had
any trouble whatsoever with her digestive apparatus.
C. D. Martinetti.
128 Department of Abstracts
Larson, W. P. : Principles of Foreign Protein Therapy.
(Minnesota Medicine, September, 1919, p. 332.)
The author states that medical men of to-day are beginning
to doubt the principle of specific therapy as numerous cases have
been reported in which a vaccine or a protein entirely foreign to
the infectious agent has improved or cured the infection. This
has been seen when a chronic infection of long standing disap-
pears sometimes completely as a result of the incidence of some
other infection such as typhoid fever, erysipelas, etc., or when
the condition of eczema disappears following the administration
of typhoid vaccine. Likewise, during the past year, favorable
results have been reported for treating chronic arthritis with
typhoid vaccine. Larson explains this by referring to Ehrlich's
theory that two antigenic stimuli are necessary to bring about
antibody prodiictions, one stimulus causing the tissue cells to
produce antibodies, and the other causing the cell to throw off
these antibodies into the blood stream — i.e., specific and exfolia-
tive stimuli. He also states that an antibody attached to a body
cell is not only valueless, but positively a liability while so at-
tached. He then proceeds on the theory that many bacteria such
as streptococci, pneumococci, etc., are imperfect antigens, not
possessing the second stimulus (exfoliative) that is necessary
to cause the antibodies to be thrown oflf into the blood stream,
and therefore, not sufficient immunity results to cause the infec-
tion to subside. This stimulus he believes was provided by the
foreign protein : typhoid vaccine, foreign serum, proteoses, etc.
By means of experiments carried on by immunizing rabbits
against sheep corpuscles, it was found that animals producing a
serum of low or mediocre antibody content, would often produce
a serum of unparalleled potency following the injection of a for-
eign protein such as typhoid vaccine or ascitic fluid. It was also
found that in animals producing a serum of high antibody titer,
this could not be augmented by injecting foreign protein. He
draws the deduction that the therapeutic effect of foreign pro-
tein in certain cases, is due to the non-specific exfoliative stimulus
which it provides, and which cause the antibodies that have re-
mained sessile, and associated with the cell which produced them
to be thrown off into the blood stream.
James Hoyt Kerley.
Archives of Pediatrics
MARCH 1920
HAROLD RUCKMAN MIXSELL, A.B.. M.D.. Editor
CHARLES ALBERT LANG, M.B., M.R.C.S., Associate Editor
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TO CONGENITAL OR PRENATAL SYPHILIS.*
By John A. Kolmer, M.D., Dr. P.H., M.Sc. (Hon).
Professor of Pathology and Bacteriology in the Graduate School of Medicine of the
University of Pennsylvania; Head of the Department of Pathology of the
Dermatological Research Laboratories of Philadelphia.
In view of the widespread distribution of syphilis and the
danger of its parental transmission it would appear that few sub-
jects are worthy of more attention and study on the part of pedia-
trists than congenital or prenatal syphilis; tlie now well known
dictum of Osier, "know syphilis in all its manifestations and rela-
tions and all other things clinical will be added unto you" has as
•Presidential address delivered before the Philadelphia Pediatric Society, January
13, 1920.
129
130 Kolmer: Immunity in Syphilis
much bearing upon this form of the disease as that acquired by
adults. At the present time there is a general awakening of the
profession to the prevalence of syphilis and its important relation
to public health, and systematic efforts are being made to facili-
tate its diagnosis and treatment; as stated in my address before
this Society last year^ pediatrists should not fail to take an inter-
ested and prominent part in this movement because of the un-
fortunate possibility and probability of the disease being transmit-
ted to offspring by a syphilitic father or mother.
That our knowledge of congenital syphilis is inadequate cannot
be denied; there are few subjects more worthy of clinical and
laboratory investigation and especially as bearing upon the mode
of transmission and the clinical signs and symptoms of the infec-
tion. It is not my purpose to enter into these phases of the dis-
cussion ; there is little in the nature of definite data on the mode of
transmission and abler hands can present the clinical features. I
am quite sure, however, that with further investigations we shall
learn to recognize that prenatal or congenital syphilis is more com-
mon than surmised and that much can be done for the improve-
ment of infant mortality by closer study of this disease.
In pondering over the matter of a suitable subject for this ad-
dress, which is one of the duties imposed upon your president, I
have thought that a review of our present knowledge of immunity
in syphilis may be of some value in this symposium ; it is important
for example, to know how much we may depend upon nature in
the cure of syphilis and how much resistance the unborn fetus may
possess to infection. These subjects are of particular importance
when we realize that very probably a large portion of syphilitics
are undiagnosed and a still larger number receive inadequate
medicinal treatment or none at all.
If the mere presence of living treponemata in the potential
father or mother, or both, means the possibility of prenatal infec-
tion of their children, then the subject of immunity becomes very
important and I may state at the outset, that all of our present in-
formation indicates that corhplete sterilizing immunity, that is,
complete cure, occurs but rarely, if at all, without specific medici-
nal aid, and that while the untreated parent may acquire some re-
sistance, he or she will probably always harbor virulent trepone-
mata capable of causing recrudescences of the disease in tissues
and organs of diminished resistance and eventually kill by degen-
Kolmer: Immunity in Syphilis 131
erative processes. Clinical opinion is generally to the effect that
while the male is infectious for only 2 to 5 years after contracting
the disease, depending upon the kind and thoroughness of treat-
ment, and that he infects his child by first infecting his mate rather
than by direct primary infection of the ovum with treponemata
carried over in his semen, the mother may continue to transmit
the disease for a longer period of time and bear syphilitic children
for years after the disappearance of her own symptoms; it is
probable, however, that further investigations will show that the
untreated and uncured syphilitic of either sex may continue to
transmit treponemata of attenuated virulence for longer periods,
the lesions and symptoms of the transmitted disease being cor-
respondingly mild and apt to escape clinical detection and particu-
larly by those physicians whose knowledge of the disease is limited
to the text book descriptions of the typical and relatively severe
forms of syphilis seen in the new born. For these reasons we
must refine our clinical perceptions and laboratory tests and de-
vote closer study to the subject of familial syphilis in all its
phases ; unfortunately the disease may manifest itself in so many
different ways and involve so many different organs that no one
physician is prepared and equipped to make the necessary study,
this being possible under best conditions only with the assistance
and cooperation of others especially prepared as specialists in the
diagnosis of disease of special organs.
Our knowledge of immunity in syphilis has been greatly
advanced since the discovery of treponema pallidum by Schaudin,
by means of animal experimentation with apes and rabbits; and
since the cultivation of this microparasite in vitro in pure culture
by Noguchi. Prior to these epoch making discoveries, opinions
were based upon clinical impressions and relatively few experi-
ments upon willing volunteers. The general results of inocula-
tion experiments has been to show that the syphilitic person or
lower animal acquires definite resistance to reinoculation soon
after the appearance of the initial lesion and at a time when the
microparasites may be regarded as having gained a wide dis-
tribution; this resistance becomes almost absolute during the
secondary or most active period of the disease, declining some-
what in the tertiary stages. With complete cure there appears
to be a gradual return to susceptibility to reinfection, a fresh
instance of this being recently recorded by Dr. Schamberg.^ Of
132 Kolmek: Immunity in Syphilis
particular importance therefore are the well established facts that
the only persons or such lower animals as apes and rabbits
possessing resistance to syphiHs are those harboring living trepo-
nemata and that this resistance rapidly disappears with the steriH-
zation of the body, indicating that antibodies, if produced at all,
do not persist in the body cells and fluids as occurs in many other
of the infectious and notably in the acute infectious diseases. As
Neisser has said, direct inoculation with syphilitic virus is the best
index of cure or persistence of the disease. He found in his
experiments with apes that immunity existed only while the ani-
mal harbored living treponemata. Susceptibility to reinfection
followed cure by specific medicinal agents.
Resistance to reinfection, however, cannot be said to be abso-
lute in any stage of the disease ; there are a sufficient number of
experiments to indicate this and of course, it is well known that
the uncured syphilitic is subject to recrudescences and new organs
and tissues may be successively attacked during the progress of
the disease. Animal experiments have shown that this immunity
in syphilis or resistance to reinfection is largely local in nature;
in monkeys and man where the microparasites are rapidly distri-
buted throughout the body, resistance becomes more general and
complete, but in rabbits, in which the lesions develop in a few
organs only, notably the testes and cornea, resistance is apparent-
ly limited to the particular organ or organs that have previously
been the seat of a lesion.
A study of the body fluids and especially blood serum and
cerebrospinal fluid of syphilitics have shown that known anti-
bodies are not developed at all or but to a slight extent. Follow-
ing the successful cultivation of the treponema by Noguchi, I
found that agglutinins were produced in rabbits by immunization
with these cultures,^ but only to a slight extent in persons suffer-
ing with syphilis ;* treponemicidal substances could not be demon-
strated in the blood at all in any stage of the disease. Subsequent
experiments by Zinsser, McBurney and Hopkins^ have shown,
however, that these agglutinins for culture pallida do not aggluti-
nate virulent pallida, thereby reducing in value any significance
that may be attached to the immunological significance of aggluti-
nins in so far as resistance to syphilis is concerned. It is highly
probable that phagocytosis of virulent treponemata likewise plays
but a minor role in resistance to infection by normal tissues al-
Kolmer: Immunity in Syphilis 133
though the resistance of syphihtic tissue to reinfection may be due
in part to local phagocytosis by the fixed tissue cells, constituting
in part the "tissue indifiference" or "anergie" of Neisser.
As is now well known, the Wassermann reaction cannot be
regarded as indicating the presence of protective antibodies, inas-
much as the reaction is biologically non-specific and due to the
presence of a secondary product of the body cells, treponemata or
both, independent of true resistance or immunity. Complement
fixation tests conducted with salt solution extracts of pure cul-
tures of treponema pallida may be accepted as indicating the
presence of pallida antibodies, but the percentage of positive re-
actions is relatively small and weak in all stages of the disease and
their significance, as an indication of immunity, further diminish-
ed by the experiments of my colleagues and myself and later
confirmed by Zinsser and his associates, showing that the positive
reactions are in part non-specific as is the Wassermann reaction,
due to the presence of lipoidal substances which may be obtained
from other microparasites as B. typhosus and B. coli. The Was-
sermann reaction is an indication of infection and to a certain
degree of the severity of the infection, but it is not an expression
of immunity. While biologically non-specific, its practical diag-
nostic value remains high and scarcely to be over-estimated, be-
cause the peculiar changes in the serum and spinal fluid responsi-
ble for the reaction appears in so few other diseases despite the
fact that a review of the early literature leaves one with the im-
pression that it may occur in all the diseases to which human flesh
is heir.
The luetin anaphylactic skin test is likewise a reaction of in-
fection rather than of immunity. My own studies with this and
similar reactions^ have indicated quite clearly that the positive re-
action is not to be accepted as an indication of immunity ; in this
connection, I may state that subsequent studies have shown that
anaphylactic skin reactions, including the tuberculin reaction, are
produced only in the presence of living infection and that their
severity is to a certain degree a measure of the acuteness and
extent of the particular infection under study. While Noguchi
believes that a positive luetin reaction may occur after the cure
of syphilis due to the persistence of antibodies after complete
sterilization, it is highly probable that a persistently positive skin
reaction is like the persistently positive Wassermann reaction an
134 Kolmer: Immunity in Syphilis
indication of incomplete cure, even though the patient is clinically
free of the disease.
All studies indicate, therefore, that unfortunately persons pos-
sess no natural immunity to syphilis ; when such appears to be the
case, it is highly probable that the immunity is due to the fact
that they harbor living treponemata; apparent exceptions to this
rule, as when one man contracts the disease from a woman while
another escapes even though exposed by intercourse either imme-
diately before or after, are most probably to be explained on the
basis of injury to the epithelium, the former having an abrasion
or portal of entry for the virus and the latter not. Even when
infection occurs, the resulting immunity is but of minor degree,
probably sufficient to protect the majority of persons against re-
infection but not enough to protect themselves against extension
of their own infection to new tissues or organs in their own
body ; the antibodies in cells and body fluids are so few as to
largely escape detection and rapidly prove ineffective for protec-
tion after complete cure. In other words, the only persons ap-
parently immune to inoculation with syphilis are those who are
actually syphilitic, although their infection may be dormant and
escape clinical detection, but frequently discovered by such im-
munological tests as the Wassermann and luetin reactions.
It is now pertinent to inquire what relation these facts have
to the subject under discussion, namely, congenital or, what I pre-
fer to designate as prenatal syphilis, when referring to infections
occurring in utero.
In the first place, it appears quite certain that the great major-
ity of syphilitics, and particularly among the white race, have no
natural means of curing themselves ; that while the body cells in
a local part or as a whole in general syphilis, may become re-
sistant to reinfection as long as living treponemata persist in the
body, the actual degree of curative immunity is relatively slight
and scarcely more than may bring about a disappearance of
obvious lesions and hold in check the disease for a longer or
shorter time. This means that every untreated or inadequately
treated syphilitic of either sex and particularly the woman of
child bearing age, is potentially capable of transmitting the dis-
ease and the number of such persons must be appallingly large.
In the second place, it would appear quite certain that the
fetus possesses no natural resistance to infection with treponema
Kolmer: Immunity in Syphilis 135
pallidum in so far as its own tissues are concerned and that it
may be infected through the mother at any time from conception
to late in pregnancy. Fournier taught that if the mother con-
tracted syphilis after the sixth month of pregnancy, the child may
escape but there are now authentic instances on record of later in-
fections ; the escape of the child in the last month or two of
pregnancy, however, is not to be ascribed to natural immunity but
rather to the fact that sufficient generalization of the infection of
the mother has not taken place with the passage of treponemata
from her circulation to the tissues of the child.
The interpretation of the law of the celebrated Irish surgeon,
Abraham Colles, announced in 1837 and independently by
Baumes in 1840, is now readily understood ; according to this so-
called law the apparently healthy mother of a syphilitic child may
suckle her offspring without danger of contracting syphilis,
whereas a healthy wet-nurse may become infected and usually
with the production of a chancre on the nipple. Since the mother
appeared healthy it was naturally surmised that she had been im-
munized to syphilis as the result of carrying in her uterus a
syphilitic child ; it is now known, however^ that the blood sera of a
large percentage of these mothers yield positive Wassermann re-
actions and according to Keyes, the majority develop tertiary
syphilis in later years. These facts indicate that there is very
probably a sufficient degree of true immunity produced to keep
the infection of the mother in a latent or dormant condition but
not the high immunity supposed to exist by Colles and universal-
ly believed until a few years ago, the resistance of the mother to
reinoculation by her child being due rather to a state of "anergic"
or local resistance of the tissue cells as a result of the presence
of living treponemata in her body.
Likewise, the so-called law of Guiseppe Profeta, promulgated
in 1865, has undergone a similar revision; according to this law
an apparent healthy child, born of a syphilitic mother, may be
nursed by its mother or a syphilitic wet-nurse with impunity,
whereas another child may be infected with syphilis by either
woman. This so-called law was based upon the assumption that
the child was immunized in utero against syphilis by its syphilitic
mother, and this may be true to the limited extent of being able
to keep virulent treponemata in a dormant state, but the real
resistance of the child to infection is probably due to the presence
136 Kolmer: Immunity in Syphilis
in its little body of living treponemata and these children are
especially deserving of close clinical and serological study for the
evidences of latent syphilis.
Therefore, the majority at least of apparent healthy mothers
of syphilitic children, and the apparent healthy children of syphili-
tic mothers may be regarded as infected with syphilis and espe-
cially so if both have been exposed to inoculation and have es-
caped, which is probably the best evidence of local tissue resist-
ance due to latent syphilis ; certainly all attempts to confer im-
munity in syphilis by either active immunization with vaccines of
treponemata or by passive immunization with the injection of
blood serum from syphilitics, may be said to have failed because
free antibodies in the blood are not produced in syphilis and cer-
tain other protozoan infections to anything near the same extent
as in the majority of bacterial infections. In other words, there
is no evidence to support the original beliefs of Colles and Profeta
that antibodies against syphilis are produced by the cells of a
syphilitic mother and passively transferred to her child or that
these are produced by a syphilitic child and passively transferred
to its mother.
As part of the present day propaganda for the wider recogni-
tion of syphilis and its adequate treatment, I would urge upon
pediatrists the closer clinical and immunological study of all chil-
dren born of syphilitic parents, even if the only evidence of
syphilis in the latter is a positive blood Wassermann ; likewise
the children born of a marriage in which one or both of the par-
ents are known to have had syphilis but pronounced cured or safe
on the basis of treatment, should receive special study. As pre-
viously stated, these clinical studies may require the services of
several specialists working in cooperation because syphilis may
manifest itself in so many ways and attack practically every tissue
and organ of the body. It would also appear advisable to regard
every child of syphilitic parentage as infected and administer an-
tisyphilitic treatment even though it appears healthy and gives a
negative Wassermann reaction ; the same practice should hold for
the apparently healthy mothers of syphilitic children. The adop-
tion of these rules may mean that sometimes treatment may be
given unnecessarily to both mothers and children because there is
much clinical opinion to support the view that syphilitic parents
may not transmit the disease, but our knowledge of the transmis-
Kolmer: Immunity in Syphilis 137
sion of syphilis is woefully incomplete and I personally believe it
safer practice to regard the possibility of transmission always
present as long as either or both of the parents are uncured and
especially so, since the amount of investigation upon congenital
or prenatal and familial syphilis is comparatively small and its
clinical detection apt to escape the majority of physicians ; further
than this by reason of the latency of these infections there may
not be either clinical or immunological evidences of the disease at
a given period which constitutes another argument in favor of
the routine treatment of all children of syphilitic parents and all
apparently healthy mothers of syphilitic children, if the physician
regards as good practice the treatment of latent syphilis.
In both classes of patients the provocative Wassermann test
may prove of value in aiding diagnosis, but since the Wassermann
test is not yet sufficiently delicate, too much weight must not be
placed upon a negative result. It is among this class of persons
and especially children with latent congenital syphilis, that I have
found the luetin test of considerable value and when undoubtedly
positive, it may be accepted as evidence of syphilis even in the
absence of definite symptoms and with a negative complement
fixation test.
In conclusion, I beg once again to express the same hopes
voiced in my address before this Society last year, namely, that
the interests of individual pediatrists and of local and national
societies concerned in the welfare of children, will be aroused and
stimulated to more intensive study of congenital or prenatal
syphilis, as part of the nation wide program to reduce the incid-
ence and mortality of syphilis in the interests of public health and
welfare. At least clinics devoted to the prenatal care of women
and children can do much if organized upon a cooperative plan,
designed to give the subject of prenatal and congenital syphilis the
intense clinical and laborator)^ study that the subject deserves in
view of the widespread dissemination of the disease, the frequency
of inadequate treatment and eminent possibilities of transmission
to the unborn.
BIBLIOGRAPHY
1. Kolmer, John A.: Prenatal syphilis with a plea for its study and prevention.
Amer. Jour. Dis. Child (in jjress).
2. Schamberg, J. F. : A second attack of syphilis two years after the first. Jour.
Amer. ^Ied. Assoc, 1919, 73, 826.
138 Kolmer: Immunity in Syphilis
Kolmer, J. A.: Concerning agglutinins for treponema pallidvtm. Jour. Exp. Med.,
1913, 18, 18.
Kolmer, J. A., Broadwell, S., and Matsunami, T. : Agglutination of treponema
pallidum in human syphilis. Jour. Exper. Med., 1916, 24, 333.
Zinsser, H., Hopkins, J. G., and McBurney, M.: The Difference in behavior in
human serum between cultivated non-virulent treponema pallidum and virulent
treponemata from lesions. Jour. Exper. Med., 1916, 18, 341.
Kolmer, J. A., Williams, W. W., and Laubaugh, E. E.: A study of complement
fixation in syphilis vifith treponema antigens. Jour. Med. Research, 1913, 28, 345.
Kolmer, J. A.: The mechanism and clinical significance of anaphylactic and pseudo-
anaphylactic skin reactions. Johns Hopkins Hosp. Bull., 1917, 28, No. 315.
Rapid Diagnosis of Diphtheria Bacilli (Presse Medicale,
Paris, Sept. 11, 1919). Debre and Letulle expatiate on the dif-
ferential importance of Babes' polar granules, shown up by double
staining, in true diphtheria bacilli. Their two years of experience
with this method of differentiation has confirmed its precision and
reliability. The pseudodiphtheria bacilli never show these granu-
lations at the poles when stained by the technic described, which
is a modification of Neisser's first method. The specimen is incu-
bated at 35 C. for twenty hours and each loop of the culture is
spread on two slides. One slide is treated with the Gram, the
other after fixation by heat is covered with a solution made by dis-
solving 1 gm. of methylene blue in 20 c.c. of 95 per cent alcohol,
and adding 950 c.c. of distilled water and 50 c.c. of glacial acetic
acid. The smear covered with this solution is heated until it
begins to steam. It is then heated a second time, and is then left
in contact for five minutes. It is then rinsed rapidly with distilled
water and then is covered with the second stain for ten or twelve
seconds and rinsed quickly in distilled water. This second solu-
tion is made by dissolving 0.50 gm. vesuvine in 250 c.c. of boiling
distilled water, filtering while still boiling. The granules clustered
at the poles of the bacilli, or only in some of them, show up a black
oval, and larger than the body of the bacillus. In their 800 tests
they never found these polar granulated bacilli except with true
diphtheria and they always found them then. They warn that one
other bacillus may present these granulations. Bacillus cutis-com-
mune. But they never found this in the throat in any of their
tests. It differs from the diphtheria bacillus further in attacking
saccharose. In case of diphtheric lesions elsewhere than in the
throat, it might be advisable to test a loop on a sweetened litmus
culture medium to exclude this bacillus. — Journal A. M. A.
THE PROBLEM OF THE PREMATURE INFANT.*
By John F. Sinclair, M.D.
Pediatrist to the Babies Hospital
Philadelphia
The premature infant presents certain problems which must
be met promptly and with minute attention to detail. Indeed,
success in treatment depends largely on the care and treatment
which the infant receives from the moment of its birth and the
scrupulous and exact carrying out of every detail.
The first problem which presents itself is the maintenance of
the body heat. There must be no chilling of the infant at birth.
The baby should be immediately wrapped at birth in a previously
warmed flannel blanket. It should then be removed to a hot room
(80" to 85° F.) where it is cleaned and anointed with warmed
olive oil. This process should be done as rapidly as possible and
the infant should be wrapped in the warmed premature blanket
and placed in the premature crib.
The premature blanket is made of 2 layers of canton flannel
having an intervening layer of non-absorbent cotton. The blanket
has a hood of the same material which covers the head. Only the
face and buttocks are left uncovered. No diaper is used but a
pad of absorbent cotton is placed under the buttocks. This may
be changed when necessary without disturbing the baby.
The premature crib consists of a 24-inch clothes basket padded
at the bottom with a layer of non-absorbent cotton to the depth of
8 inches. Over the cotton is fitted a sheet of oil-cloth and the
edges are stitched to the basket. On the oil-cloth a small flannel
blanket doubled on itself is laid, with a pad of absorbent cotton
so placed on the blanket as to serve as the napkin on which the
buttocks are placed. The sides of the basket are lined with pads
or blankets. Half a dozen citrate of magnesia bottles, with wire
and rubber corks, filled with water at 110" F. and covered with
flannel are hung on the inside of the basket. The infant wrapped
in the premature blanket is placed in the basket and along side of
it is placed a thermometer. The ordinary bath thermometer pro-
tected by a wooden frame is very suitable for this purpose. A
small blanket covers the lower two-thirds of the basket. A rub-
•Read at the meeting of the Philadelphia Pediatric Society held December 9, 1919.
139
140 Sinclair: The Problem of the Premature Infant
ber sheet covers this at night or when the temperature of the
room is lowered.
The thermometer in the basket should be kept at as even a
temperature as possible for varying temperatures are prejudicial
to the good of the infant. A temperature in the basket of 80° F.
is sufficient for many babies, if the moisture in the air of the
room is between 60 and 70 per cent. However, many infants
require a higher basket temperature, i.e., a temperature of
85° F. and even of 90° F. If there is not sufficient moisture in
the air of the room, the premature infant's lips and mouth become
very dry and the appetite and digestion are disturbed. It is to
be remembered in respect to the temperature, as in all the details
of the management of the premature infant, that we are dealing
with individuals and they must be treated as such. No hard and
fast rules can be laid down which will be found applicable to all
the babies and under all circumstances.
The temperature chart of the infant is the best guide as to
the degree of heat which it is necessary to maintain within the
basket. The rectal temperature of the infant should be taken
and recorded each morning and evening. At first there is noticed
a tendency to subnormal temperatures or to subnormal tempera-
tures alternating with marked rises in temperature. The latter
is likely to be the case if the bottles in the basket are filled with
water at high temperature, or if all are refilled at once instead
of the bottles being refilled in relays.
The temperature of the room should be 80° F. with sufficient
ventilation to furnish an atmosphere that is constantly being
replaced.
A premature ward should be equipped with a hygrometer.
The infant should be disturbed or handled only when abso-
lutely necessary. The removal of the pad of absorbent cotton
from beneath the buttocks of the baby can be accomplished with-
out undressing the infant, as can the taking of the rectal tem-
perature. The initial anointing with olive oil should suffice for
4 or 5 days, after which the baby may be oiled on alternate days.
The premature basket or crib should be so placed that the infant
is not subjected to either bright sunlight or artificial light.
It is also important that only those adults whose presence is
absolutely necessary should be admitted to the room. This rule
Sinclair: The Problem of the Premature Infant 141
is obligatory because these premature infants are especially sus-
ceptible to respiratory infections.
The next and equally important problem, that of the nutrition
of the premature infant, is usually a much more difficult one to
solve. The needs of the premature infant are greater than in the
case of a child born at term, yet the powers of digestion in the
first instance are markedly less than they are in the latter in-
stance. Whereas the normal infant at term requires 100 calories
per kilogram of body weight to furnish the necessary heat,
energy, and gain in weight, the premature baby is found to need
from 120 to 180 calories. The explanation for this lies in the
fact that in the premature child there is a rapid loss of body
heat due in part to its proportionately larger body surface, with
its thin, poorly developed skin, and small amount of subcutaneous
fat, and in part to the unstable and inefficient nerve center regu-
lating heat radiation.
The prognosis depends largely on the weight and length of
the baby and the cause of prematurity, the weight being the most
important factor.
Breast milk, either that of the mother or a wet nurse, should
be employed in feeding premature infants. These babies are too
weak usually to nurse at the breast, or to feed from the bottle,
and require to be fed by means of the Breck feeder, or by gavage.
The Breck feeder is a graduated tube with a small nipple on one
end and a rubber bulb on the other. Breast milk is obtained by
the breast pump, or by being expressed by the hand, and should
at first be diluted and sometimes predigested before being fed
to the baby. One may usually start with breast milk one-half and
whey one-half. If the Breck feeder is used, from y^ to I ounce
may be given every 2 hours. If gavage is employed, the same
or slightly larger amounts may be given, but at 3 or 4 hour inter-
vals. Later the breast milk is given in gradually lessened dilu-
tions until the baby is able -to digest the undiluted breast milk.
At the same time the quantity given at each feeding is also gradu-
ally increased and the period between feedings extended until
the baby is taking 2 ounces every 3 hours, 7 to 8 feedings in 24
hours.
There is a great diversity of opinion as to the proper interval
between feedings and consequently as to the number of feedings
to be given in 24 hours. My own opinion is that we cannot be
142 Sinclair: The Problem of the Premature Infant
dogmatic in this connection. We must, as the late Doctor Abra-
ham Jacobi once said, in discussing this subject, "Use your
brains. Every case has to be treated individually."
In general, if using the Breck feeder, the hours may be closer
together as, the baby is likely to get smaller amounts, while if
gavage is employed larger amounts are given at a time and hence
are not needed so frequently. In either case vomiting is the
danger signal which warns us of overfeeding and to it we must
give immediate heed and at once either reduce the amount of
food given at a feeding or increase the length of the interval
between feedings.
The weight increases very slowly as a rule in premature babies
and at first we must be satisfied with gains of 1 or 2 ounces per
week.
Feeding with modifications of cow's milk is possible, but
should be avoided, unless breast milk is not obtainable. Artificial
feeding is very difficult and is accompanied by many risks as pre-
mature infants are very susceptible to gastrointestinal distur-
bances.
Whey, weak modifications of cow's milk boiled, either with or
without predigestion with pancreatic extract, and artificial formu-
lae, such as the formulae employed at Bellevue Hospital, New
York, may be useful in feeding these babies. The formula used
by Dr. La Fetra at Bellevue Hospital is as follows : 5 ounces of
6 per cent, top milk, 10 ounces of whey, 5 ounces of Imperial
Granum water, and Dextri-maltose from ^ ounce to 1^^ ounces.
While the premature infant should, as has been said, be moved
and disturbed as little as possible, yet it is absolutely necessary to
know that the baby is actually getting the amount of nourishment
that it is intended it should have, and consequently, if there is any
doubt about this the baby should be weighed before and after each
feeding.
A liberal supply of body fluids should be maintained under all
circumstances. This may make necessary the use of normal salt
solution subcutaneously, or better intraperitoneally, or, as I prefer,
into the longitudinal sinus. A 5 per cent, glucose solution may
also be advantageously employed in using the longitudinal sinus.
Whatever method of feeding be employed in these cases, it is
important to be on our guard for the regurgitation of food with
Sinclair: The Problem of the Premature Infant 143
subsequent lodgment of a curd in the larynx. This may happen at
any moment and if not promptly recognized and the infant quickly
inverted may be, as has often been the case, the cause of sudden
sufifocation and death.
Cyanosis is a frequently occurring symptom in premature in-
fants. It may be due to pressure, as in the case of tight or heavy
covers; to feeble muscular power; to fatigue of the respiratory
muscles; and to insufficient nourishment. To meet attacks of
cyanosis and to combat them promptly is imperative. For this
purpose a tank of oxygen should be kept constantly at hand. Also
caffeine sodio benzoate.
The lessened immunity of the premature infant as evidenced
by its extreme susceptibility to infections of the respiratory and
gastrointestinal tracts, as well as to those of the skin, and the
liability to general sepsis, is probably due to a smaller quantity of
immune substances in the body, or to the immaturity of the
organs that manufacture them.
As maternal milk tends to increase immunity this is an addi-
tional reason for insisting on the use of breast milk in feeding
premature infants. Anemia is usually present in a greater or
lesser degree in all premature infants and is due to an insufficient
deposit of iron in the body.
As iron, phosphorus, and calcium are all stored up in the body
of the infant during the last months of pregnancy, it is easy to
understand the frequency of certain degrees of anemia in these
premature babies and the relatively frequent development of vari-
ous symptoms and signs of rickets in those who survive.
Anemia calls for the administration of iron in some form pref-
erably in foodstuffs at as early a time as possible. And rickets
requires the administration of phosphorus, calcium, and codliver
oil as soon as these substances can be safely given.
FEEDING THE NEW-BORN*
By William N. Bradley, M.D.
Instructor of Pediatrics, University of Pennsylvania; Visiting Pediatrist to the
Howard Hospital
Philadelphia
The problem of feeding the new-born is one which has come
to us in comparatively recent times and may be considered an out-
growth of our modern civilization. Until the middle of the Eigh-
teenth Century, no scientific thought was given to the feeding of
infants, the matter being left entirely to the mother or caretaker,
and enveloped in ignorance and superstition.
In 1679, John Peachy published a work in which no mention is
made of any but maternal feeding, even a wet-nurse being classed
as an evil of the time. It is interesting to note also, that Peachy
advised maternal feeding until dentition was complete, and with
strict observance to wean the baby only when the moon was in its
ascendency.
Almost coincident with the birth of the baby, milk appears in
the mother's breasts. This is the nourishment provided by nature,
and that it is the ideal food for the new-born is now undisputed.
It is preeminently available, automatically produced and conveni-
ent beyond anything that man could devise. That it is perfectly
suited to the baby's needs has been proven scientifically in the
laboratory, and practically, by all the generations that have gone
before. It possesses all the elements that are required for normal
growth and development of the infant, while being perfectly
adapted to its digestion. There are exceptions to this generaliza-
tion which will be considered later.
Perhaps more important than any of the other advantages of
breast milk is that of safeness. Mother's milk is absolutely safe
because of the method of its production and direct intake by the
infant. All substitute foods, because of the complications of pro-
duction, handHng, and transportation, are bound to become
heavily laden with bacteria.
Laboratory examinations and mortality and morbidity statis-
tics furnish. conclusive evidence of the foregoing statements. But
one breast fed baby dies for each 6 artificially fed, and the sus-
ceptibility of the latter to disease is markedly greater. Griffith
*Read at the meeting of the Philadelphia Pediatric Society held December 9, 1919.
144
Bradley: Feeding the New-Born 145
states that Moro has shown that although no bactericidal sub-
stances could be found in human milk, yet the blood serum of
breast fed children exhibited a bactericidal power much greater
than that of the artificially fed, and the former do not contract
pyogenic diseases so readily. Specific agglutinins are also probab-
ly transmitted to the child through the mother's milk. Therefore,
from these standpoints of availability, suitability and safeness,
breast milk is the logical food for the new-born.
There is a fourth advantage which in the present day of high
prices is not to be overlooked. To thousands of mothers the
present cost of cow's milk and its products is prohibitive. The
family at present is laboring under a heavy financial strain and
the added expense of buying milk or other food for the new-
comer is an unnecessary burden. Often only the poorest grade of
milk is financially possible, and in a limited quantity. Finally,
since ignorance and poverty usually are found in the same home,
the mother is mentally unable to cope with the intricacies of modi-
fication, and an unsuitable and badly prepared mixture is inevit-
able.
If even a small portion of the time which has been devoted in
years past to devising new and exact methods of artificial feeding,
had been spent in encouraging and improving maternal nursing,
many infants might have been spared the early struggle and suf-
fering which is so frequently the lot of the bottle fed baby, and
thousands of them could have been saved to their families and the
State.
More and more is the importance of the feeding of infants
becoming recognized as a subject worthy of special scientific
study; one very practical form of this recognition is the practice
now common among the better known obstetricians of referring
the baby to a pediatrist for feeding and care, immediately follow-
ing its birth.
Since maternal nursing is the most important function of
motherhood, the preparation of the mother for the performance of
the function is a vital part of prenatal care. With few exceptions,
every mother can nurse her baby if she so desires.
In support of this statement the statistics of The Starr Centre
in 1912-13 show that only 48 per cent, of the babies under care
were breast fed. Now after 6 years of insistence upon breast
feeding, the statistics of the last fiscal year show that of 92
146 Bradley: Feeding the Nezv-Born
mothers delivered, who had been cared for by the Pre-natal De-
partment, 90 of these babies were entirely breast fed at 1 month
of age, 1 partially breast fed and 1 bottle fed.
Attempts at maternal nursing should never be abandoned be-
cause of the delayed appearance of milk in the breasts, failure of
supply due to nervous influences, shock, or an upset condition in
the baby. In all such cases a little patience and encouragement
will usually bring about success. The subsequent ability of the
expectant mother to nurse her baby demands adequate pre-natal
care of breasts and nipples to prevent depression or fissures. If
the infant is given the breast at absolutely regular intervals dur-
ing the first few days of life, there is reasonable probability that in
every case the infant can be successfully nursed.
Preceding the birth of the baby and persisting for 1 or 2
weeks, colostrum is present in the breasts. This is believed by
Pritchard to serve the purpose of developing the infant's diges-
tion before the advent of the milk supply. An average analysis of
breast milk is as follows :
Specific gravity, 10 28-34.
Amphoteric or faintly alkaline in reaction.
Fat, 3-4 per cent.
Protein, 1-1 3^ per cent.
Sugar, 6-7 per cent.
Water, 87-88 per cent., and the salts of calcium, magnesium,
potasium, sodium and iron.
Talbot states that the percentage of lactose rapidly increases
during the first few days of life; protein rapidly decreases, while
fat remains practically constant. He further states that a speci-
men of fore milk is usually richer in sugar, while the after milk is
richer in fat. Milk taken from both breasts simultaneously is
practically the same in composition.
The production and quantity of breast milk is in direct pro-
portion to the demand made upon it; the quantity in most cases
being sufficient for the needs of the individual infant.
The quaHty, quantity and character of breast milk are all in-
fluenced by the habits of the mother. Special attention should
therefore be given to her mode of living. Her diet should be
liberal, well balanced and nutritious, including generous amounts
of milk and water. One bowel movement daily and exercise in the
open air are essential. Her life should be quiet and as free from
Bradley : Feeding the New-Born 147
care and worry as possible, as any emotional disturbance may
cause temporary lessening of the flow of milk, while anger or
fright may render it unfit for the baby. Complete emptying of
the breasts will greatly aid in the maintenance of the milk supply,
and absolute regularity in nursing should be strictly adhered to
from birth.
As soon after delivery as the mother's condition will permit,
the baby should be put to her breast for a period of 10 minutes.
This should be repeated every 4 hours until the appearance of the
milk supply. After that, every 3 hours for 15 to 20 minutes, with
but 1 night feeding.
The writer believes the 3 hour feeding interval during the
early months of life necessary to provide the infant with its caloric
requirements. These general rules apply only to the normal baby,
exceptions must receive appropriate management.
During the first few days of life when there is no milk present
in the breast and the baby is nourished entirely on colostrum, there
is always a loss of several ounces in weight, which the writer
regards as entirely physiological, being due to the process of ad-
justment from the fetal state to that of an individual organism.
Attempts to prevent this loss have resulted in the employment of
various forms of supplementary feeding, notably water, lactose,
and wet nursing as studied by Griffith and Gittings. The conclu-
sions of the latter, namely : that this loss cannot be entirely over-
come and that such experiments do not offer sufficient advantages
to justify their employment, are in acordance with our own views.
In spite of our firm contention that maternal nursing is the
ideal method of feeding the new-born, it must be conceded that
frequently cases are met which severely try the skill and patience
of both physician and mother.
The prominent symptoms which confront us in disturbed di-
gestion in the early weeks of life are regurgitation, vomiting, colic
and undigested bowel movements. Added to these may be men-
tioned the one which gives the mother the greatest concern and is
the surest index of the baby's condition to the doctor, viz : failure
to gain, or actual loss in weight of the infant. All these symptoms
require investigation to ascertain the exact cause of the disturb-
ance. A chemical examination of the breast milk at the outset
often aids in detecting the source of trouble. A moderate degree
of regurgitation in the breast fed baby may be considered physio-
148 Bradley : Feeding the Neiv-Born
logical, as sometimes no limit is put on the length of time of nurs-
ing and the baby gets too much and the excess amount is regurgi-
tated.
Excess of fat in the m!lk may result in sour vomiting with an
odor of butyric acid. According to Griffith, when there is an excess
of fat intake or an inability on the part of the baby's digestion to
properly handle the ingested amount, the condition is manifested
in the stools in 3 distinct types: (1) soap stool, containing an
excess of fatty acids combined with calcium or magnesium to
form soap. The color, white or grey, shiny, fairly firm, homo-
geneous, crumbly or salve-like, acid in reaction and having a ran-
cid or sour odor ; when combined with protein, cheesy in odor and
alkaline in reaction. (2) fatty stool, bright yellow, soft and
greasy, containing a large amount of neutral fat and fatty acids,
sometimes thin and frequent enough to suggest fatty diarrhea.*
(3) curdy stool, numerous large or small curds, acid in reaction,
the curds are usually soft, white, composed of fat ; aside from the
white curds the stool is green and yellowish, diarrheal, and mucus
is always present.
Excessive amounts of protein cause colic while the stools are
alkaline in reaction, brownish yellow of putrefactive odor, and
mucus is always present. Occasionally, tough, yellowish protein
curds are found. Excessive sugar is rare, but if present may
cause watery vomit with irritating, watery or frothy bowel move-
ments, sometimes green in color, which excoriate the skin of the
buttocks and thighs.
Occasionally cases occur in which both fat and protein are
present in amounts to which the infant's digestion is unequal.
Such cases occur in overfed mothers who take insufficient exer-
cise. Dietetic and hygienic measures on the mothers part are
usually sufficient to correct the difficulty. Milk rich in protein and
low in fat is usually found in nervous, overworked, under fed
mothers, overburdened with cares and anxiety. The babies suffer
with vomiting, colic and loose, offensive stools. The correction of
these cases becomes a difficult problem, but breast feeding should
be persisted in, unless the condition of the baby is steadily down-
ward.
Underfeeding is usually indicated by an unsatisfied condition of
the baby, restlessness, crying before nursing intervals and during
the act of nursing, because of ^he inability to get sufficient milk,
Bradley : Feedini^ the Nciv-Born 149
or as rapidly as desired. These symptoms are associated with
small brownish or brownish-green stools with mucus. Under such
conditions baby should be weighed upon a beam scale before and
after nursing, and the gain in weight accurately noted. It is also
well to determine the total weighings for a 24 hour period, in
order to estimate the caloric intake which in a new baby should be
100-120 calories per kilogram of body weight. A very young baby
should gain ^ to 2 ounces at each nursing. The best dietary
stimulants for the mother of an underfed infant are milk, cocoa,
water and gruels. Fats are increased by feeding with fats ; car-
bohydrates, by limited exercise.
Intercurrent disease in the mother of a transient nature is not
sufficient cause for weaning the baby. The baby may be nursed
on a substitute mixture, measures being taken to retain the
mother's milk supply until the baby is returned to the breast.
Galactogogues have been proven to be worthless. Hess be-
lieves that massage and steaming the breasts are of decided value
in improving the milk supply. Only after persistent efforts at
maintaining the milk supply of the mother and modifying it in
every conceivable manner to fit it to the infant's digestion, and
there is still a failure to gain, or an actual loss of weight of the
infant, should maternal nursing be discontinued. Any serious or-
ganic or systematic condition in the mother, viz. : tuberculosis,
chronic heart or kidney disease, typhoid fever, rheumatism, or
septicemia, contraindicate breast feeding. However, if weaning
becomes necessary, a wet-nurse is the next best choice, and if this
be impracticable, artificial feeding is the only alternative.
No method of artificial feeding can perfectly replace maternal
nursing. As nearly as possible the different constituents of the
substitute milk should resemble those of the mother's milk, both
in their chemical composition and in their behavior to the digestive
fluids. These conditions are fulfilled only by the fresh milk from
some other animal. Cow's milk, for practical reasons, has been
found to be the one best suited for the purpose. The chief differ-
ences between breast milk and cow's milk lie in the character of
the fat, protein and salts. It has been definitely established that
fat plays an important part in the nutritional disturbances of the
artificially fed infant. The butter prepared from cow's milk con-
tains 10 per cent, of volatile acid, while that prepared from human
milk only 1.5 per cent.; also the irritant butyric acid glycerid,
150 Bradley: Feeding the New-Born
which occurs in 6 per cent, in the butter of cow's milk, occurs
only in traces in human milk. The fat globules are much larger
than those of human milk. The protein of human milk consists
of .59 per cent, casein and 1.23 per cent, lactalbumin, while cow's
milk contains 3.02 per cent, casein and .53 per cent, lactalbumin.
The curd from cow's milk is usually tougher and occurs in larger
masses than human milk, thereby throwing extra work upon the
infants' digestion. The salts of cow's milk consist mainly of
potassium and sodium bases.
During the first few weeks of life, cow's milk should be highly
diluted, boiled, and less sugar added than for older infants.
While a highly diluted formula gives a lower caloric value than
will meet the infant's requirements, it is important to begin with
a dilution not greater than one-sixth to one-fifth of whole milk
and to strengthen the formula gradually in order to accustom the
infant's digestion to this form of food. The quantity given at
birth should be Ij^ to 2 ounces, increasing gradually according to
age. The same general rules apply as for maternal nursing.
It would be impossible to attempt to discuss in the brief time
remaining, all the difficulties of artificial feeding. Every baby's
metabolism and digestion is an individual problem, and each case
requires observation to determine the formula, interval, and nurs-
ing period best suited to its needs. Milk used for artificial feeding
should be produced under the best possible conditions from tuber-
culin tested cattle. Whenever the financial status of the patient
will permit, certified milk should be used as this is the only raw
milk on the market, practically safe. Special emphasis should be
laid upon the care of the milk in the home to keep it safe and the
physician should teach and insist upon careful handling in the
process of modification,
REFERENCES
Hess, Julius H. : Principles and Practices of Infant Feeding, 1918.
Griffith, T. P., C: The Diseases of Infants and Children, 1919.
Pritchard, Eric: The Infant; Nutrition and Management, 1914.
Griffith, J. P. C, and Gittings. J. C: Archives of Pediatrics, XXIV (1907), 321.
Denis, W.. and Talbot, Fritz B.: American Journal Diseases of Children, August, 1919.
Holt, L. E.: The Diseases of Infancy and Childhood, 1912.
THE NEWER KNOWLEDGE OF THE NEW-BORN.*
By A. Graeme Mitchell, M.D.
Instructor of Pediatrics, University of Pennsylvania; Clinical Assistant, Children's
Hospital; Physician to the Dispensary of the Children's Hospital;
Assistant Pathologist to Children's Hospital.
Philadelphia
Much remains to be done to determine what the new-bom
baby is chemically, or metabolically if you will. However, results
that have accumulated from the investigations of different ob-
servers have already tlirown considerable light upon this subject.
In this paper there will be presented some of this newer knowl-
edge, much of which has a practical bearing in the care of the
young baby. In addition, and allied to a certain extent with the
chemistry of the child, are phases of the question of immunity
against disease which the new-born possesses. This, with the
gastrointestinal physiology, may be considered with profit in con-
nection with the normal metabolism.
A large percentage of babies die in the first weeks of life.
Most of these deaths can be attributed to premature birth, con-
genital malformation, congenital or inherited disease, injury at
birth or to that rather ill-defined condition called "congenital de-
bility." The importance of the death rate in the new-born is
emphasized when a few statistics are studied. In Philadelphia, in
one year (1917), the infant mortality exclusive of still-births was
A6\7} Of these deaths, 507 occurred in babies less than 1 day of
age; 1149 in babies less than 1 week of age, and 1800 in babies
less than 1 month of age. In other words, almost 40 per cent, of
the babies who died before the age of a year died in the first
month of life. It should be stated that almost half of the 1800
deaths occurring before the age of 1 month were in premature
infants and most of these died before the age of 1 week. In New
York, of 900 births among 898 women, there was a death rate
among the babies under 1 month of age, based on living births, of
19.5 per 1000.^
In carefully kept records of 10,000 consecutive births, the
deaths during the first 14 days were 3 per cent, of the living
births.^ In confirmation of the statistics from Philadelphia, one
finds other statements * ^""^ ° that prove that a large percentage
*Read at the meeting of the Philadelphia Pediatric Society held December 9, 1919.
151
152 Mitchell: The Neiver Knowledge of the Nezv-Born
of the deaths in babies occurs before the expiration of the first
month succeeding birth.
It has been variously estimated that from 60 to 75 per cent, of
the infantile deaths under 1 month of age are due to prenatal
causes, and much interest has been stimulated in prenatal care
4 and G Skillful obstetrics is also playing its part in lowering the
death rate. But, in combating infant mortality, an increased
knowledge of the baby's metabolism and a consequent better un-
derstanding of his requirements should ai4 in postnatal care.
It is not definitely stated just when the human animal ceases
to be a "new-born" and enters upon the still unstable career of
babyhood. The transition is a gradual one and there is no sharp
demarkation. In this paper we shall consider the baby under 1
month of age.
Diseases of the New-horn. — There are certain diseases that
are peculiar to the new-born. With some of these we are quite
familiar and they often present obvious symptoms. Suffice it then
to mention in this connection hereditary syphilis which usually
presents manifestations before the end of the first month of life ;
atelectasis ; the several varieties of icterus ; the acute pyogenic in-
fections of the new-born including ophthalmia and pemphigus ;
tetanus ; sclerema and the hemorrhagic diseases. One should be
on the lookout for meningitis, as it occurs in very early life and
may have as an etiologic organism the tubercle bacillus, bacillus
coli communis, meningococcus, micrococcus catarrhalis, pneu-
mococcus, bacillus mucosus capsulatus, staphylococcus, streptococ-
cus, bacillus pyocyaneus or the bacillus lactis aerogenes.^ ^, ®, "
and 11 jj- jg j^Q longer doubtful that tuberculosis may be a con-
genitally transmitted disease. ^^, ^^, ^* ^"^ ^^.
One is accustomed to thinking of the young baby as immune to
the common contagious diseases. While this is true to a large
extent, nevertheless diphtheria, scarlet fever, measles, whooping-
cough and small-pox do occur in the new-born. ^'^ Diphtheria is
a disease uncommon in very young infants but only those infants
are insusceptible whose mothers have immunity. ^^ ^"*^ ^^. Others
are susceptible from birth.'** Scarlet fever has been leported in a
newborn infant. ^^ ^"'^ ^^^ As to measles, infants under 2 months
are usually immune. The immunity is probably conveyed through
the placental circulation, only those infants whose mothers have
Mitchell: The Nezver Knowledge of the Nezv-Born 153
had the disease seeming to enjoy this immunity. ^- ^"'^ -^. Measles
has been reported in infants as young as 16 days of age. -* ^^^ ^^^
Whooping-cough has begun as early as the fourth day of life with
distinct whooping on the eighth day. ^^, ^"^ *"*^ '*'
Pneumonia, in the first few days of life, is not so uncommon^
and this has been proved by autopsy.^^ Pneumonia and pulmo-
nary inflammations at this age have been considered to be in-
fections of umbilical origin,^^ Pyelitis may occur in the new-
born.-** Gall stones have been found in the new-born at autopsy.^"
Polycystic kidney is reported in the very young infant. ^^ The ap-
pendix has been successfully removed from an infant 12 hours
after birth. ^-
Thus it is evident that not only must the new-born infant com-
bat certain diseases that belong to his time of life, but he is also
occasionally liable to diseases that commonly affect older chil-
dren ^^^ ^^* ^^ ^* ^^ ^"^ ^'^
Physiology of the Gastrointestinal Canal. — Saliva is probably
secreted during the first day of life and has the power of convert-
ing starch into sugar at this time. ^'^ ^"^ ^*
At birth the stomach has a capacity of 1.2 ounces, which has
increased to 1.5 ounces at the end of the first month. The gastric
capacity, as measured postmortem, is a false guide. The quantity
of milk given may exceed the measured gastric capacity by a con-
siderable margin. ^" That is to say, the physiologic capacity is
greater than the anatomic capacity, because the food begins to
leave the stomach almost as soon as it enters it. Hunger contrac-
tions in babies up to a month of age begin about 2 hours after the
last meal, and reach their maximimi in three hours. *° The
stomach should be empty in 3 hours and frequently is empty in
less than this time.*^ With breast fed infants, of less than a week
of age, the stomach is often empty in an hour. *'^
The new-born, as well as other babies, should be held erect for
a short time after feeding. *^ Free hydrochloric acid is present in
the stomach at birth or soon thereafter. *-, ** '*"'* *^ The acidity
of the infant's stomach of the first month remains nearly station-
ary during the first hour after a meal, after which it rises steadily
until the next meal, and if this is delayed 4 hours the acidity may
become as great as in the adult's stomach (0.005), measured by
means of hydrogen electrodes. ^" The stomach at birth contains
154 Mitchell: The Newer Knozvledge of the New-Born
pepsin, rennin and lipase. *" '*"'^ " While the concentration of
hydrochloric acid in the stomach of the new-born is sufficient for
the action of the ferments, lipase and rennin, there is some doubt
as to whether it is in enough concentration for the action of pep-
sin.
The pancreatic ferments, trypsin, amylopsin and steapsin, are
present at birth. Secretin, enterokinase, invertin, lactase, mal-
tase and erepsin have also been found in the intestinal secretions
of the new-born. Bile begins to flow during the first 12 hours
after birth, and after a few days there is a marked increase in
the volume secreted. ^** ^""^ ^'*
The new-born is required to digest apd assimilate fat, sugar
and protein, and it is seen that under normal conditions he has the
necessary ferments present in his gastrointestinal canal to assist
in preparing these food elements for absorption.
Bacteriology of the Gastrointestinal CanaP^, ^^ ^^^ ^°. —
There is a practically sterile condition of the gastrointestinal tract
in the new-born at birth. The meconium is sterile and bacteria do
not make their appearance in the intestinal discharges until. 18 to
24. hours after birth. ^^ Soon after birth, a few bacteria are found
in the mouth. Bacteria also quickly enter by the rectal route and
the second day after birth may be found in all parts of the intes-
tinal tract.
Urine^^^ ^^^ ^^. — During the first few days of life, the new-
born passes but little urine. The amount of urine voided during
the first and second day is about 50 c.c. After this, there is a
rapid increase to 200 c.c. and this amount, or more, is normally
passed by the tenth day. ^^^ There is usually some urine in the
bladder at birth. This does not contain albumin but after this,
for the first four days of life, there is an excretion of albumin in
the urine. Immediately after birth, the urine is clear. It then be-
comes cloudy for the next 4 or 5 days, and the sediment shows
epithelial cells, leucocytes, hyaline and epithelial casts and amor-
phous hyaline substance. A brick red sediment appears in the
urine on the second to the fourth day, which consists of am-
monium urate. A condition of uric acid infarction is normal in
the kidney of the new-born, and this accounts for the ammonium
urate. Uric acid excretion in the urine of children during the
first days of life is both relatively and absolutely high. It reaches
its maximum of 0.083 gm. on the third day. ^^ ^^ ^"^ '* The
Mitchell: The Newer Knowledge of the New-Born 155
urinary excretion of phosphorus is also high during- the first 3
days of life. ^^ New-bom infants excrete oxalic acid in the urine
in varying amounts up to 9 mg. per day. °^ Contrary to the earlier
findings, phenol is quantitatively present in the urine of every
new-born infant, the average being about 11 mg. for the first 3
days of Hfe. ^® The urine of the normal new-born is nearly always
acid. It takes on an average 1.7 gm. of sodium bicarbonate to
turn the urine from an acid to an alkaline reaction, giving 0.16
gm. every two hours by mouth." Infants as young as 3 weeks
of age eliminate about the same percentage of phenolsulphoneph-
thalein as adults (47.7 per cent, at the end of the first hour and a
total of 69.4 at the end of the 2 hour period^*).
Blood. — It has been pointed out that much of the work which
has been reported as examination of the blood in the new-bom,
has in reality been analysis of the blood taken from the cord at
birth, and as such represents rather the fetal condition than that
of the new-born. ^'
The blood of the new-born is richer at birth in corpuscles and
hemoglobin than the adult. A count of over 6,000,000 red blood
cells, or 30,000 white blood cells is not to be considered abnormal.
This increase is only apparent and is easily explained by the va-
riation in the quantity of blood plasma. ^^ All these changes are
marked up to the fourth day after birth and then gradually ap-
proach the adult type. ^^*= The hemoglobin has been carefully
studied by the spectrophotometric method and shows that during
the first 2 weeks of life the normal hemoglobin content is 30 per
cent, greater than in the normal adult. ®"
Blood sugar has been investigated and the reduction power of
the blood in the new-born has been found to be essentially the
same as in the adult or in older children. In 93 observations on
12 infants from the first to the ninth day of life the average was
0.0878 gm. of sugar per 100 c.c. of blood. ^^
At birth there are 3.0 mg. of uric acid per 100 gm. of blood.
This rises to a maximum of 3.9 mg. by the third day. The blood
uric acid then falls off slowly to 2.9 mg. on the fifth day, and then
rapidly to 1.6 mg. by the eighth to eleventh day. ®-
In 9 cases in which the fat from the umbilical vein was ex-
amined there was a variation of from 0.14 per cent, to 0.49 per
cent, with an average of 0.27 per cent. "^
156 Mitchell: The Newer Knozvledge of the Nczv-Born
The total non-protein nitrogen per 100 c.c. of the systemic
blood in the new-born is 24 to 30 mg. (approximately the same as
in the adult). The age and weight of the infant and the period
after feeding have no bearing. The percentage of urea nitrogen
is uniformly high and averages about 50 per cent, of the total
nitrogen. It is lowest in the new-born infant one-half hour old
and in infants who have not been fed. The amount of urea nitro-
gen is extremely small. Aminoacids are constantly present in ap-
preciable amounts even when no feeding has as yet been given. ***
and G5_ 'pj^g mono-amino-acid-nitrogen in the blood taken from
the umbilical vein at the moment of birth varies from 9.5 to 15.8
mg. per 100 c.c. of blood. ''^ ^"<i "^
The total creatinin in the plasma of fetal blood is 1.93 mg., and
reformed creatinin 1.07 mg."'^
Metabolism of the New-born. — The knowledge so far gained
about the metabolism of the new-bom is not hard to understand
provided one starts with certain facts and definitions in mind.
Much that we know about this subject is due to the splendid
studies of Benedict and Talbot. "^ ^"^^ ^^
Basal metabolism is taken when there is a complete absence of
extraneous muscular activity (i. e. during sleep, and an absence of
the heat elimination incidental to the specific stimuli of the food
materials accompanying the digestion and absorption of food (i.
e. when the stomach is empty) °^, *"* ^"'^ '^''. Indirect calorimetry
is using the respiratory exchange to compute the total calori-
metry. *"• The respiratory quotient means the volume of carbon
dioxid expired, divided by the volume of oxygen used. "When
pure carbohydrate is burned up outside the body the volume of
oxygen necessary for its combustion is always the same as the
volume of carbon dioxid given off as a result of the combustion.
CO..
The respiratory quotient of carbohydrate is, therefore, always
1.00. The respiratory quotient of fat is 0.713, and of protein
0.801. "*^ An extremely simple method for calculating the cata-
bolism is to multiply the total amount of carbon or oxygen meas-
ured by the corresponding calorific equivalent. "^ With a knowl-
edge of these facts the infant has been studied in a calorimeter,
and energy requirements ascertained.
It will be well to give the formulas used for calculatinsf the
Mitchell: The Neiver Knowledge of the Ncw-Born 157
body surface. The first is that of Meeh"^ in which the equation
given is body surface = 11.9 Y'V Weight. Lissauer's formula "
is better for use in babies and is as follows : body surface ■= 10.3
V Weight 2-
Tlie gaseous metabolism of the new-born studied in the calori-
meter has shown certain facts of interest and practical value. The
respiratory quotient for the new-born indicates that the child is
born with a supply of carbohydrate sufficient only for its energy
requirements for a portion of the first day. A new-born infant
requires about 60 calories per kilogram of body weight per 24
hours and the energy quotient varies in individual cases from 40
to 75 calories. '^° ^""^ ^'\ The total calories of the basal metabolism
of a new-born infant may be calculated from the following form-
ula: length X 12.65 x body surface. ''*' This is the basal meta-
bolism and the actual calories required in the food are about twice
those of the basal metabolism as allowance must be made for the
calories lost in excreta, those used for growth and those required
for muscular activity and crying. '^* The infant needs more
calories per unit of body weight than does the adult. For ex-
ample, the energy production of a grown person in health and
while resting in bed is 1 .0 calory per kilogram of body weight per
hour. An infant of 10 days old, while sleeping, has an energy
metabolism of 2.0 calories per kilogram of body weight per
hour. ^^ Benedict and Talbot hold that there is no intimate rela-
tion between body surface and fundamental metabolism but that
the determining factor is the active protoplasmic mass. "^
It is apparent, therefore, that infants, at least during the first
10 days of life, do not require the 100 calories per kilogram of
body weight which older writers have claimed were necessary. In
this connection it is important to note how much nourishment
the baby would get provided the colostrum were depended upon as
the sole source of food intake. The figures given by various
authors vary to a certain extent ^" ^"^^ "^^ but it is quite certain
that the calorific value of colostrum is insufficient to supply the
needs of the new-born infant. During the first 24 hours there is
secreted 4 to 6 c.c. of colostrum, giving approximately 3^2 cal-
ories. During the second day, the baby receives from 78 to 129
c.c, or 51 to 84 calories. On the third day, the amount of colos-
trum varies between 199 and 238 c.c, which give 129 to 154 cal-
ories. ^" After this time the breast milk increases in quantity so
158 Mitchell: The Newer Knowledge of the New-Born
by. the tenth day 400 to 500 c.c. are being secreted. " At the same
time the secretion becomes richer in fat and sugar. ^"^
Before discussing the feeding of the new-born it is neces-
sary to consider the question of the initial loss of weight which
occurs after birth. This loss of weight, occurring in the first 3
days, is about 8-9 per cent, of the total body weight, and varies
from 100 to 300 grams. ", " ^"•i ^«
A loss of weight of more than 500 grams or a continuation of
loss over a period of more than 4 days is an abnormal condition. "'''
Loss of weight in the new-bom is of 2 kinds, mechanical and
physiological. ''^ The mechanical loss is caused by the passage of
meconium and urine, the vomiting of allontoic fluid, the removal
of the vernix caseosa and the evaporation of water from the skin.
The physiologic loss is to be attributed to an insufficiency of the
entire metabolism, especially the water metabolism,^* and is the
most important cause of loss of weight in the new-bom. ^^ The
water lost from the child's body has been measured and found to
be 28.12 grams per kilogram of body weight for the first 12 hours,
and 40.74 and 53.6 grams per kilogram of body weight, respec-
tively, for the next two 24 hour periods. ^^ The water content of
the blood of the new-born has been compared to that of older
children. In 9 babies, from the first to the thirteenth day of life,
22.3 per cent, of dry substance and 77.7 per cent, of water was
found in the blood, whereas in 9 babies from 1 to 10 months of
age the dry substance was only 18 per cent, and the water 82 per
cent. ^^ It is then quite well established that the water concentra-
tion of the blood runs parallel to the weight curve. *"
In deciding whether or not an infant should be fed in the first
few days of life, these facts are to be taken into consideration : the
new-born infant requires 60 calories per kilogram of weight per
24 hours ; in the secretion from the breast he receives only a frac-
tion of such an amount (not enough to supply the energy require-
ments for combustion alone) ; there is considerable loss of water
from the child's body and a consequent concentration of the
blood ; the higher the percentage of water the easier are the pro-
cesses of metabolism ; when the glycogen in the liver and tissues
has been used up (as it is within a few hours after birth) it is
necessary for the baby to use its own tissues to supply energy.
Although it is certain that the mechanical loss of weight cannot
entirely be prevented, it seems logical, in view of these facts, to
supply the new-born either with water or easily digestible food
Mitchell: The Newer Knowledge of the New-Born 159
of some calorific value. In spite of this, some authors advocate
giving nothing until the breast milk comes in and believe that
artificial feeding at this time prolongs and increases the weight
loss. ''^ Again it has been stated that there is no relation between
the nature of the feeding and the grade of development of initial
loss of weight," and that the giving of water does not seem to
have effect except in cases where practically no milk is secreted. "
It has also been used as an argument against artificially feeding
new-borns that the digestive processes are but feebly developed
and that it is only the fat and serum albumin of colostrum which
are closely related to those to which the infant has been accus-
tomed in intra-uterine life.'^* The giving of 50 calories per kilo-
gram of body weight per day in formula feedings and diminishing
this as the breast milk comes in, has been practiced. ^' The
feeding of cow's milk at such an early age, however, means intro-
ducing a foreign protein, which may be absorbed directly into the
blood, and the best procedure is to give breast milk from a healthy
woman which has been diluted with boiled water. ''° ^""^ ''®. Fail-
ing this, 5 per cent, lactose solution should be used. ''" The weaker
and smaller the infant the more the necessity for early feeding.
Some of the problems that concern us in older babies and
children are not of such first importance in the new-born. For
example, if the young baby is to be nourished on human or cow's
milk it is not necessary to consider the "vitamins" or growth
promoting substances which are perhaps better called fat-soluble
A and water-soluble B.*^ These substances are contained in
both human and cow's milk in sufficient quantity.
All these studies in physiology and metabolism have resulted
in helping us to understand the infant's requirements and the
various factors related to nutrition. It is well to remember what
Mendel says : "However essential food may be to growth — and
no one can gainsay its pre-eminent importance — it can in no
sense be regarded as the supreme cause of growth. Nutrition
can only give the growth impulse free play. Of what we have
called the internal factor in growth — the growth impulse, the
tendency to grow, the capacity to grow — the factor that is heredi-
tary in its origin and sets to growth the limits which nutrition
cannot fundamentally alter, little further can be said." ^^ This
should not deter us, however, from doing our utmost to under-
stand, and meet the requirements of the new-born infant.
160 Mitchell: The Neivcr Knowledge of the N civ-Born
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Mitchell: The Newer Knowledge of the New-Born 161
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HEALTH CLASSES FOR CHILDREN.*
By Ira S. Wile, M.D.
New York.
The trend of modern medicine into prophylactic ways is mani-
fested in numerous institutions and agencies designed to protect
childhood. By a strange process of reasoning, or possibly because
of the ease of accomplishment, efforts at the protection of child-
hood began with children in industry. Following upon this,
school medical inspection was inaugurated, later supplemented by
the advent of the school nurses. The next step was the establish-
ment of a practical and serviceable system of infant milk stations,
which evolved into infant welfare centers. As a natural out-
growth of efforts in this direction, interest was focused upon prob-
lems of pre-natal care, out of which has grown the plan of mater-
nity centers, and pre-natal clinics. Incidentally, it may be re-
marked that the term pre-natal care, as applies to the oversight of
pregnant women, is not sufficiently inclusive. With the develop-
ment of this systematic plan of oversight and protection from
conception to the age of employment, there exists one gap which
merits attention. Insufficient provision exists for the health care
of children during the pre-school age, which, in view of potential
agencies, represents the span of years between the cessation of
efforts of the infants welfare stations and the beginning of school
medical inspection. From the standpoint of disease, this period
might well have been left until the last, but there remains the
obvious fact that it presents a marked opportunity for constructive
service.
The pre-school age requires some organized system of health
supervision so as to preserve the continuity of educational and
protective service from infancy to the period of school life. It is
patent that during these years it is possible to accomplish a marked
saving of health, and a reduction in the development of defects
and handicaps. Furthermore, considerable economic gain results
from the earlier attention to errors in development and to defects
acquired during the pre-school age, instead of waiting several
years until the costly machinery of school medical inspection is
set in motion. Another advantage of health work during the pre-
* Read before the New York Academy of Medicine, Section on Pediatrics, Deccii
ber IJ, 1919.
162
Wile: Health Classes for Children 163
school age arises in and from the educational advantages that
ensue from the possibility of classifying children physically and
mentally previous to their entrance upon school work. In many
ways the opportunities for service are of greater moment between
the ages of 2 and 6 than between the years of 6 and 14. It is for
these various reasons that I believe that the establishment of health
classes is particularly desirable in the plan for conserving child
health during the pre-school age.
The health class presents the possibility of communal service
along various lines. While preeminently dealing with children,
its benefits extend to families as a whole, and inure to the welfare
of the general public. It is an agency for general family adjust-
ment in the matters relating to childhood. On the physical side
its efforts are preventive as well as remedial. It possesses a
vantage point for the prevention of tuberculosis, cardiac diseases
and the development of defects of sight and hearing, as well as
the correction of postural errors, and incipient deformities of the
feet and spine. In a remedial way, it eliminates or palliates die-
tetic errors and lessens the likelihood of malnutrition affecting
other children in the household. By reason of the early detec-
tion of visual, oral, nasal, pharyngeal and other defects, early cor-
rection becomes possible with a consequent improvement in the
general physical health of childhood, and with a corresponding
gain in vitality and resistance.
The mental hygiene of childhood merits considerably more
attention than has been given in the ordinary run of clinics. The
health classes, however, should aim to investigate mentality, to
ascertain the intelligence quotient, to test the channels of sensa-
tion, to localize and define the mental limitations with a view to
instituting the requisite educational or therapeutic measures neces-
sary to secure the maximum mental development as a preliminary
to attendance at school. By this means it is possible to provide
sufficient information to fix the place of a child in the school sys-
tem and to lessen the wastage of time, effort and nervous force
due to maladjustment in school grading.
The moral aspects of health classes involve the formation of
moral habits through the gain in powers of self control and inhi-
bition. The moral gains secured through the control of lisping,
biting nails and pica, are by no means secondary to those resulting
from overcoming masturbation.
164 Wile: Health Classes for Children
A social aspect of a health class is found in the attempt to
deal justly with childhood, the presentation of an opportunity of
achieving health despite the incubus of poverty and ignorance.
The awakening of a sense of responsibility for maintaining health
and the arousing of a consciousness of the worth of health during
childhood serve as points of positive advantage over the mere
teaching of hygiene. The social benefits center around personal
experience and the recognition of the personal gain during and
through the pursuit of a higher coefficient of energy, mental
power, and moral control.
Health classes, to function properly, should be articulated
with a general dispensary or hospital, the home, and various
agencies which can supplement and augment the work of the
class. To provide for these articulations, it is essential to have
a social service nurse and one or more friendly visitors who can
correlate the various activities and agencies. It is patent that the
physicians in the various other departments of dispensaries may
at times have their reports coordinated by the physician in charge
of the health class, so that the benefits of group diagnosis are
achieved, without any unnecessary disturbance of dispensary
routine.
The form of organization which I am using at the health
class at Mt, Sinai Hospital Dispensary is in a state of develop-
ment and does not yet contain all the elements I deem necessary.
At present we have a volunteer capable of taking histories and
through whose hands each new patient passes. The number of
new patients per day is limited to from 5 to 10 children, depend-
ing upon the number of physicians in attendance.
A social service nurse devotes her entire time to the health
class, and during consultation hours attends to the weighing and
measuring of the children and gives such other aid as circum-
stances require. She secures the directions for treatment and
instructions from the physicians, visits the homes to see that
advice is followed, makes the necessary social investigations, and
keeps the reports essential for the following up of the progress
of the family.
The doctors make the regular physical examination of the
children, largely in the nature of a complete physical examina-
tion. Whenever particular defects are noted that require special
investigation, they refer the children to other dispensary depart-
Wile: Health Classes for Children 165
ments for examination and report or to institutions for the special
corrections indicated. Children acutely ill are not treated, but
are referred to the pediatric or other departments for therapeutic
attention. At present the mental problems are handled by myself,
and the cooperation of the nurses and parents is secured in the
interest of the children's mental development.
Two agencies which are not in existence but are under con-
sideration and I trust will soon become active are a clinical psy-
chologist and a teacher of domestic sciences and arts. Mental
examinations require so much time and careful study, that it is
preferable to have a clinical psychologist devote himself to this
phase of the work under the direction of the chief of the class,
rather than to lessen the efifectiveness of the physician in the man-
agement of the regular group of children demanding his care.
WEIGHT CHART
WEIGHT NO
LOST I I
STATIONARY 2
GAItJED 97
With the report of the clinical psychologist in hand, it is possible
to cooperate through discussion concerning the needs of individual
children, to lay out a rational program for their development, and
to institute the measures of mental hygiene deemed necessary for
the protection and advancement of the children.
In as much as I regard the family as the focal unit for health
work with children, it is necessary to have some one capable of
assisting in raising home standards. The knowledge and experi-
ence of social service nurses, broad as they may be, are insufficient
to enable them to deal satisfactorily with many home problems.
For this reason a teacher of domestic sciences and arts is almost
a necessity. In addition to her particularized work with the home,
it is designed to arrange for various classes for mothers and
older children, with a view to instilling a working knowledge
concerning the numerous phases of home making that are so
166
Wile : Health Classes for Children
intimately related with familial health. Our experience has
demonstrated the willingness of parents to cooperate and their
sincere desire to improve their manner of home making in con-
sonance with the principles of hygiene and health.
By enlisting the services of a few socially minded persons to
serve as friendly visitors to assist in transporting children to
various clinics or social agencies, considerable advantage is gained,
family morale is raised, and the certainty of appointments being
kept is assured.
NUMBER OF DEFECTS PER CHILD
NO.
DEFECTS
10
or
CHILDREN
2a
Di
1^1 1
n2
7?l 1
□5
%l 1
1 l4
?fll 1
1 \S
91 1
1 ^6
71 J
rrFFcr5 606| ., j
This type of organization may appear to be too elaborate, but
it represents my conception of an effective scheme of health class
administration, providing that one person is responsible for the
working out of all plans and policies. To bring about a coordina-
tion of ideas and to encourage the enthusiasm for the work, occa-
sional meetings of the administrative group should be held for
the purpose of discussing results, criticising weaknesses, and
elaborating the plans in the light of multiple experiences. The
group of workers must function as a whole or the class fails to
reap the greatest benefits.
Wile: Health Classes for Children
167
When it becomes necessary to make specific investigations
into particular defects, the child is referred to the proper depart-
ment, but after a report is received, even though special treatment
be instituted, the child returns to the health class. Rarely is it
necessary to relegate a youngster to a special class for the relief
of malnutrition, for -cardiac care, or supervision, or for anti-
tuberculosis hygiene. As a matter of psychology, I believe it to
be disadvantageous to segregate children in classes designed to
treat specific deficiencies. In the first place, it tends to focus the
FREQUENCY OF DEFECTS NOTED IN 100 CHILDREN
T c e:th67E
"EDCUUSBa/NiSsf
EVES
sp(NeJI6L
HE^VRTJIIZE
izZ
sE
J7l
MENT/Mjn
HERNIA
nWHBSUCKlNG
BONES/JOINTS
LUNCS
mximnstm
SPEECH
EARS
CHORCA
LARGE LlVEt
ENURESIS
7[
4 ED
iD
iD
child's attention too much on its own ailment, and secondly, it
helps to create a sense of inferiority, both of which are undesirable.
By centering the attention upon the health aspects of the class, the
subsidiary examinations are considered as part of the general
investigation, and the necessity for subdividing attention becomes
less imperative. There are of course exceptions to this rule, as
for example, when it is necessary to send a child to a calisthenic
class in order to create proper postural habits or develop muscles
functioning improperly. Even under these circumstances, how-
ever, the child reports back to the health class with regularity.
168
Wile: Health Classes for Children
A large measure of our efforts is along educational lines. To
this end, use is made of posters, booklets, lectures, demonstrations,
and exhibits of various kinds, to illustrate the important phases
of health and hygiene. The educational message is delivered at
the class and supplemented by instruction in the home. Teaching
is personal and in groups, but always with the idea of the building
up of family health, as well as with the aim of securing the
physical betterment of the individual children belonging to the
group. We have established a certain amount of competition
among mothers by having 3 types of admission cards, indicating
3 relative degrees of proficiency in carrying out the instructions
GAIN PER MONTH PER CHILD
ROUMTim
mm
z
Ml
,95[
,96[
,65[
.75C
4r5C
.77C
.60[
given, and in cooperating towards a higher standard of health
habits and methods of living. Mothers are promoted and their
own efforts determine the rating deserved. The children bear
witness to the progress under home direction and more especially
maternal supervision.
The visitor is particularly struck by the fact that the health
class possesses an atmosphere peculiarly its own and unlike that
found in an ordinary clinic. The waiting room is not a place of
rigid discipline and formality, but abounds in cheerfulness and
activity. Adults and children are free to move about as they
Wile: Health Classes for Children
169
please and are encouraged to interest themselves in the work
going on, to study the educational material available, to compare
gains in weight, to note the progress of other children, and to
acquire the point of view that health is an asset worth achieving.
A sense of beauty and joy is fostered through an ample provision
of books, games, toys, rocking horses, a blackboard and the like,
for the use of the children. Tears are avoided or banished and
GAIN PER CHILD PER MONTH
5
6
8
9
10
IN OVERWEIGHT
■ SrtI
.5 1 I
.691
NORMAL WEIGHT
.0 1
11.4-C
2.0C
.5C
UNDER VIEI&HT CROUP
i.oi:
I.OC
ii.0C
IOC
I.ISC
141
the tone of a house of childhood predominates. As a result, there
is a feeling of friendliness and mutual interest which merges
into a spirit of cooperation and mutual assistance. Not merely
do adults aid with their children, but elder children willingly
assume responsibility for the correction and re-education of their
younger brothers and sisters. The humanizing element is essen-
tial in order to create the idea that the health class possesses a
high value and an attraction that makes it a real factor in pro-
moting familial health and morale.
170
Wile : Health Classes for Children
It is scarcely necessary to point out to this group the necessity
for health classes, or to dwell upon the physical benefits to be
derived from their further development. They represent . an
advance in health administration only in so far as they may be
regarded as the legitimate extension of the activities begun at
Infant Welfare Stations. They possess an added advantage in
that they impress the child's mind directly as well as indirectly,
and arouse a personal interest that is impossible during infancy.
They possess another valuable feature in that they serve to lessen
TOTAL
DURATION Na GAIN
LBS.
IMONTW
ZMONTOS
3M0NTHS
WONTTHS
TOTAL (00 250.50
''"J'w^AGE CAW PER CHILD
TIME UNDER SUPERVISION -AVERAGE GAIN PER CHILD
AND GAIN PER MONTH PER CHILD
II SU5
32 6X25
25 66.50
3X 112.50
J^AGE GAIN PER MONTH PCR CHILD
975L
SSfiL
1
the fear of children for physicians and reveal the profession to
them as interested in their health and happiness as well as in their
diseases and the distresses occasioning pain and discomfort. Fur-
thermore, it represents a further penetration of the wedge opening
up the common mind to the advantages of repeated physical ex-
amination when no recognizable invasion of disease exists. The
educational advantages are self evident and the opportunities for
promoting a rational plan of mental hygiene are plain.
Wile: Health Classes for Children
171
The question as to tangible results may properly be raised
and in order to bring these out clearly I have prepared certain
charts indicative of the statistical facts which will demonstrate
some of the benefits derived. It is impossible, however, to inter-
pret gains in weight in terms of gain in mental power. The
bare statistical statement of defects noted and corrected affords
no measure of the improvement of mind and soul, any more than
THEORETICAL VS. ACTUALGAIN PER CHILD PER MONTH
TH
AGE
EO
NO.'
2
J2
2
a
4
5
5
J2
6
9
7
JO
§
J3
9
8
\0
6
00
8
it can serve as an index of the gain in muscular power. For this
reason I am presenting few tabulations because I realize that
while mathematically correct they afford little information regard-
ing the actual improvement in the physical, mental, and moral
welfare of the children and their families. To calculate the num-
ber of children cured of nail-biting or lisping, or to enumerate in
bulk the number of mental defectives who have been studied and
directed gives no information regarding the complete results aris-
172 Wile: Health Classes for Children
ing from better self control or the enthusiasm which has been
developed for work within the range of mental possibility.
A long period of time must elapse before one can judge the
social benefits that accrue as a result of health classes. This
much, however, is certain — no agency possesses greater potentiali-
ties along physical, mental, and moral lines than health classes for
children. Their aims and methods are distinctly social and seek
to offer justice to childhood despite the difficulties of hereditary
or environmental origin. Their machinery is simple, their methods
rational, their service direct, and their results powerful for bet-
tering and strengthening the lives of children and potential citi-
zens. The plan should commend itself to those grappling with
the problems of Americanization, as one effective approach to this
difficult problem.
264 West 73rd Street.
Operation for Diaphragmatic Hernia (Paris Medical, Aug.
30, 1919). A. Schwartz and J. Quenu have been making a special
study of the best technic for correcting diaphragmatic hernia, and
they expatiate on the advantages of an incision in the seventh
interspace, starting at the axillary line and continued down to the
umbilicus. There is no need for rib resection. The incision is
carried down deep enough to open the pleura and peritoneum.
The cartilaginous margin of the thorax, to which the diaphragm
is c^ttached, is cut with scissors, and the incision resulting is con-
tinued in a straight line in the diaphragm to the hernia opening.
Both the thorax and the abdomen are thus opened up. The or-
gans that protrude into the thorax -are readily recognized and
reduced, the diaphragm sutured, the cartilage reconstructed and
a drain left in the pleura if adhesions had to be broken up. The
only drawback to this technic is the operative pneumothorax, but
this is regarded as of not much moment nowadays. The article is
illustrated. — Journal A. M. A.
AN INFANT HYGIENE CAMPAIGN OF THE
SECOND CENTURY.*
By John Foote^ M.D.,
Washington, D. C.
Much has been written concerning the degeneracy of Roman
civilization and the brutal indifference displayed by the civilized,
but not humanized, nations of antiquity in their treatment of the
newborn. There is abundant evidence in Roman literature of the
prevalence of the custom of exposure of infants and of abandon-
ment and infanticide. Plautus and Terence made merry with this
theme in more than one comedy, and many of the "modern"
cynical quips on matrimony unquestionably have come down from
the later days of the Roman Republic when, as Seneca says,
"some women reckoned their years by their husbands." And
yet — there is another side to this story of which we have heard
very little — the side which deals' with the efforts made by thought-
ful men and women of that day to put an end to practices which
they realized must eventually sap the foundations of national
virility and which in the second century A. D. crystallized into
what seems to this writer, at least, as a more than sporadic effort
to teach the lessons of infant hygiene to the general public.
We learned in our primary schools that the legendary Romulus
was himself an exposed infant who had been suckled by a wolf.
To increase his warlike subjects when he became ruler he obliged
his people to bring up all male children, except those deformed
and crippled, and also the first born of all females. But there
was also a human note in this decree, for even the crippled could
not be exposed unless 5 neighbors gave approval.
The word proletariat, so much used nowadays, had a specific
application in its original meaning : the proletariat consisted of
citizens wHo had no property, but who were valuable to the State
through the children which they produced. In the Rome of
Augustus, corruption of morals, with the consequent inroads upon
the legitimate population of the great world-metropolis, caused
that astute ruler to give early attention to legislation regulating
marriage and celibacy — the "lex Julia et Papia." In the old Rome
of the patria protestas, the father had the power of life or death
• Read before the American Child Hygiene Association at the Tenth Annual
Meeting in Asheville, N. C, Nov. 11-13. 1919.
173
174 Foote: An Infant Hygiene Campaign of the 2d Century
over his children ; now, however, the mere possession or non-
possession of offspring determined a man's legal rights. A mar-
ried man with no children could only take half of an inheritance.
In the holding of certain offices the candidate who had the most
children was given preference. All personal taxes were remitted
to Roman citizens who had 3 children. Citizens who lived in
Italy enjoyed this privilege if they had 4 children and those who
lived in the provinces if they had 5.^
These laws remained at least partly in force, despite the
changes of Caracalla and Constantine, until their abrogation by
Justinian. Augustus also set aside a reward of 2000 sesterces
(about $40.00) for anybody who would bring up an orphan.
From the death of Augustus, 14 A. D., to the accession of Nerva,
96 A. D., little social progress obtained amidst the political and
military turmoil of Rome. But from the time of Nerva to the
passing of the Antonine Emperors, such advances were made as
to emphatically warrant the assumption that child welfare of a
primitive kind was being propagated in Rome during the second
century. Nerva tried to put a stop to infant abandonment by
having the State subsidize poor parents (97 A. D.). Three years
later, 5000 children were receiving state aid. A coin shows the
emperor seated in a chair dispensing charity to a boy and girl,
with the inscription, "Tutela Italia." Trajan loaned money to
land owners, the interest of which was used to support parentless
or abandoned children.
Hadrian, who had Plutarch as a master and Suetonius for
a secretary, and who was himself a tremendous student and a
great traveler, might be expected to have enlightened and liberal
views in spite of his imperial absolutism. "Here in the second
century we see an emperor," Duruy says, "employing logic in
the service of humanity." For he ruled that any woman who
had been free at the time of pregnancy must as a result give birth
to a free child. Women were allowed to make wills and inherit
rights in the property of sons who died intestate. Carthaginian
priests had been forbidden by Tiberius to offer children in sacri-
fice to Moloch ; this law was repeated and enforced by Hadrian.
The right of the Roman father to kill his own son was abro-
gated— Hadrian banishing a father who had done this. The
reign of law as interpreted by jurists began with this emperor.
» "The Child in Human Progress," G. IT. Paine, New York, 1916, pp. 227, et seq.
FooTE: An Infant Hygiene Campaign of the 2d Century 175
Antonius Pius extended throughout Italy the loan system of
Nerva, the large income derived therefrom being devoted to the
care of abandoned children. An institution for the care of female
orphans, heretofore exposed without scruple, was founded in
honor of his wife Faustina, the "puellae alimentariae Faustinae."
A medal shows on one side Faustina and on the obverse Antonius
surrounded by children and inscribed "Puellae Faustinae."^
This work was continued and amplified by the great philo-
sophic emperor, Marcus Aurelius. But not only were these
passive measures employed to prevent destruction of child life, but
books were written bearing on the problems of the care of the
child and the importance of rearing healthy offspring — to spread
the propaganda of infant care.
It was during the reign of Trajan, between 110 A. D. and
130 A. D., that Rome became the home of the greatest obstetrician
and pediatrician of antiquity — Soranus of Ephesus. This won-
derful physician was the most illustrious of the school of Metho-
dists, founded by Asklepiades — but he was too great to be bounded
by the limitations of any narrow cult. He was probably educated
in Alexandria, but he came from a highly civilized region of
Asia Minor which had flourished under Grecian influences for
many generations, although today little remains but a memory
of the name of its beautiful city — Ephesus. The obstetrics of
that day was practiced by midwives, usually slaves. In difficult
or important cases, the physician was called. In the work of
Soranus, it is obvious that the directions for the care of the child
were written for use by the nurse or the mother, and that this
was to a certain degree a popular treatise similar to the "baby
books" of today. Translations and commentaries on Soranus
have been made in Latin, German and Russian ; Lieutenant Col-
onel Fielding Garrison, in an abstract not as yet published, was
probably the first to summarize the pediatrics of the Ephesian
physician in English.
At the XI International Medical Congress in Rome, (1895),
I, V. Troitski, writing in Russian, compared in parallel columns
the practice of Soranus of the second century with the teachings
of authorities of the late nineteenth century, an interesting docu-
ment, which, through the assistance of Mr. J. H. Ohsol, of
Washington, I am enabled to study carefully.^
'Ibid I, p. 248
' Soranus Ephesius," I. V. Troitski, Kiev, 1895. (In Russian).
176 Foote: An Infant Hygiene Campaign of the 2d Century
Anyone who examines Soranus's work on pediatrics, even
without its commentaries, will scarcely doubt that the Roman
physician wrote the most modern work on infant nursing that
appeared up to a century ago. The changes in modern nursing
care would be surprisingly few, if we excluded the innovations
due to our knowledge of antiseptics, while the practical instruc-
tion is so sound, that with some editing and the abandonment of
swaddling and wet nursing, Soranus's textbook could be used
in the education of the nurse or mother certainly to greater ad-
vantage than any work of a similar kind written up to the time
of Underwood.
Beginning with the twenty-sixth chapter of his book,* Soranus
tells how to determine the strength and vitality of the newborn,
by its cry and its appearance. The method of tying the umbilical
cord is next considered. He shows splendid surgical sense in
his directions, warning against the use of dull instruments and
lacerating methods. He tells how to care for the skin of the
newborn, and dismisses several faulty methods of the past. Swad-
dling he thinks necessary to keep the infant's limbs straight, yet
he cautions against certain vicious practices in connection with
this custom, gives each procedure in great detail, and insists
on cleanliness. The bedding and bedroom of the newborn next
claim his attention, and he insists on a soft mattress filled with
grass or linden fluff, again frequent changes of clothing and
absence of bad odors.
The feeding of the infant forms an extensive chapter. Soranus
declaims against giving foreign food to the newborn. No food
is needed for 3 days, he says. Possibly a little honey may be
given with water, but nothing else. As most of the obstetrics of
that day was performed by midwives there was much hemorrhage
and many infections in childbirth. "Milk under these conditions
is bad," says Soranus, "so it is best to secure a wet nurse for
the first few weeks." He believes in wet nurses — "it saves the
mother for future childbearing," he says, "and also saves her
beauty." Slaves were most frequently used for this purpose.
Soranus does not say that wet-nursing is the best practice — but
that it is the most expedient. Of course only the wealthy em-
ployed physicians and only the very wealthy an obstetrician.
*"Sorani Gynaeciorum," ed. Valentine Rose, pp. 248, 292 cap. XXVI — XLII,
Greek text, Liepsic, 1882.
Foote: An infant Hygiene Campaign of the 2d Century 177
Soranus unquestionably had a wealthy clientele, for he advises
not one wet nurse, but 2 or 3, in case one should be taken ill.
He tells very explicitly what kind of a woman to choose as
a wet nurse, how she should qualify physically and mentally.
"The essential mental qualities of a good nurse," he says, "are
patience, common sense, good nature or gentleness and neatness."
No one before or since has written more intelligently or more
exhaustively on this subject.
To judge of the quality of the nurse's milk he gives several
tests. "Do not judge the milk simply by a poor appearance of
the infant," he says, "for the milk may be of the best, and the
infant have some disease which prevents proper nutrition." To
test the milk he gives information as to its proper color, its odor,
its consistency. Its density is established by mixing it with water
and observing its behavior. He describes the taste of normal
human milk and how it should act when exposed to the air. Its
behavior when shaken, and the appearance and persistence of air
bubbles furnishes another index to its density. Also when a drop
of milk is placed on the finger nail it should not run off quickly,
nor change its shape when the finger is shaken moderately, but it
should do so when the hand is shaken rapidly. "When milk
proves satisfactory under these tests, even when the mother is
not on a proper diet, it is very good milk," says Soranus. Crude
as these tests were, they were valuable, and practical, and showed
what a careful, reasonable observer Soranus must have been.
He not only prescribed a rational diet for the nursing woman,
but also special exercises. The influence of indigestion on the
quality of milk is known and emphasized by him. He warns
against excessive use of wine by the nurse, and dissipation, gener-
ally, he condemns. The technic of breast feeding is next taken
up, conditions when the nurse should not nurse the child, the
proper position for nurse and infant, etc. "Feeding at irregular
intervals and often during the day and especially during the
night may be the cause of sickness in the infant." Soranus em-
phasizes this by saying that the infant should never be nursed
to satiation, nor should the nurse sleep with the infant nor allow
the infant to sleep while at the breast. Moderate crying is helpful
to the infant as exercise. "Crying," he says, "is not caused by
hunger alone. An inconvenient position, pressure of the clothing,
irritation of the skin, too much food, excessive heat, colic, and
178 FooTE : An Infant Hygiene Campaign of the 2d Century
various diseases may cause crying." He then tells with great
patience how to differentiate between the various causes. We
have read this same material in our ''modern" baby books ; it has
changed very little.
"Be careful not to move or swing the baby after feeding it —
or you will have vomiting," he says ; "and if the baby crys after
feeding it, do not threaten it or yell at it ; caress it, amuse it. Fear
is bad for infants."
To increase the quality and quantity of milk he advises a
careful examination of the nurse to see if any disease is present.
If none is discovered, then the watery milk may be improved
by eating concentrated foods such as eggs, goat's milk, flour meal,
etc., and drinking less water. Light exercise, singing, discus
throwing, deep breathing and massage are also recommended.
"All medicines and popular remedies used to increase the quality
of milk produced injure the stomach and the digestion of the
nurse," he says ; continuing, "the use of such medicines is simply
injurious."
To correct heavy milk he prescribes baths, lighter food and
more liquids.
He tells in great detail how to bathe and clothe the infant. To
atone for the inactivity produced by swaddling, Soranus gives a
complete system of massage and passive movements, which exer-
cise the infant's muscles. In all of these he is striving to prevent
asymmetrical development and deformities of the limbs.
How to care for the umbilical cord, to prevent hernia, when
and how to discontinue swaddling, how to teach the baby to sit
up and walk, and when and how to wean, are among the things
he writes about. He warns against the premature use of starchy
foods — "nothing but milk should be given up to the sixth month."
Honey is first allowed, later barley soup, then gruel from parched
grain, last of all eggs. The change to more solid foods is per-
missible at 1^ or 2 years. The infant should preferably be
weaned in the spring — never in the summer. Partial breast feed-
ing may be continued for I y'2 to 2 years.
The fat infant should be given less food ; the thin one, more
nourishing food. He discusses rational methods of curbing the
tendency of some children to overeat and of inducing others, with
poor appetites, to eat enough. "If a child becomes ill during
weaning," he says "stop weaning at once."
Foote: An Infant Hygiene Campaign of the 2d Century 179
The eruption of teeth is written of briefly. The gums must
not be pressed on or bruised at this time. The nurse also should
modify her milk by taking less solid food and more water.
Nothing written up to the late eighteenth century has equaled
the work of this physician of 1800 years ago in clearness, in
sound hj^gienic sense and in independence of thought. This will
be all the more remarkable if we remember that he wrote on a
subject that is even today overgrown with unsound tradition.
Soranus did not emphasize but rather approved the custom
long established in both Greece and Rome of allowing infants
to be nursed by wet nurses rather than their mothers. This course
was to him, perhaps, the path of least resistence. He was a Greek
and many of the ethn"ic arguments used later by Gellius did not
occur to him. It was better to have infants nursed by healthy
slaves than by dissipated mothers — that was probably his real
meaning when he said wet-nursing was "more expedient" than
maternal feeding.
History cannot trace Soranus after the year 130 A. D. In
that same year, Aulus Gellius, noted later as a Roman lawyer and
literateur, was born. Gellius spent some time in Greece, and
returning to Rome published his Noctes Attica-e, a series of dis-
courses on language, literature, history, sociology and many
other things. The Emperor Antonius Pius, whose reign began
in 138 A. D., inaugurated an unprecedented era of peace and
happiness in Rome. Conditions were favorable for the diffusion
of knowledge and the spread of ideas relating to public welfare,
and to the growth of altruism. So when the Greek philosopher
Favorinus speaks in the pages of Gellius, he is undoubtedly voic-
ing a positive sentiment concerning the custom of wet nursing
that had been growing up in Greece as well as in Rome, in marked
contrast to what was believed and practiced even in the time of
Soranus. Strangely enough, this speech of a legendary Greek
philosopher left a far deeper impress on the later medical litera-
ture than the splendid treatise of the historical Greek physician —
perhaps because the metaphysical style and emperical method of
Gellius appealed more strongly than Soranus' rational aphorisms,
to the post-medieval mind. The didactic poem, La Balia, written
about 1560 by Luigo Tansillo, was a metrical setting in Italian of
180 FooTE : An Infant Hygiene Campaign of the 2d Century
this essay.'* The same theories were set forth in Scaevole de St.
Marthe's Latin didactic poem, "Paedotrophia," pubHshed in 1584.®
In fact its influence can be seen in most of the early writers on
nursing — Bagellardo being one of the very first. Omnibus Fer-
rarius, of Verona (1577), quotes the lambs and goats-wool inci-
dent, as also does John Peachey in his treatise on infant feeding
(London, 1596). Jacques Guillemau (1609) says "the mother
who nurses her own infant is the complete mother," almost the
exact quotation of Gellius.'^ Van Swieten's "Aphorisms of Boer-
have" also shows its influence.^ In spite of its praiseworthy pur-
pose and its undoubted influence, the essay was very defective in
its physiology. Perhaps it made even better propaganda because
of that, but it is not true that milk is simply blood turned white,
nor are mental and physical characteristics transmitted by mater-
nal milk. Thus have the microscope and the test tube shattered
many a picturesque belief. The disregard shown by the great
philosophers, Plato and Aristotle, to the rights of the living child
is in marked contrast to the stand of Favorinus on the question
of the destruction of the embryo "while it is still in the hands of
its artificer nature," which he characterizes a practice "deserving
of public detestation and abhorrence." This would seem a strange
doctrine for that day — yet it is simply another evidence of a
changed sentiment of thinking men and women in their attitude
toward the child.
The following is a translation of the Gellius essay, a familiar
work to all students of Latin literature:
"Dissertation of the philosopher Favorinus in which he induced
a lady of rank to suckle her child herself, and not to employ
nurses."^
"Word was brought to Favorinus, the philosopher, when I
was with him, that the wife of one of his disciples had been con-
fined and a son was added to the family of his pupil. 'Let us go,'
he said, 'to see the woman and congratulate the father.' The
father was a senator and of noble family. All of us who were
<* "The Nurse," a poem, translated from the Italian of Luigo Tansillo, by William
Rosco, Liverpool, London, 1798.
* "Paedotrophia," translated from the Latin of Scaevole de St. Marthe, by H. W.
Tytler, M.D., London, 1797.
' "Some Seventeenth Century Writings on Diseases of Children," G. Still, in
Osier Anniversary Volume, New York, 1919.
* "The Commentaries on the Aphorisms of Herman Boerhave," Van Swieten,
translated by Kapton and others, Edinburg, 1776.
* Noctes Atticae, Aulus Gellius, Lib. xii Cap. i. See also translation by Beloe,
London, 1797.
FooTE : An Infant Hygiene Campaign of the 2d Century 181
present, followed him to the house and entered with him.' As
soon as he had entered, embracing and congratulating the father,
he sat down and inquired whether the labor had been long and
painful. When he was informed that the young mother, over-
come with fatigue, had gone to sleep he began to converse more
at ease. 'I have no doubt,' he remarked, 'but that she will suckle
her son herself.'
"But when the mother of the lady said that she must spare
her daughter and find nurses for the child, that to the pains of
childbirth might not be added the toilsome and difficult task of
suckling the infant, he replied-: *I entreat you, madam, to allow
her to be the sole and entire mother of her own son. For how
unnatural it is, how imperfect and half motherly only, to bring
forth a child and instantly send him away ; to nourish in her own
womb, with her own blood, something which she has never seen
and then to refuse to support with her own milk the object which
she now sees, endowed with life and human attributes, imploring
the tender care of a mother.'
" 'And do you suppose,' he continued, 'that nature has given
bosoms to women only to add to their beauty — more for the sake
of ornament than for the purpose of nourishing children. Be-
cause some women believe this (and may this be far from you),
they unnaturally endeavor to dry up and extinguish that sacred
fountain of the body, the natural nourishment of man, with great
hazard, turning and corrupting the channel of their milk, lest it
should render the distinction of their beauty less marked.
" 'They do this with the same insensibility as those who en-
deavor by the use of quack medicines and in other ways to destroy
their conceptions, lest the same should injure their persons and
their figures. Since the destruction of a human being in its first
formation, while he is still in the hands of his artificer nature, re-
ceiving life itself, is deserving of public detestation and abhor-
rence, how much more so must it be to deprive a child of its
proper, its accustomed and congenial nutriment when at last it
is perfected and produced to the world ? It will be said, perhaps,
that this omission is of no consequence provided it be nourished
and kept alive by human milk, whoever may nurse it. Why does
not he who says this, if he be so ignorant of nature's workings,
suppose likewise, that it is of no consequence from what body or
from what blood a human being is formed and put together? Is
182 FooTE : An Infant Hygiene Campaign of the 2d Century
not that which is now in the breasts the blood of the mother which
has become white in color by much spirit and warmth — indeed
the same that was in the womb? And is not the wisdom of nature
apparent also in this — that as soon as this blood, which is the
artificer, has formed the new human body within its penetralia,
it rises into the upper parts and is ready to cherish the first parti-
cles of life and light, supplying known and familiar food to the
newborn infants? Wherefore it is believed with reason, that as
the power and quantity of the parent cells avail to form likenesses
of the body and mind, in the same degree also the nature and
properties of the milk are potent toward effecting the same pur-
pose. Nor is this confined to the human race ; it is also observed
in beasts. For if kids are brought up by the milk of sheep, or
iambs with goats, it is plain by experience that in the former is
produced a harsher sort of wool, in the latter a softer species of
hair. So in trees and in corn, their strength and vigor is great
in proportion to the quality of the soil and moisture which nourish
them, rather than of the seed which is put in the ground. Thus
you often see a strong and flourishing tree when transplanted die
away from the inferior quality of the soil. What can be the
reason, then, I ask you, that you should corrupt the dignity of a
newborn human being formed in body and mind from principles
of distinguished excellence, by the foreign and degenerate nour-
ishment of another's milk? Particularly if she whom you hire
for the purpose of supplying the milk be a slave, or of servile con-
dition, or, as often happens, of a foreign or barbarous nation, or
if she be dishonest, or ugly, or unchaste, or drunken ; for often,
without hesitation, anyone is hired who happens to have milk
when wanted. And shall we then suiTer our own child to be pol-
luted with a pernicious contagion, and to inhale into its body and
mind a spirit drawn from a body and mind of the worst nature?
This, no doubt, is the cause of what we so often wonder at, that
the children of chaste women often turn out unlike their parents,
being dififerent both in body and mind. Wisely and skillfully has
our poet Virgil (4th Aeneid — V 367) spoken in imitation of
Homer's lines :
* Sure Peleus ne'er begat a son like thee
Nor Thetis gave thee birth ; the azure sea
Produced thee, or the flinty rocks alone.
Were the fierce parents of so fierce a son.'
FooTE : An Infant Hygiene Campaign of the 2d Century 183
" 'He charges him not only upon the circumstance of his birth,
but his subsequent education, which he has called fierce and sav-
age. Virgil to the Homeric description has added these words :
'And fierce Hyrcanian tigers gave thee suck.'
" 'Undoubtedly in forming the manners, the nature of the milk
takes in a great measure the disposition of the person who sup-
plies it, and then forms from the seed of the father, and the person
and spirit of the mother, the infant offspring. And, besides, who
can consider it a matter to be treated with negligence or con-
tempt that while they desert their own offspring, driving it from
themselves and committing it for nourishment to the care of
others, they cut off, or at least loosen and relax, that mental obli-
gation, that tie of affection, by which nature binds parents to their
children? When a child is removed from its mother and given
to a stranger the energy of maternal fondness is checked little
by little, and all the vehemence of impatient solicitude is put to
silence. And it becomes much more easy to forget a child which
is put out to nurse than one of which death has deprived us.
Moreover, the natural affection of a child, its fondness, its famili-
arity, is directed to that object only from which it receives its
nourishment, and as a consequence (as in the case of infants
exposed at birth), the child having no knowledge of its mother,
does not regret her loss.
" 'Having by this destroyed the foundations of natural affec-
tion, however, children thus brought up may seem to love their
father or mother, that regard of theirs is not natural but the
result of civil obligation and social opinion.
"These sentiments, which I heard Favorinus deliver in Greek,
I have related so far as I could for the sake of their common
utility. But the elegancies, the copiousness and the flow of his
words could hardly be arrived by any power of Roman eloquence
— least of all by any which I possess."
When this was written, the Emperor Antonius Pius was in
power and was destined to be succeeded by Antoninus Marcus
Aurelius. There can be little doubt that during these years,
which have been characterized as the happiest for children in the
history of ancient Rome, the gentle and humanitarian trend of
the Stoic philosophy, diffused and inculcated by the Antonine
Emperors, had done much to spread the germinal ideas of such
pioneers as Soranus and Aulus Gellius. A campaign for infant
184 FooTE : An Infant Hygiene Campaign of the 2d Century
hyg-iene, small in its beginnings, was in the making, though its
immediate and even remote effects were soon to be swept away
in the bloody days that stretched from the end of the reign of
Marcus Aurelius to the accession of Septimus Severus.
1861 Mintwood Place.
The Nervous Child (Jour. A. M. A., Oct. 11, 1919). Ac-
cording to E. B. McCready, the well-poised, efficient, emotionally
stable adult is the exception rather than the rule in modern life,
and procrastination as regards proper treatment of nervous and
mental disorders is altogether too common. The physicians are
apt to belittle the cases when first consulted, and this class of dis-
ease is insidious in its onset. Pessimistic prognoses are also dan-
gerous. While some children are born nervous from heredity,
some acquire nervousness from habits or disease and others have
nervousness thrust on them through faulty home and school train-
ing. It is the physician's duty to counteract all these conditions
and influences, which tend toward aggravation at puberty. There
are physical anomalies — cranial or facial asymmetries, ocular de-
fects, enlarged tonsils, nasal deviation, delayed puberty, abnormal
growth, etc. Attempts to classify and label cases are useless —
it is enough to say the child is nervous, and, therefore, a potential
neuropath or psychopath. Its defects must be looked after as
early as possible and its environment modified. Unfortunately,
this is adapted to meet the adults' conditions, especially in cities,
and no matter how conscientious the parents may be they may
lack the training required. Most children are overstimulated in
modern life, and many deleterious conditions are overlooked be-
cause they are common. Overfatigue in children brings about
irritability, and the exciting conditions of urban life are liable to
cause it. Diet is also important, as well as fresh air and exercise.
Country life is likely to be better in all these respects than city
life. The utilization of nature insisted on by Sequin in the edu-
cational system is specially important and his general rules for
garden schools are quoted, but his ideas, unfortunately, have not
been, as a whole, put in practice. McCready promises a descrip-
tion of a practical method of education for nervous children, based
on Sequin's theories, in a further article. — Journal A. M. A.
DEPARTMENT OF ABSTRACTS
Francioni, C. : Acute Polyencephalitis with Narcolepsy.
(Bullettino delle Scienze Mediche, June, 1919.)
A boy, 7 years of age, was suddenly seized with spasmodic
movements of both eyes and profound somnolence. Gradually
extreme difficulty was experienced in opening the eyes, while mic-
turition became scant. Slight irregular elevation of temperature.
On entering the clinic this child presented bilateral ptosis, rigid
attitude, indifference to all surroundings and great tendency to
fall asleep. This all through a lengthy examination. Tendency
to cjttalepsy of all limbs. Exaggerated reflexes, clonus of feet.
Temperature 38 C, pulse 80, not very good. Lumbar puncture,
done several times, only revealed lymphocytosis in moderate
degree, gradually disappearing as the patient improved. Blood
count normal. Wassermann negative in spinal fluid, undecided
in the blood.
No previous history of illness. Only 3 months previously the
boy had had a slight attack of influenza.
Francioni after discussing his diagnosis emphasizes the fact
that for centuries past there has been in Europe a periodic recur-
rence of what has been variously called encephalitis lethargica or
epidemic stupor. He would not venture to connect the present
illness with the attack of influenza, C. D, Martinetti.
ScHREiBER, G. : Early Congenital Myxedema. (Archives
de Medecine des Enfants, No. 5, 1919.)
This condition is not frequently met and is well illustrated by
the case referred to in this paper. The child was seen at 5
months. Was the first of perfectly healthy parents, breast fed and
was seen by the author only because it refused suddenly to nurse.
Weight had remained stationary for some time (kg. 4.120). All
the signs of myxedema were present. No thyroid was discernible
on palpation. Length of body 56 cm. Thyroid was administered
to the mother, giving 10 centig. of thyroid extract for 10 days,
then again after a rest of 5 days. At the age of 11 months the
baby weighed kg. 4.480. No teeth had appeared, the characteristic
185
186 Department of Abstracts .
aspect continued, although some improvement was evident.
Thyroid was being administered to the baby itself when it became
ill and died of another disease. C. D. Martinetti.
, Morquio, L. : Malignant Endocarditis in Infancy. (Ar-
chives Espanoles de Pediatria, March, 1918.)
This condition in infancy is rare. Three cases were seen, all
following acute articular rheumatism or typhoid fever (1 case).
In all was seen embolism with right hemiplegic symptoms. All
cases ended fatally. The general course of the disease was that
of a general septicemic infection. In only one case was autopsy
possible, confirming the diagnosis. C. D. Martinetti.
Spolverini, L. M. : Etiology and Pathology of Infantile
Asthmatic Nervosis. (La Pediatria, October, 1918.)
Nineteen cases of children who had repeated asthmatic attacks
have been studied by Spolverini. Four principal facts have
emerged, as follows : All the cases presented a well pronounced
lymphatic habitus. In all was evident extreme irritability and
excitability of all the peripheral nervous system. There was in
almost all a history of uricacidemia in the parents. In all cases
considerable improvement was derived from adrenal preparations,
iodides, calcium and mineral waters.
The adrenal preparation employed was one named adrenofer
and was given upon the theory that in asthma of nervous origin
the primary cause might be a lesion of the bronchial sympathetic
system. This was proved true by experiments with an agent that
caused depression of tone of the sympathetic, such as lympho-
gangline, whereby the symptoms were immediately aggravated.
The precise nature of infantile nervous asthma would thus be
found to be in a loss of balance in the endocrine function of the
lymphatic ganglia. More light on the subject will be given later
by the accurate determination of hyperfunction of the lymphatics
and of the hypofunction of the adrenals. C. D. Martinetti.
Earl, Robert: Surgical TREATME^^^ of Jacksonian Epi-
lepsy. (Minnesota Medicine, September, 1919, p. 325.)
The author believes that the outlook in Jacksonian epilepsy
without the help of surgery is practically hopeless. Under this
Department of Abstracts 167
head he places the clonic spasms which are known to have the
exclusive origin in the motor area of the cortex, and which fol-
low the anatomic arrangement of the cortical centers, affecting
first one, then the other, and so on in rotation. Consciousness
may be retained or lost ; the latter is usually the case where the
entire body participates in the seizure. The course of the disease
is progressive so that in time it may become similar to the grand
mal of essential epilepsy, but from the surgical standpoint they
must be kept separate for surgery will have much to do with
the Jacksonian type and little to do with the essential form. The
etiology is most frequently trauma, including birth injuries, with
resulting meningeal hemorrhages, cortical lacerations which may
result in cyst formation, brain softening, meningeal adhesions
and scars. As operations with the removal of cortical irrita-
tion have not been particularly brilliant, it is all the more neces-
sary to take preventive measures. Immediate surgical treatment in
all cases of head injuries, in which there is evidence of fracture,
depression, hemorrhage, or severe edema, will do much to avoid
a possible future epilepsy. In operating, cerebral localizations
should be our guide to remove focal lesions causing Jacksonian
epilepsy. When there is difficulty in determining the exact loca-
tion of these lesions, the faradic current is of great assistance,
the electrode being applied directly to the cortex and watch made
for muscular contractions of the face, trunk and extremities.
The prognosis for focal epilepsy although better than that for
the idiopathic group, is still far from what we could wish. In
the cases, however, in which a definite lesion is found and re-
moved, a complete cure may be looked for.
James Hoyt Kerley.
Pastore, R. : Clinical Results of Vaccine Therapy in
Pneumococcus Infections. (La Pediatria, September, 1918.)
In the Pediatric Clinic of Palermo, the author has been giving
a thorough trial to vaccine therapy in infective diseases of child-
hood. While administered hypodermically the vaccines have
seldom given favorable results, the same vaccines administered
intravenously have proved remarkably efficacious. Eight cases
of pulmonary infection from pneumococcus are reported, several
188 Department of Abstracts
of them with empyema. The vaccine in all apparently arrested
the process without surgical intervention.
C. D. Martinetti.
Gerstenberger, H. J. AND Champion, W. M. : The Consti-
pating Qualities of Orange Juice, (American Journal of
Diseases of Children, August, 1919, p. 88.)
Observations made by Gerstenberger and Champion in a
normal infant 10 months of age to ascertain the relative position
as a cathartic or laxative of orange juice to an equal amount of
a 10 per cent sugar solution composed of 6.5 per cent glucose
and 3.5 per cent sucrose show in one period no difference be-
tween the two solutions, and in the other period a relative laxa-
tive advantage of the sugar solution over the orange juice, or
better, a relative constipating ability of orange juice as compared
with the effect obtained with the 10 per cent sugar solution.
During the sugar solution period anywhere from 95.71 to 96.53
per cent of the water output went by way of the kidneys, and
from 4.29 to 3.47 per cent went through the intestines, while in
the case of the orange juice from 97.15 to 97.25 per cent of the
fluid output went by way of the kidneys, and from 2.85 to 2,74
per cent by way of the intestines. In other words, orange juice,
relatively .speaking, has been less laxative than a 10 per cent sugar
solution when given in doses of 15 c.c, six times in 24 hours.
This observation confirmed their practical experience that orange
juice in the maximum amounts ordinarily used had more of a
constipating than a laxative effect, and, therefore, should only
be used as an antiscorbutfc or as a diuretic, but not as a laxative,
and especially not for children who are already constipated.
These observations they claim point to the important role that
diuresis may play in the production of constipation, and it may
be possible that some of the cases of constipation in infants sup-
posed to be due to an abnormally long retention of the feces in
the gut and a consequent too complete absorption of water in
the large intestine are primarily due to the presence of a factor
that causes an abnormal increase in the excretion of water
through the kidneys.
C. A. Lang.
Department of Abstracts 189
An Electro-myographic Study of Chorea. ' (Johns Hop-
kins Hospital Bulletin, February, 1919, p. 35.)
In a clinical study of the neuro-muscular phenomena of chorea
by a graphic method, quite a new attitude is taken from the usual
endo-carditic or infectious standpoint. The following conclusions
were reached after making studies of voluntary contractions of
normal muscles, voluntary contractions of involved muscles, and
of involuntary contractions of involved muscles :
1. Choreiform movements give an electro-myo-gram similar
to that of a short, normal voluntary muscular contraction,
2. The inability to maintain voluntary contraction is clearly
shown in the electro-myo-grams.
3, Weakness of muscular contraction is shown electro-myo-
graphically by the lessened electrical discharge.
Hugh Chaplin.
Holt, L. Emmett; Courtney, Angelia M. ; and Poles,
Helen L. : Fat Metabolism of Infants and Young Chil-
dren. H. (American Journal of Diseases of Children, June,
1919.)
The authors continue their observations on fat metabolism.
The material in this article consisted of 128 stools of 77 infants,
whose ages ranged from 2 to 18 months, fed on modified cow's
milk formulas. The average fat percentage of the dried weight
in normal stools was 36.2. The hard, constipated stools showed
no variation from this figure. In the stools not quite normal in
appearance, the average fat per cent was slightly lower. In
severe diarrhea the fat per cent of dried weight was much higher,
reaching an average of 40.7 per cent. The soap per cent of total
fat was very high in both normal and constipated stools, aver-
aging, respectively, 72.8 and 73.8 per cent. As the stool became
less normal in appearance, the soap fat diminished rapidly and
averaged in the loose stools only 30.6 per cent of the total fat,
in the diarrheal stools 12.4 per cent, and in those of severe
diarrhea only 8.8 per cent of the total fat, the neutral fat was
less than 10 per cent of the total fat in normal and constipated
stools. It increased as the soap fat diminished and in diarrheal
conditions made up about 60 per cent of the total fat in the
stools. The free fatty acids constituted about 17 per cent of the
190 Department of Abstracts
total fat of normal and of constipated stools. It was increased
somewhat as the stools became less like the normal and in the
diarrheal stools was over 30 per cent of the total fat of the stool.
No definite relationship was shown between the daily fat intake
and the per cent of fat or the distribution of fat in the stool.
The average per cent of the fat retained with normal stools was
91.3 per cent of the intake. The retention was but little lower
when the stools were somewhat harder or softer than normal, or
were not homogeneous, or contained more or less mucus without
being distinctly watery. As the water in the stools increased, the
per cent of retention dropped markedly, reaching in severe diar-
rhea 58.4 per cent of the intake. There was no striking relation
between the fat intake and the per cent of the intake retained,
except when the intake was abnormally low. C. A. Lang.
Austin, R. S. : Bacillus Tuberculosis in the Tonsils of
Children Clinically Non-tuberculous. (American Journal
of the Diseases of Children, July, 1919, p. 14.)
In a review of the literature, Austin found that Latham re-
ported 45 cases, 7 of which showed tuberculosis. Friedmam
reported 145 cases with 17 showing tuberculosis. Kingsford re-
ported 17 cases with 7 cases of tuberculosis. Hess reported 13
cases with 1 case of tuberculosis. Mitchell reported 100 cases
in which the tonsils were removed from patients with tubercu-
lous neck glands ; 44 of these had tuberculosis of the tonsils.
He reported also 100 cases in which the tonsils were removed
from patients without signs of tuberculosis ; 13 of these had tuber-
culosis of the tonsils. Before commencing the examination of
the tonsils from the group of cases on which his paper is based
Austin developed a method by which inoculation of guinea-pigs
with tonsillar material would not produce a high mortality, but
which at the same time would not involve destruction of the
tubercle bacillus. Five pairs of tonsils were removed from
healthy children and after removal were received into a sterile
tube, washed thoroughly, then placed in a sterile glass mortar,
minced into fine pieces with pointed scissors and ground with
a glass pestle, all with aseptic precautions. A small amount of
physiologic salt solution was found to facilitate the grinding.
The ground material, after being thoroughly mixed, was then
Department of Abstracts 191
divided into two portions. To one of these portions was added
a very small amount of growth from a culture of tubercle bacil-
lus which was mixed in thoroughly. Each of the two portions
of tonsillar material was then mixed well with about twice its
volume of antiformin and the mixture placed in a centrifuge
tube in the incubator at 37° for 3 hours or less. The antiformin
was then removed as much as possible by successive washings
in the centrifuge with saline solution. After the last washing,
about 3 c.c. were left in each tube, half of this being used to
inject into the crushed lymph glands in the left groin of a guinea-
pig of about 300 grams weight, the other half being preserved in
case the animal died prematurely. Of the guinea-pigs injected
with the material to which no tubercle bacillus culture had been
added all but one survived for 7 weeks ; they were then killed
and were found to show no evidence of tuberculosis at necropsy.
All but one of the animals receiving material to which tubercle
bacilli had been added developed firm enlarged glands in the
groin on the left side in from 2 to 5 weeks. They were then
killed and revealed tuberculous lesions in these glands, in the
spleen and sometimes in the liver and elsewhere. The excised
tonsils from 45 children were examined for the presence of
tuberculosis, using the inoculation test as above described. Of
the 45 children, 15 were from 2y^ to 5 years of age, and 30 from
5 to 12 years of age. All were well or fairly well developed
and nourished. There was a history of tuberculosis in the fam-
ilies of two of the children but none of the latter had any record
of tuberculosis in their past histories. The cervical lymph glands
were enlarged in 21 cases, in none to any very marked degree
or with suggestion of tuberculosis; in the other 24 cases these
glands were not enlarged. In no case was there evidence on
physical examination of tuberculosis in the lungs or elsewhere.
Only one case gave a positive test for tuberculosis which proved
to be of the human type. The author states that although tuber-
culosis of the tonsils in children is not rare yet most of the cases
occur when there are tuberculous lesions to be found elsewhere
in the body, especially in the cervical lymph glands. The occur-
rence of the tubercle bacillus in the tonsils of children without
clinical evidence of tuberculosis, however, is not frequent.
C. A. Lang.
BOOK REVIEW
Diseases of the Chest and the Principles of Physical
Diagnosis. By George William Norris, A.B., M.D., Assis-
tant Professor of Medicine in the University of Pennsylvania ;
Visiting Physician to the Pennsylvania Hospital; Assistant
Visiting Physician to the University Hospital ; lately Colonel,
M.C., U. S. Army. And Henry R. M. Landis, A.B., M.D.,
Assistant Professor of Medicine in the University of Pennsyl-
vania; Director of the Clinical and Sociological Departments
of the Henry Phipps Institute of the University of Pennsyl-
vania; Visiting Physician to the White Haven Sanitorium.
With a chapter on the Electrocardiograph in Heart Disease by
Edward B. Krumbhaar, Ph.D., M.D., Assistant Professor of
Research Medicine in the University of Pennsylvania. Second
Edition Revised. Philadelphia and London, W. B. Saunders
Co., 1920.
The reviewer of this book first came across it 2 years ago
while in the Army. Books were scarce, and a medical library
was not at hand. Being a children's man, and not having listened
to adult hearts and lungs for some years, he was frequently
puzzled in regard to the interpretation of the signs he found, as
naturally they were quite different to those found in infants and
children. He accordingly used Norris and Landis as the basis
for brushing up half forgotten lore on the physical examination
of the chest, and incidentally discovered what an unusual book
it 'was in every way. This second edition more than fulfils the
promise of the first. It still remains the best book of its kind
written. Much has been added. Among the new topics may be
mentioned spirochetal bronchitis^ influenza, streptococcus empy-
ema, chronic inflammatory conditions of the lungs of uncertain
etiology, calcification of the lungs, pneumopericardium, etc. In
addition, the rest of the book has been somewhat re-written in
the light of present day additions to our knowledge. Of especial
interest to pediatrists is the section on physical findings in infants
and young children written by Dr. Gittings. Another interesting
section is the chapter on the electrocardiograph in heart disease
by Dr. Krumbhaar. The book is profusely illustrated through-
out, and contains many cuts of anatomic sections which prove a
real help in elucidating the text. It is a book that should be in
every doctor's book case, be he pediatrist or general practitioner.
192
Archives of Pediatrics
APRIL, 1920
HAROLD RUCKMAN MIXSELL. A.B., M.D.. Editor
CHARLES ALBERT LANG, M.B., M.R.C.S., Associate Editor
COLLABORATORS :
L. EuMETT Holt, M.D New York Fritz B. Talbot, M.D Boston
W. P. NoRTHRUP, M.D New York Maynard Ladd, M.D Boston
Augustus Caiiaj&, M.D New York Charles Hunter Dunn, M.D Boston
Henry D. Chapin, M.D New York Henry I. Bowditch, M.D Boston
Francis Huber, M.D New York Richard M. Smith, M.D Boston
Henry Koplik, M.D New York L. R. De Buys, M.D New Orleans
Rowland G. Freeman, M.D....New York S. S. Adams, M.D Washington
Walter Lester Carr, M.D. . .New York B. K. Rachford, M.D Cincinnati
C. G. Kerley, M.D New York Irving M. Snow, M.D Buffalo
L. E. La FfiTRA, M.D New York Henry J. Gerstenberger, M.D. .Cleveland
Royal Storrs Haynes, M.D... New York Borden S. Veeder, M.D St. Louis
Oscar M. Schloss, M.D New York William P. Lucas, M.D... San Francisco
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Edwin E. Graham, M.D Philadelphia Frederick W. Schlutz, M.D.Minneapolis
J. P. Crozer Griffith, M.D.Philadelphia Julius P. Sedgwick, M.D. . .Minneapolis
J. C. Gittings, M.D Philadelphia Edmund Cautley, M.D London
A. Graeme Mitchell, M.D. .Philadelphia G. A. Sutherland, M.D London
Charles A. Fife, M.D Philadelphia J. D. Rolleston, M.D London
H. C. Carpenter, M.D Philadelphia T. W. Ballantyne, M.D Edinburgh
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PUBLISHED MONTHLY BY E. B. TREAT & CO., 45 EAST 17tH 8TBEET, NEW YOBK.
ORIGINAL COMMUNICATIONS
HELIOTHERAPY: ITS GENERAL USE IN PEDIATRICS.
By William Palmer Lucas, M.D.,
Professor of Pediatrics, University of California Medical School
San Francisco
Historical: The mythology of Egypt, Syria, Persia, and
Greece constantly refer to the sun and its intimate relation to man
and his destinies. The sun was life giving and not to be feared,
but to be reverenced and worshipped. Aesculapius, the famous
Greek physician, was supposed to be the son of Apollo. In Roman
days, its use was certainly appreciated, especially from a pleasur-
able aspect. We find that the Roman aristocracy built solaria in
their homes and enjoyed the sun bath, Herodotus going so far as
to outline the method of taking one. The Romans made use of
it also for nervous diseases, arthritis and certain gynecological
193
194 Lucas: Heliotherapy; Its General Use in Pediatrics
conditions as well as in diseases of the skin and of the extremities,
such as edema and elephantiasis. Amontj elementary races, we
find the power of the sun considered from a religious rather
than a medicinal standpoint. In Central America, even before the
Spanish days, we find that it was used in various conditions and is
now used in syphiHs, tuberculosis, and rheumatism. In North
America, the Indians worshipped the sun and believed in its
healing power. Due to this fact, that the sun had been worship-
ped, scientific medicine has more or less discarded what seems to
be a valuable adjuvant to ordinary hygienic treatment. In modern
times we find prominent physicians, Swedish, Russian, French,
English, German and Austrian, more and more applying direct
rays of the sun as an aid in the treatment of various chronic
conditions. Certainly, since the beginning of this century, its use
has become more and more general among members of the
medical profession and this is based on definite physiological re-
actions which are produced by the sun's rays.
Physics of the Sun's Rays: The sun's rays, on account of
the extreme heat of the sun, proceed at a tremendous rate through
the surrounding ether. Waves are thus created, which are sup-
posed to be spherical and to move in all directions from the cen-
ter. The rays proceed at the same rate but as various rays are
of various lengths, the speed at which they proceed varies very
considerably. The distance of the earth from the sun, calculated
to be 90,800,0CX) miles, is traversed by these rays in approximately
8 minutes. Scientific investigations have demonstrated that the
vibrations from the sun possess various qualities, the ones which
we usually appreciate being heat and light. These qualities depend
on the various wave lengths and the number of oscillations per
second, the rate of all waves being the same, that is 186,500 miles
per second.
We are all familiar with the spectrum, produced by the sun's
rays passing through a prism, giving red at one end and violet
at the other. The 7 colors of the spectrum are simply the wave
lengths which the human retina can distinguish. There are,
however, many other rays on either side of the red and violet
which modern scientific investigations have clearly demonstrated.
The presence of infra-red rays can be demonstrated by placing a
thermometer beyond the red rays which we appreciate as being
the main heat rays of the spectrum. Beyond the violet rays, by
Lucas: Heliotherapy; Its General Use in Pediatrics 195
equally delicate instruments, we can distinguish other photographic
rays or ultra-violet rays. Beyond the infra-red rays are the so-
called Hertz waves and the N-waves, both of which are supposed
to be heat waves of various intensity, whereas beyond the ultra-
violet rays, at the other end of the spectrum, are the x-rays or
roentgen rays. From the N-waves, which are the longest waves
and the waves with the least frequency per second which have so
far been demonstrated, and the x-rays which are the shortest rays
and the ones with the greatest frequency per second, we have
many variations in wave lengths. All these waves, however, are
supposed to have 3 definite properties, heat, light and chemical
action, though these differ quantitatively in the various wave
lengths.
Beyond the Hertz waves are the electric waves which are sup-
posed to originate from sun spots and to produce meteorological
and magnetic conditions on our planet. Among these sun rays or
waves, we find the waves which have been used for wireless
telegraphy and which were first described by Professor Hertz in
1886. They are termed electrical because they can be produced
by such apparatus as the Leyden jar and the RuhmkorfT coil.
These rays are not electrical waves but are ether waves, though
they can be transformed into electrical waves as we know them.
Their efifect on the body is probably much the same as high fre-
quency currents of electricity which are used therapeutically and
are undoubtedly concerned with nerve action. Especially is this
probably true of N-waves which were first described by Blondlot
of Nancy (Nancy-N). Their exact position in the spectrum has
not been finally settled, some holding that the N-rays are really at
the other end, near the x-rays. The N-rays have been shown by
Charpentier to increase the luminesence of the glowworm and this
he believes to be a proof that the sun's rays intensively influence
the body cells.
These rays are also produced in a number of ways, as when
we compress matter by muscular contraction. They emerge from
irritated nerves and they radiate from brain centers when they
are momentarily in action. The action of the heat and light rays,
in the neighborhood of the red and yellow rays, is far better
understood than is that of the so-called chemical rays, in the
neighborhood of the violet and ultra-violet, which possess power-
ful chemical action. This chemical action is produced by the fact
196 Lucas: Heliotherapy; Its General Use in Pediatrics
that they link together atoms of oxygen to form ozone, and ozone
has a very marked bactericidal property, clearing the atmosphere
as well as polluted water. For this reason, these waves are pre-
sent in greater numbers at higher altitudes for from 25-30 per
cent of these chemical rays are taken up by dust in a lower alti-
tude, especially in cities. The roentgen or x-rays probably never
reach the earth but nevertheless exist in the sun's rays.
The bactericidal action of the sun's rays has been known for
many years. Down and Blount in 1877 and T. P, Hunt in 1878,
showed the bactericidal action of the sunlight. Dieudonne found
that direct sunlight killed or inhibited bacteria. The bactericidal
power of the ultra-violet rays varies somewhat according to alti-
tude. The higher the altitude the quicker and more certain is the
bactericidal eflfect, being nearly twice as rapid at 5,000 feet altitude
as at the seashore. Diffuse light also requires much longer for
its bactericidal action.
This chemical action is not only proved to exist by its action on
bacteria but also by its action on toxins and antitoxins, having a
very much greater effect on toxins than on antitoxins. The diph-
theria toxin quickly loses its toxic property by the "action of these
chemical or actinic or ultra-violet rays, whereas diphtheria anti-
toxin is much less affected and takes a longer time to lose its
antitoxic property. Further demonstration of its chemical action
can be easily shown in its power in the photographic plate.
Chalons (Bleyer) said "No substance can be exposed to the sun's
rays without undergoing a chemical change. Chlorine and hydro-
gen will not unite in the dark nor will chlorine and carbonic acid
gas, but if the same gaseous mixtures are exposed to the sunshine,
they combine with the force of an explosion. In 1832, Sir John
F. W. Herschel demonstrated the chemical activity of the sun's
rays by the following experiment. If a solution of peroxalate of
iron be kept in a dark place, or if it be exposed to 212° F. for
several hours, it does not undergo any sensible change in its
physical properties, nor does it exhibit any phenomena which may
be considered as the result of any elementary action. If, however,
it be exposed to the influence of solar light in a glass vessel pro-
vided with a tube, the concentrated solution of oxalate of iron
soon presents a very interesting phenomenon. In a short time the
solution receiving the solar rays develops an infinite number of
bubbles of gas which rise in the liquor with increasing rapidity
Lucas: Heliotherapy; Its General Use in Pediatrics 197
and give the solution the appearance of a syrup undergoing strong
fermentation. This ebulHtion always becomes stronger and almost
tumultuous when an unpolished glass tube is immersed in it with
a small piece of wood. The liquid itself is afterwards thrown
into ascending and descending currents, becoming gradually yel-
lowish, turbid and eventually precipitates peroxalate of iron, in
the form of small brilliant crystals of a lemon yellow color, gas
continuing to evolve. When a solution of platinum in nitro-
muriatic acid, in which the excess of acid has been neutralized by
the addition of lime, and which has been well cleared by filtration,
is mixed with lime water, in the dark, no precipitation, to any
considerable extent takes place for a long while ; none whatever,
indeed, though after very long standing a slight, flocky sediment
is formed, after which the action is arrested entirely. But if the
mixture, either freshly made or when cleared by subsidence of
this sediment, is exposed to sunshine, it instantly becomes milky
and copious formation of a white precipitate (or a yellow one,
if the platinic solution be in excess) takes place, which subsides
quickly and is easily collected. The same takes place more slowly
in cloudy daylight."
The sun's physiological action has been studied less than its
physical action. It is rather more difficult to accurately measure
the effects of light and sun from a physiological point of view than
it is from the point of view of physics. Still certain rather sig-
nificant observations have been made during the past few years.
RoUier mentions the increase in hemoglobin and red blood cells,
also the increase in eosinophiles. D'Oelsnitz has carried on some
very interesting observations at Nice, in which he attempts to
demonstrate changes, immediate and late, in the temperature, re-
spiration and blood. Temperature and respirations are usually
increased at the first of the treatment. Very soon the respiration
strikes an equilibrium unless there is intolerance to the treatment
when it continues to be irregular. Temperature is always ele-
vated, as is the pulse, but this acceleration strikes a constant
equilibrium which has more or less of an individual variation
and an hour after treatment it is back to its normal. Irregularity
in temperature and pulse, which continues after the treatment, is
a direct indication of intolerance and if more than a degree of
fluctuation in temperature occurs, especially, if this is irregular,
it should be taken as an indication that the treatment is not
198 Lucas: Heliotherapy; Its General Use in Pediatrics
being well tolerated. As to the change in the blood, the number
of red blood cells is increased and the hemoglobin is also in-
creased. The variation in both red cells and hemoglobin may not
be noticed immediately. However the leukocytes respond more
quickly. This response, of course, varies considerably according
to whether the tuberculous process is open or closed.
The mononuclear changes are perhaps more significant. Ar-
nith's formula is of some value from a prognostic standpoint, be-
ing pushed to the right in favorable cases. There is a definite in-
crease in the eosinophiles. This is equally true of marine baths,
as well as sun baths, which would be a point in favor of having
treatment carried on at the sea level instead of at a high altitude.
The tuberculin reaction is increased in active cases and this is an
indication of proper progress of the disease. D'Oelsnitz considers
that keeping close observation over the variations in temperature,
circulation, respiration and blood gives us a definite criterion by
which to judge the success or failure of the treatment. In pul-
monary tuberculosis, as well as in intestinal tuberculosis, hemor-
rhage is always a contra-indication to continuance of the treat-
ment. Progressive loss of weight is also a further contra-indica-
tion, though at first loss of weight may occur in cases that prog-
ress otherwise favorably ; however, loss of weight should not be
allowed to continue very long, and indicates a diminution in the
amount of treatment. Pigmentation is always a sign of tolerance.
D'Oelsnitz made an extended report before the French Pediatric
Society, November, 1913, in which he considered the normal and
abnormal reaction to heliotherapy, also the indication for its use
in tuberculous infants. This is practically the only attempt to
make a clinical and physiological study of its action in children.
There seem to be no studies carried on with any show of accuracy
or with any attempt to draw up any formulae for carrying on this
type of treatment. Many authors mention that anemia is bene-
fitted by an increase in the hemoglobin and red cells. They do
not state what their conclusions are based on. The discussion of
whether the treatment is better carried out at sea-level or altitude
varies almost entirely as to whether the writer is located on the
sea or at an altitude. The unanimity of opinion seems to be that
moderate altitude is best except in children where marine treat-
ment is of considerable value especially in open tuberculosis of
the bones. The general feeling is that pulmonary tuberculosis is
Lucas: Heliotherapy; Its General Use in Pediatrics 199
not much benefitted by treatment with the direct rays of the sun.
Conditions in which it has been used are tuberculosis of the bony
system, open tuberculosis with fistulas and secondary infections.
Practically all the literature, especially from the time that Bern-
hardt and Rollier started to develop their sanitoria, have been
along the lines of chronic tuberculosis of the bones. There seems
to be little doubt but that this form of tuberculosis receives a
distinct benefit from it.
Tuberculous peritonitis has also been treated extensively by
French, German and English writers and their reports are on the
whole very favorable. Rollier mentions its value in peritonitis,
and, in combination with surgery, especially in peritonitis cases
with extreme ascites. D'Oelsnitz also considers that tuberculous
peritonitis can be very successfully treated even if there is con-
siderable temperature., Simon thinks there is no question that in
chronic cases, where the peritonitis has passed the active inflam-
matory stage, it is markedly beneficial. Catalena mentions its use.
Osborne, in New Zealand, reports an interesting case of tuber-
culous peritonitis healed by its powers.
In cervical adenitis, there is little doubt that it is of consider-
able value, not only in the stage before abscess has set in but even
in cases that have been treated for a long time and apparently
have gotten a secondary infection. In these cases it is especially
indicated. Rollier believes that it is of definite benefit in glandular
cases, both cervical and tracheobronchial. Joubert and Rivier
also believe that glandular tuberculosis is favorably affected, both
cervical and tracheobronchial. The sea shore is probably better
for glandular tuberculosis and tuberculosis with secondary infec-
tion than the high altitudes. Rollier, Leriche, Joubert, Rivier and
others believe that it is applicable to the treatment of renal tuber-
culosis and cystitis, especially noting that the pain and discomfort
in cystitis and pyuria are markedly diminished, even where cure
is not affected. Authorities differ considerably as to the efficacy
of this treatment in pulmonary tuberculosis. Apparently it de-
pends on what stage the pulmonary tuberculosis has reached and
the individual reaction of the patient. These are the 2 important
considerations. There is little doubt that in active progressive
cases of pulmonary tuberculosis, where there have been frequent
hemorrhages, where the parenchyma is rapidly being involved, and
where there is a septic type of temperature, sun baths are contra-
200 Lucas: Heliotherapy; Its General Use in Pediatrics
indicated, whereas the chronic or fibrous types of pulmonary tuber-
culosis, which are not progressing in a septic manner, may be
greatly benefitted by the tonic action of the direct sun rays. There
should be very close medical supervision in such cases. Simon
considers that in the torpid bronchial form, even where there are
cavities that are stationary, the results may be beneficial, but in
the febrile type it increases the fever and there is also the chance
of hemorrhage and in these cases the nervous symptoms are also
increased and the weight and appetite are adversely affected.
On the other hand, Pottenger believes that it is an individual
matter that some cases of pulmonary tuberculosis are benefitted
and that the difference between stimulation and irritation in these
cases is only one of degree. He thinks that if cases are watched
carefully it can be noted which cases are losing weight and appe-
tite and where nervous irritation is being increased. In such cases
it is contra-indicative, whereas in anemic cases the hemoglobin
and number of corpuscles are increased in the circulation, tissue
tone is improved and condition of skin benefitted. Pottenger
believes very strongly that sunlight has no specific action and can-
not be considered as a cure, but as an aid to be classed with open
air, good food, hygiene, proper adjustment of rest and hydro-
therapy. A. Treves and J. Andrien both say that heliotherapy is
not a form of treatment. Malgat does not think it applicable to
pulmonary tuberculosis and tuberculosis of the pleura, as he says
it provokes congestive processes and may bring on hemoptysis.
Even in latent cases, he thinks it brings out the processes and
makes them active. He also cautions its application in the
tracheobronchial adenopathies.
Its use in this country in tuberculous conditions has been
carried on very extensively by Campbell. He reports many cases
of tuberculosis of bones in which there has been very marked
improvement. These have also been reported by Hammond of
Providence and Yelt. Pottenger has used it as an accessory in
the treatment of pulmonary conditions and also Kim-e.
A number of men have reviewed the work as seen at Rollier's
Clinic, especially Dietrich, Yelt and Austin. The use of heliothe-
rapy in non-tuberculous conditions has received considerable
attention. Aimes, in a very good article on the use of heliotherapy
in non-tuberculous affections, speaks of its afifect. He believes
that it should be used more with convalescents as it shortens their
Lucas : Heliotherapy; Its General Use in Pediatrics 201
period, especially where there is a tendency to anemia, but in
connection with cachectic and wasting conditions, it may be a
contra-indication as they cannot stand the stimulation. How-
ever, under the treatment from a convalescent standpoint, hemo-
globin is increased and weight is put on very rapidly. He found
it of considerable benefit in scoliosis, rachitis, acute articular
rheumatism and in tracheobronchial adenopathies. He quotes from
Emmett of Philadelphia and Sneguriefif of Moscow, who also
claimed that it was very valuable. Kellogg, at Battle Creek,
makes the same claim. The debilitated functions are exhilarated,
nutrition is very markedly improved, activity of secretions is
marked and the internal organs are better oxygenated. Kellogg,
with Singer of Berlin, says that neurasthenic patients are ben-
efitted by sun baths, especially in combination with other mechan-
ical and therapeutic measures.
Local Action of the Sun : Aimes finds it of great benefit
as in healing wounds and varicose ulcers, also in erysipelas. Its
local effect is mentioned by many writers. Apery, Bernhard,
Widener, and Joubert. Borel, in a report before the Congress
at Rome, 1912, said it could be used in actinomycosis, cutaneous
syphilis and mycoses. These effects are all probably due to
hyperemia. Percy speaks of its affect on fractures ; he thinks
that the callous formation is increased. Hammond thinks it of
value in fractures and osteomyelitis.
Borel, Lundsgaard and Grunholm have used it with success
in the treatment of the conjunctiva and trachoma, though they
mention the treatment as dangerous and should be carried out
with care.
According to Malgat, heliotherapy is not found to be success-
ful in tuberculous conjunctivitis or in tuberculous infections of
the larynx. However, in this connection, Johnston tells bow he
treated his own larynx by direct sunlight with remarkably rapid
results apparently getting more relief in 6 weeks by applying
direct rays by means of laryngeal mirrors to the larynx than by
any other means of treatment, and concludes that the direct rays
on mucous membranes are apparently successful. Singer com-
ments on its use in nervous conditions. Aimes mentions its use
in gynecological conditions. Badin and Gilbert de Balaruc have
obtained results in perimetritis ; Snegurieff of Moscow in met-
202 Lucas: Heliotherapy; Its General Use in Pediatrics
rorrhagfia. Markoe reports cases of septic gynecology in the New
York Lying-in-Hospital, which have apparently done far better
than by any other form of treatment. Young and Williams, in
the City Hospital in Boston, mention its effect on septic gyneco-
logical cases also. Both Markoe's and Young's and Williams'
mortality statistics are worthy of consideration by gynecologists.
Campbell also mentions it in non-tuberculous cases, especially
osteomyelitis. Willy Meyer of New York, Pryor of Buffalo and
Crile of Cleveland, speak enthusiastically of its use during the
present war.
There has been considerable discussion as to whether light
really penetrates the body. Finsen, in his original experiment,
apparently proved to his satisfaction that light rays undoubtedly
penetrated far more than we had ever considered they did before
his time. He placed a photographic plate under the lobe of the
ear and exposed it to the direct sun rays and found that when he
used no pressure on the plate, against the lobe, the plate was not
affected in 5 minutes, whereas if he pressed the lobe of the ear,
pressing out all the blood, the plate darkened in 20 seconds. He
concluded that the red blood corpuscles absorbed the light rays.
Malgat, Rivier and Aimes claim that the red blood corpuscles
become saturated with the sun's rays and they convey this energy
to all parts of the body. As proof of this, they placed a photo-
graphic plate against the shaded part of the body and found
that it was acted upon. They claim that it is in this way that
anemic and rachitic children, removed from dark tenements to
the country, show the marvellous therapeutic effect of pure air
and sun rays. They feel very strongly that the red blood cor-
puscles make use of the chemical rays and that metabolic processes
are augmented. Finsen's experiment of painting his forearm
with India ink and preventing the intense erythema which de-
veloped on portions of his skin not so painted, seemed to prove
that pigmentation converts chemical rays into heat rays. This
is probably the reason why the dark skinned people, as the negroes,
are protected from the chemical rays more than the blondes and
it can be demonstrated clinically that white, unpigmented skins
do develop pigmentation which apparently protects them from a
harmful action of the sun's chemical rays. Zimmern considers
the pigmentation as a multitude of thermic foci, transmitting the
energy to the blood plasma beneath. That pigmentation is of con-
Lucas: Heliotherapy; Its General Use in Pediatrics 203
siderable value is found throughout literature. Rollier believes
that it is one of the main indications in the prognosis of the treat-
ment. An individual, who does not pigment, will not do as well
as one who does, though this is not an invariable rule, as under
care, even those who do not pigment will derive considerable
benefit from short exposures and apparently their skin becomes
accustomed to the sun's rays so that in time they can stand long
exposures. Rollier feels that pigmentation further protects against
other infections. He cites an interesting experience in his san-
itorium during an epidemic of varicella. The children who were
thoroughly pigmented and bronzed had no lesions, except in
areas where they were not pigmented, as under casts. Unpig-
mented sections were uniformly afifected. He also feels that pig-
mentation prevents the appearance of furunculosis and acne.
Dangers: Besides the dangers of heliotherapy mentioned
in connection with pulmonary tuberculosis, there are certain
others that are to be considered. Romer mentions 2 cases of sun
stroke, which, however, did not occur among patients taking sun
baths, but uses them as illustrations of dangers that may occur.
Singer, Pottenger and others mention the nervous irritation that
occurs in some patients from over-exposure and over-stimulation.
Unless care is taken during the early part of the treatment, sun
burns and erythemas may be developed which are not only annoy-
ing, but prevent a successful carrying out of the treatment. Care,
therefore, should be taken in the dosage, especially until the skin
becomes accustomed to the sun's rays. Where there is a mod-
erate increase in temperature and loss of appetite, the length of
exposure should be diminished or it may have to be discontinued
for a short time. Melaschen also mentions the dangers of over-
exposure; the fact that fever, palpitation, insomnia and painful
erythema may be produced unless care is taken in the dosage of
the sun's rays.
In February, 1918, during the war, I visited Rollier's San-
atorium at Leysen and to my surprise found his institution
crowded with children and some French and English soldiers.
Altogether some 2000 cases. The hillsides were dotted with the
various hotels for the treatment of different types of cases. The
children came from all over the world, Russia, Germany, America,
France, Italy, Switzerland, etc., and the majority were suffering
204 Lucas: Heliotherapy; Its General Use in Pediatrics
from bone tuberculosis. These cases were being treated by the
direct rays of the sun and practically without surgery and with-
out casts. Upon arrival the patients are gradually accustomed
to the direct rays of the sun. Rollier's method is to begin by
exposing the feet of the patient first, and by slow ascending ex-
posure of legs, thighs, abdomen, chest, back, etc., to reach the
sun bath for the entire body for over an hour at a time, by the
end of the first month. The body becomes pigmented in varying
degrees, shading from a light brown to a rich mahogany color.
As the patients become accustomed to the sun, they spend the
entire day out of doors with loin cloths and sun hats and sandals
as their only covering. The children have their lessons, their rest
periods, their games, all out of doors, and when our party was
there, it was a cold winter day with winter snow crust covering
the hills and we were cold in spite of our fur coats and heavy
clothing. But the children, playing and working in the sun with
just loin cloths and sandals, were glowing with warmth. Those
lying out on their beds were even moist with perspiration. The
war time picture was there, in the many French and English
soldiers suffering from bone tuberculosis.
The great impression made upon me was the fine healthy
condition of the children. Their faces were bright, animated,
filled with life and spirit and not the usual passivity of the insti-
tution case. Their color and the tone of their muscles, I shall
never forget. They were so normal and healthy and their muscles
were hard and beautifully rounded out. The afifected areas were
usually in a healthy condition, even where there were discharging
sinuses. This impression of the splendid general tone of the
children only confirmed my own previous personal experience
with the sun treatment in California. The length of stay at
Rollier's Sanatoria averages a year and a half. Rollier told me
that very few had major operations during their stay at Ley sen
and there were few relapses after leaving the sanatoria as cured.
A point Rollier makes, and one which my own experience con-
firms, is that every child must be treated as an individual ; that
there are few routine rules. Every child has a careful regimen
worked out as to diet, sleep, recreation and study, as well as the
amount of direct sun exposure. Rollier's success is undoubtedly
due to this careful individualistic attention.
In France during the war. Dr. Paul Armand-Delille, Medicin-
Lucas: Heliotherapy; Its General Use in Pediatrics 205
Chef of Rapatries, carried on a sun school, in connection with
the American Red Cross work, at Mounetier, in the mountains
near Evian. These children came from repatriated families, some
members of which had developed tuberculosis. The children were
first accustomed to the sun's rays and to the elevation. After that,
they were allowed to go to outdoor school in loin cloths, sandals
and hats. I visited the sunny hillside one cold spring afternoon
and the children with their teacher, sitting at their portable desks,
which had been carried into the open field opposite the buildings,
were hard at work for a time. Then would come a period of
play and gymnastic exercises. They were in the sunshine from
8.00 A.M. in the morning to 4.00 or 5.00 P.M. These children
showed the same pigmented skin, the same firm hard tissues. Their
general appearance was that of exuberant life and health. This
school was not for a cure of any disease but was to prevent disease
by building up resistance. It was the modern preventorium which
is being agitated so extensively and developed in many places
throughout this country for children from tuberculous families.
In connection with Madame Gillet Motte of Lyons and Dr.
Armand-Delille, we organized a preventorium where the sun
treatment was carried out at Sylvabelle on the Mediterranean.
The children there were largely from the occupied area of the
north of France, who were repatriated through Evian before
the armistice and directly from the north after the armistice. The
cases were mostly those of malnutrition, due to the poor food and
hygiene these children had been forced to endure for 3 or 4 years.
These children from the north showed great retardation in growth
and development, children of 10 and 12, looking like children
of 7 and 9. After from 3 to 6 months at Sylvabelle, they would
entirely recapture their normal development and growth. In
countless cases, the changes wrought were almost unbelievable;
under their pigmented skin the connective tissue had not only
recovered its elasticity and tone, but the limbs had acquired a
most astonishing muscular development. Their entire bodies had
beautiful symmetrical modellings, in sharp contrast to the wasted
flabbiness shown when their sun treatment began.
All these foreign experiences and study of these different ex-
periments have confirmed me in my valuation of the sun treat-
ment for the children of our own country. Since coming out to
California, 6 years ago, I have consistently used heliotherapy as
206 Lucas: Heliotherapy; Its General Use in Pediatrics
a part of definite treatment for a large number of children with
various conditions. Feeling that the sun treatment is simply a
part of a definite regimen in the treatment of various conditions,
and that its main effect is that of a general tonic, I have used it
for that effect wherever needed. In the type of cases I shall
describe, I have found it of great assistance. The sun treatment
alone cannot create the effect desired. The use of the sun becomes
one of the factors in a course of treatment that includes diet,
exercise, play, rest, and sleep, and all these factors must be worked
out separately for the individual child. I have found the greatest
success in cases where every detail of the regimen has been carried
out faithfully. Most of the cases represent chronic conditions
where malnutrition and delayed development have been produced
from various factors. In such cases a carefully worked out dietary,
recognizing their digestive capacity, is most important. The reg-
ulation of the bowels is to be constantly guided by the amount
and kind of food, fruit and water taken into the system and special
exercises rather than by medicine. One might say that the factor
of rest cannot be over emphasized, as, upon analysis, the majority
of these cases expend more energy, than their food intake war-
rants, for normal growth and development. These cases are
found to be growing and developing at a sacrifice of their vital
energies, especially their nervous systems. This makes the amount
and kind of exercise, the amount and condition of sleep most
important factors in the regimen if we expect them to regain
their normal weight, growth rate and nervous poise. The consid-
eration of the nervous and psychological systems is just as im-
portant as the emphasis placed upon a well balanced diet. In this
connection, the type of play and exercise must be considered as a
definite part of the treatm.ent. The school work can be adapted
to each child, so that during the treatment, more rapid progress
in their school work is often made than at any previous period.
The application of the sun treatment rests, first, upon the
well established point emphasized by Rollier, ''that heliotherapy
has just so much the greater efificacy, the greater surface of in-
tegument exposed and the more prolonged the duration of the
exposure." For this reason, much better results are obtained
from general rather than the local exposure of one part of the
body. The second point emphasized is the progressive exposure
in order to accustom the child to the sun rays and to avoid the
Lucas: Heliotherapy; Its General Use in Pediatries 207
danger of burning, which, in certain children, such as blonde and
red haired children, is easily produced by too long exposure to
the sun at the beginning. In giving any programme for the sun
treatment, the constant individual variations must always be re-
membered and allowances made for them. The effects of the
sun's rays cover a wide range of individual idiosyncrasies. Some
children respond quickly, others slowly. Some have rise of tem-
perature, others may have increased pulse rate, others may be-
come excessively irritable under the treatment. It is a common
Fig. l.^Girls taking sun treatment at Sunshine Preventorium. This sanitorium was
opened in July, 1919, under the auspices of the California Tuberculosis Association.
There are accommodations for 12 girls from 6 to 12 years of age. Only cases from
tuberculous homes without open lesions are taken. The majority of these girls were
10 to 20 pounds under weight on entrance and the average gain has been a pound a
week during the first two months. Only one case has failed to gain consistently and
with her there is a question as to whether there is not a beginning pulmonary in-
volvement of both apices. As noted in the text, pulmonary cases do not do well
under sun treatment.
characteristic that brunettes pigment more quickly than blondes
and that red haired children pigment more slowly than any other
type. A certain index to the rapidity with which the sun treat-
ment may be extended is gained through pigmentation. The
prognosis is usually better for children who pigment well and
this may be entirely apart from the question of the rapidity with
which pigmentation takes place.
The programme consists in successively exposing to the sun
all the different parts of the body :
The First Day — the exposure should consist of from 1 to 3
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Lucas: Heliotherapy; Its General Use in Pediatrics 209
periods of at least hour intervals of from 3 to 5 minutes each on
the feet.
The Second Day — the exposure consists of 1 to 3 periods of
hour intervals of 5 to 10 minutes on the feet and 3 to 5 minutes
on the legs.
The Third Day — the exposure consists of from 1 to 3 periods
at hour intervals, of 10 to 15 minutes to the feet and 5 to 10
minutes to legs, and 3 to 5 minutes to the thighs.
The Fourth Day — the total exposure consists of from 1 to 3
periods of at least hour intervals of from 15 to 20 minutes to the
feet, 10 to 15 minutes to the legs, 5 to 10 to the thighs and 3 to 5
to the abdomen.
The Fifth Day — the total exposure consists of from 1 to 3
periods of at least hour intervals of from 20 to 25 minutes on the
feet, 15 to 20 on the legs, 10 to 15 on the thighs, 5 to 10 on the
abdomen, 3 to 5 on the forearms.
The Sixth Day — the total exposure consists of from 1 to 3
periods of at least hour intervals of ^ hour to the feet, 20 minutes
to the legs, 15 to the thighs, 10 to the abdomen, 5 to 10 to the
forearms, and begin a 3 to 5 minute exposure to the back.
The Seventh Day — increase the 6th day exposures by 5 min-
utes to each part, same number of periods at same interval and
begin a 3 to 5 minute exposure to the chest, the total exposure
being 45 minutes. If there is any cardiac disturbance, protect the
region of the heart.
The Eighth Day — the total exposure consists of 3 periods at
intervals of ^ of an hour, exposing the back 15 minutes, chest
from 5 to 10 minutes and beginning a 3 to 5 minute exposure of
neck.
From Ninth to Twelfth Day — the total exjiosure consists of
the same periods at same intervals, with J/^ hour exposure of
truHk.
Front Twelfth Day to Fifteenth Day — the total exposure con-
sists of the progressively increasing periods of 1 hour duration.
The intervening periods between exposures should decrease until
the child can stay exposed most of the clear sunny part of the
day.
210 Lucas: Heliotherapy; Its General Use in Pediatrics
From the Fifteenth to the Twentieth Day — the total exposure
consists of same periods of one hour and a quarter each, with
^ of an hour for the trunk.
From the Twentieth to the Thirtieth Day — the total exposure
consists of same periods, of one hour and a half each with 1 hour
for the trunk. Short exposures for the head can now be begun.
Children vary a great deal as to the amount of direct sun they
can endure on their heads at one time.
According to this programme, by the end of the first month
the patient can remain in the sun from 3 to 5 hours a day. By
the end of the third month, he can remain from 5 to 8 hours
both summer and winter without the exposure producing the
slightest malaise. After the children have become accustomed
to the sun and have become pigmented, they do not have to lie
in one position but can carry on their play, the nurse or mother
having them change their position so that all parts of the body
receive their proportionate share of the direct rays of the sun.
My own experience with sun treatment, as part of an entire regi-
men, includes the following types of cases. Infants, with chronic
intestinal indigestion, have had more rapid recovery from the
inclusion of the sun treatment along with proper diet. Infants
and children with subacute, or chronic tracheobronchial adenitis,
some with positive von Pirquets, and some with negative, react
well to sun treatment. Some of these cases come from tubercu-
lous homes, others follow acute respiratory infections which have
left persistent bronchial glands. These children are markedly
undernourished. These are the cases that are often considered
tuberculous ; whether they are or not is difficult of positive de-
termination. They at least furnish the best possible soil in which
the tubercle bacillus may become active. Therefore their treat-
ment, whether from a curative or preventive standpoint, is most
vital to the individual, and important to the family. These cases
are often complicated with cervical adenitis of varying degrees,
or with general adenopathy. The sun treatment is very eflfective
in the cases with superficial glandular involvement. Cases of
tuberculous peritonitis, in which there is not an excessive amount
of fluid, do well with sun treatment alone, without operation.
Where there is an excessive amount of fluid, my experience has
been that it is better to operate first and carry on the sun treat-
ment after the distention has been relieved.
Lucas: Heliotherapy; Its General Use in Pediatrics 211
As an adjuvant to the rest treatment in cardiac cases, I have
found that the sun treatment increases the tone of the muscular
system, if used with care. In cases of simple malnutrition and
under nourishment I believe sun treatment has a place in the
regimen.
As a part of preventorium treatment, for children with
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Fig. 2. — Showing the less abbreviated suits which we have termed "nature suits."
These are light and airy and can be worn in the suburbs and with the short sleeves
can even be worn to school as these children do at the present time.
tuberculous infection, it has a very definite place. I have had no
experience of its use in orthopedic or surgical cases nor in cases
of pulmonary tuberculosis.
The appended protocols are examples of various types from
my own practice and from Sunshine Preventorium run by the
California Tuberculosis Association, of which I have the super-
vision : —
Case A. — Chronic intestinal indigestion with atrophy. Child
212 Lucas: Heliotherapy; Its General Use in Pediatrics
only weighed 17 pounds when first seen at the age of I41/2
months. With combined feeding, hygiene and sun treatment,
he gained 7 pounds in 28 weeks.
Case B. — Dififuse bronchial gland involvement, adenitis, not
tuberculous, and a subacute endocarditis following a tonsillar
infection. After removal of tonsils and adenoids and careful
regimen, rest, diet and sun baths, gained ^ of a pound a week
regularly during period of treatment.
Case C. — Chronic intestinal indigestion, cyclic vomiting, with
moderate bronchial gland involvement and malnutrition. Under
careful regimen, diet, rest and sun baths, progressed more satis-
factorily than the average case without sun baths.
Case D. — This boy who was in the poorest condition at the
beginning of the treatment, weighing 46^/2 pounds at the age of
7 years and 10 months, weighed 70 pounds six months later, a
gain of 233/2 pounds in 28 weeks.
BIBLIOGRAPHY.
Aimes, A.: L'heliotherapie dans les affections non tuberculeuses, Presse ined., 21:223,
1913.
Aimand-Delille, P. F. : Rapport sur l'heliotherapie, Bull. Soc. de pediat. de Paris 14:
258 1912.
Armand-Delille, P. F. : L'heliotherapie, monographies clinique No. 75, Mason et Cie.,
Paris, 1914.
Armand-Delille, P. F. et Wapler, Ph.: L'ecole de plein air et I'ecole avi soleil, A.
xMaloine et Fils, Paris, 1919.
Armand-Delille, P. F. : Traitement des tuberculoses chirurgicales par la methode
lieliotherapique, Soc. de pediat., Mars, 1912.
.'\.rtante de Vevey: Les cures de soleil, Compt. rend. Acad. d. sc, 160: 844, 1915.
Austin, Gertrude: Heliotherapy in surgical tuberculosis, Med. Rec, 81: 1074, 1912.
Baradat: L'heliotherapie en France: le Cote d'Azur et le Mont Blanc, Ann. h'hyg.,
1915, 4. s. 23: 269-280.
Bardenheuer: Die heliotropische Behandlung der peripheren Tuberkulosis, besonders
der Knochen und Gelenke. Deutsche Ztschr. f. Chir., 112: 135, 1911.
Bernhard, Oskar: Heliotherapie im Ilochgebirge, Stuttg., 1912, F. Enke.
Boucart, Revillet et Vernet: Traitement des tuberculoses curables par rheliotherapie
et la balneotherapie, Congres de climato-therapie, Nice, 1909.
Campbell, Willis C. : An Analysis of 51 bone and joint affections treated by helio-
therapy. Am. J. Orthop. Surg., 14: 191, 1916; 15: 1, 1917.
Carton: La cure de soleil et d'exercices chez les enfants, Paris, Maloine et Fils, 1917.
Dietrich, Henry: Heliotherapy with special reference to the work of Dr. RoUier at
Leysen, J. A. M. A., 61; 2229-2232, 1913.
Hebert, Georges: L'education physique raisonnee, Librairie, Vuibert, Paris.
Hickling, G. H.: The healing powers of sunlight, Brit. M. .J., 1: 1067, 1915.
Hinsdale, Guy: Atmospheric air in relation to tuberculosis, Smithsonian Misc. Col-
lections, 63 No. 1.
Jaubert, L. : De l'heliotherapie dans le traitement des plaies atones, Lyon med., 1910.
Jaubert, L. : Des conditions qui favorisent la pratique de l'heliotherapie, Lyon med..
1913, 120: 606.
Jaubert, L. : Historique de la cure solaire, Presse med., 15 Fevr. 1913.
Leo, G. : Les touts petits au soleil, Paris, Maloine et Fils, 1916.
Leriche, R. : Chirurgische Gedanken iiber die Heliotherapie besonders bei tuberkulosen
Erkranlcungen im Kindesalter, Deutsche Ztschr. f. Chir. 1913, 122: 150.
Malgat: La cure solaire dans la tuberculose, Bailliere, ed., 1912.
Markoe: Bull. Lying-in-Hosp., N. Y., 10:153, 1915-1916.
Mercier, C. A.: Healing powers of sunlight, Brit. M. J., 1: 1026, 1915.
Miramond de Laroquette: Veranderungen der Nahrungsmenge und des Korperge-
wichtes unter Einwirkung der Sonnenstrahlung in den verschiedenen Jahrtsab-
schnitten, Strahlentherapie, 6: 116-118, 1915.
Lucas: Heliotherapy; Its General Use in Pediatrics 213
Monteuuis: V^aleur pratique des bains d'air de lumiere et de soleil dans I'hygiene
journaliere et sociale, Clinique, Par., 6: 414, 1911.
D'Oelsnitz: Le traitement de la peritonite tuberculeuse par I'heliotherapie, Bull. Soc.
de pediat., Nov., 1912.
D'Oelsnitz: Reactions thermiques, respiratoires et circulatoires provoquees par
I'heliotherapie, J. med., fran?.. Par., 7: 466, 1913.
Osborne, G. M. H.: Heliotherapy, Brit. M. J., 1: 1016, 1914.
Otis, E. O.: Heliotherapy, Ref. Handb. Med. Sc, N. Y., 5: 138-141, 1915.
Poncet, A. et Leriche, R. : Heliotherapie, J. de med. int., 16: 291, 1912.
Pottenger, Francis M.: Heliotherapy and its special application to pulmonary tuber-
culosis. Interstate M. J., 22: 818, 1915.
Revillet: La cure helio marine de I'adenopathie tracheo-bronchique, Clinique infan-
tile, 1904.
Revillet: Effets curatifs du climat mediterranean et de I'heliotherapie locale, Congres
de med.,, 1904.
Rivier, G. : La cure de soleil a travers les ages, Presse med., 21: 177, 1913.
Rollier, A.: Le traitement des tuberculoses chirurgicales par la cure d'altitude et
I'heliotherapie, Congres internat. de la tuberculose, Paris, 1905.
Rollier, A.: La cure de soleil, Paris, Bailliere et Fils, 1914.
Rollier, A.: L'ecole au soleil, Paris, Bailliere et Cie., 1916.
Romer, C: Sonnenbader und Nervenpystem, Deutsche med. Wchnschr., 41: 832, 1915.
Thedering: Erfahrungen mit der kiinstlichen Hohensonne und natiirlicher Helio-
therapie, Strahlentherapie, 1915, Orig. 6: 64-69.
Vallot, J.: Sur une installation permittant d'appliquer I'heliotherapie intensive, en
hiver, aux blesses et aux convalescents militaires, Compt. rend. Acad, de sc.,
Paris, 109: 486-488, 1915.
Vallot, T. et Faure, M.: Les regies physiques de I'heliotherapie, Presse med., 1914, 22
(Annex) 421-423.
Vignard, A.: Heliotherapie artificielle, Lyon med., 122: 1458, 1914.
Vignard et Jouffray: La cure solaire des tuberculoses chirurgicales, monographies 74,
Masson et Cie., 1914.
Yelt, O. J.: Heliotherapy, its physics, -physiology and indications. Interstate M. J.,
22: 806-817, 1915.
Zimmern, A.: Les bases physico-biologiques de I'heliotherapie, etat actual de la ques-
tion, Presse med., 21: 377-380, 1913.
Etiology of Influenza (British Medical Journal, March
22, 1919, p. 331). This is a preHminary report of the experi-
mental work done by Gibson, Bowman and Connor with a filtrable
organism. They succeeded in growing a minute micro-organism
of a coccoid shape by Noguchi's cultural methods from: (a) the
kidney of infected animals; (b) the filtrates of lung tissue, and
(c) the filtered sputum from cases of influenza. The cultures
have been carried to the third generation by direct culture. The
cultures when inoculated into animals produced typical "experi-
mental influenzal" lesions, and cultures were recovered again
from the animals so inoculated. The pathologic lesions in what
may be called experimental influenza in animals closely resemble
those seen in the lungs of men. Some evidence was obtained in
favor of the view that the passage of the virus from one animal
to another may raise its virulence. Inoculation of the filtered and
unfiltered sputum taken from cases of influenza, especially at an
early stage of the disease, has been found to produce lesions in
the lungs in a high proportion of inoculated animals. — Journal
A. M. A.
THE DURATION OF BREAST FEEDING IN ONE
THOUSAND CASES FROM PRIVATE PRACTICE.*
By John B. Manning, M.D.
Seattle.
This series represents replies obtained from a thousand
mothers during the course of routine history obtained in the
office or in the home of private patients. They are taken from
the files in alphabetical order and extend over a period of
10 years. No doubt a much larger series could have been ob-
tained, but for the purposes of convenience in figuring percent-
ages an even number was chosen and 1,000 would appear a
sufficiently large number to represent the probable average of
even a far larger number of cases.
Numerous papers have appeared in foreign countries and
in our own country on this subject, which shows the lively
interest still maintained in it, because of its close association
with infant mortality. There are practically no references to the
literature in this article, since this feature has been admirably
covered by Griffith\ in 1912, Mitchell^, in 1916, and others. The
number of papers bearing on this subject since that time have
been relatively few. In the previous published reports on the
duration of breast feeding in America, in which the series have
seldom been larger than in this instance, the groups were largely
those in eastern cities.
It has always been of interest to me to know how favorably
the nursing period of babies living in a community receiving
all the natural advantages of low infant mortality, such as that
enjoyed by the cities lying west of the Cascade Range, would
compare with larger congested communities in our eastern coast
cities.
Other features than the duration of breast feeding brought
out in the routine history, which might be of interest, as some
statistics on the character of labor, whether or not the baby was
full time or premature, are included. Of the 1,000 babies, 950
or 95 per cent, were born at full time ; 50 or 5 per cent, were
prematures; Z7 or Z.7 per cent, at 8 months; 13 or 1.3 per cent,
at 7 months.
*Read before the King County Medical Society, Seattle, Washington, November
3, 1919.
214
Manning : Duration of Breast Feeding in 1000 Cases 215
Character of Labor
Normal labor ; , . , . 832, or 83.2 per cent.
Instrumental delivery 126, or 12.6 per cent.
Breech delivery 21, or 2.1 per cent.
Twins 15, or 1.5 per cent.
Caesarean section 6, or .6 per cent.
This table conforms in general with those given in the text
books on obstetrics on the relation of normal to abnormal labor,
although the number of breech deliveries is rather low. Pinard^
gives the number of breech deliveries in several hundred thou-
sand cases as 3.3 per cent. An interesting feature is the small
number of Caesarean sections encountered, in view of the fact
that there is a general feeling that this is a very common opera-
tion. Had the series included only the last 5 years, the percentage
of Caesarean sections would have been a little higher. So far
as this community is concerned I think it might be safely said that
the Caesarean section is rarely done except by a relative few
who are thoroughly acquainted with its indications and its
procedure.
The Duration of Breast Feeding: It is to be borne in mind
that these statistics are not from the poorer class of city women,
but make up in general a group who have had for several years
repeatedly placed before them the value of breast feeding in its
relation to infant mortality. The mothers represent, in the main,
young women of more than average intelligence and training.
A little over 70 per cent, of those children whose ages were
given were over 9 months before they came to me for advice.
In view of these facts, the series should represent a longer
period of breast feeding than that encountered in out-patient de-
partments among the poor of the hospitals situated in the larger
congested districts of eastern cities.
The duration of nursing months in this series is as follows:
Table I.
duration of nursing months. duration of nursing months.
Average Average
Percentages. Percentages.
Less than 1 week . . .81—8.1% 1 month 79—7.9%
1 week 18—1.8% 2 months 92—9.2%
2 weeks 40— 4.0% 3 " 98_9.8%
3 weeks 49—4.9% 4 " (,3—6.3%
216 Manning : Duration of Breast Feeding in 1000 Cases
5
6
7
8
9
10
11
12
13
14
months 68 — 6
Average
Percentages.
68—6.8%
15
months
55—5.5%
16
47 4.7%
17
42—4.2%
18
75—7.5%
19
45—4.5%
20
30—3.0%
21
61—6.1%
22
17—1.7%
24
10—1.0%
30
36
Average
Percentages.
8— .8%
4
4%
2—
2%
9—
9%
1 —
1%
1 —
1%
1 —
1%
1 —
1%
1 —
1%
1 —
1%
1 —
1%
o
c
rt
to o
1-.
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rH
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20%
80%
55%
42%
34%
27%
9%
8.1%
91.9%
64%
41%
26.8%
1 11.8%
1 1.6%
For the purpose of comparing this series, in which the moth-
ers were of more than average intelligence, with that in which
the mothers were of the poorer class of city women, a table has
been made similar to that of Mitchell's in his statements of
2,819 mothers at the Children's Hospital in F'hiladelphia.
Table II.
U U 00 u
> o a\ o »-^ *-< o ^
t3 o
n 01 1)
3 S t3
^^°
Mitchell's series, 2,819 I | I I I
cases I 20% | 80% | 55% | 42% 34% 27% 9% | 2%,
Manning's series | | J | I
1,000 cases | 8.1%| 91.9%f 64% | 41% 26.8%| 11.8%| 1.6%| .3%
It can be observed from a perusal of this table that there is
a far greater proportion of mothers nursing their babies in my
series up to and during the first 3 months than in Mitchell's
series. At about 6 months they are practically the same and from
6 months up there is a rapid falling off in the percentage of
nursing months as compared with those poorer women of dis-
pensary patients in the above series. It can be further observed
that in the case of the dispensary mothers the percentage nursing
18 months or longer is higher, no doubt owing to the fact that
probably there are many foreigners among them whom I think
make up the majority of those mothers who nurse their babies
for excessively long periods.
It would be of further interest to make a comparison between
these series and some more or less similar groups taken from
private practice in other geographic sections of the United States
Manning : Duration of Breast Feeding in 1000 Cases 217
and Canada; and for this purpose I have chosen the following
groups : KopHk's series* of 1 ,007 cases in private practice in New
York City; Sedgwick's'"' series which includes the repHes ob-
tained by addressing a questionnaire to some of the married
physicians in the United States ; and a series of Brown's" of
Toronto of 633 cases from private practice.
TABLE III.
Nursed 1 | Nursed 3
month or months or
longer longer
Nursed 4 | Nursed 6
months or | months or
longer | longer
1
Nursed 9
months or
longer
Koplik's series, 1,007 cases
Private practice
40%
Sedgwick's series, wives of
80%
Brown's series, private
76%
46.7%
30.4%
Manning's series, 1,000 1 64.1%
54.3% 41% 1 26.8%
1 1
As would naturally be expected, Sedgwick's series shows the
highest percentage of breast fed babies during the first 3 months.
In view of the fact that his questionnaire was addressed only to
wives of physicians such would be the case, for no mothers could
be in a better position to realize the importance of breast feed-
ing than the wives of physicians. The other 3 groups are quite
similar in the duration of nursing months. I realize that no very
definite conclusions of a comparative nature, other than that in
a general way they are similar, can be drawn from such a table.
Comparison with a much larger group of reports has so many
statistical difficulties in the way of arrangements, as to practic-
ally exclude any comparison in tabular form. In general it would
appear from the above table, if any conclusion could be drawn
from it, that the babies in private practice in Seattle are nursed
about the same period of time that they are in Toronto and New
York. The nursing period of mothers living in Seattle is ap-
parently not greatly influenced, at any rate during the first 4
months, by the fact that local geographical and climatical con-
ditions are favorable for low infant mortality.
Of 192 cases in which the babies were nursed c>ver a period
longer than 10 months, there are a large group of foreigners and
not a few Americans. The few of these Americans were those
218 Manning : Duration of Breast Feeding in lOCX) Cases
living, in the most part, in more or less isolated communities
where the milk supply was not under supervision, and as con-
sidered the safest procedure the baby was kept on the breast.
Of those excessively long- nursing months, some 16 to 36 months,
there are a large proportion of Japanese among whom even in
the better mercantile class of Japanese in Seattle it is customary
to nurse the baby 1 year and sometimes longer. More and more
of recent years, through contact with Americans, this is ceasing
to be so general.
Reasons Given for Taking the Baby off the Breast:
These are divided into 3 groups ; first, inability on the part of
the mother ; second, inabiHty on the part of the baby ; and third,
other reasons, under which I have grouped several which are not
so clear and definite indications for taking the baby off the breast
as in the other 2 groups.
Inability on the Part of the Mother: Sepsis, tuberculosis, in-
fluenza, anemia, infected gall bladder, pneumonia, pyelitis, con-
vulsions, eclampsia, breast abscess, and excessively high fever
of protracted nature and death of the mother were some reasons
given in the first group. One cannot have any choice in the
matter in some of these conditions, as tuberculosis in the mother
or death of the mother. In many acute infections in the mother,
however, the baby can be kept entirely on the breast. In most
of these other conditions, part or complete breast feedings can
be continued to advantage after the acute period has subsided.
In eclampsia I have repeatedly been able to get the baby back on
the breast after albumen had disappeared from the urine. In a
similar way in threatened eclampsia, where a Caesarean section
has been done, it has not been diflficult to place the baby back on
the breast after the toxemia has disappeared and the mother's
convalescence from the operation has progressed favorably
enough to permit nursing with complete satisfaction to the mother
and in the nursing results. There was one instance of a breast
abscess 2 weeks before the baby was born. Not a few of the
babies taken off the breast, owing to a severe influenza or penu-
monia in the mother, where the influenza was just prior to or at
the time of birth, were most difficult to feed. In many instances
it was possible to re-establish breast feedings in part or entirely
4 to 6 weeks after the acute illness without detriment to the
Manning : Duration of Breast Feeding in 1000 Cases 219
mother's condition. Secondary anemias of the mother with a
tendency to persist appear to be a possible indication for weaning.
There have been a few instances in which big, fat babies were
gaining at the rate of 1 ounce a day, while small anemic women,
excreting an abundance of milk, were obviously loosing in weight
and in strength. In some instances one might be justified in
attempting some bottle feedings in place of some of the breast
feedings, but this should be done only with the advice and con-
sent of the obstetrician or attending physician, since many women
of this type ignore altogether their own health and seem obsessed
in the idea that the baby must be nursed.
Inability on the Part of the Baby : There is a small group in
this series where owing to a developmental defect, as for example,
hairlip or tumor of the tongue, nursing at the breast is made im-
possible or extremely difficult; and again a group where cere-
bral hemorrhage has occurred, the baby is unable to nurse for a
shorter or longer period of time. In a certain number of these
instances perhaps enough breast milk may be obtained from the
mother to make possible a gain with supplemental feeding, but
in most instances of this sort the deep ducts of the breast are
never emptied and the superficial ducts are only slightly emptied,
for the stimulation of the baby alone at the breast is not sufficient
to prevent the closing of the ducts. In these instances, where the
degree of cooperation is insufficient, stripping of the breast, as
described by Sedgwick^, and more recently by Moore^, may be
resorted to with better results than any other method. In most
instances premature babies were able to nurse the breast within
the first week or two.
Other Reasons Given by the Mother for Taking the Baby off
the Breast : This includes a large group which constitutes a source
of perplexity to all physicians dealing with this subject, since un-
questionably many women who give up nursing could nurse the
baby longer and a certain number are probably unable to do
so under any condition. It is so difficult to tell which one could
keep the baby on the breast with the proper encouragement, the
proper advice, and an environment in which everything was
favorable to the breast feeding, where the technique of breast
feeding was appreciated and understood.
Inverted or retracted nipple was one of the reasons given in
220 Manning : Duration of Breast Feeding in ICXX) Cases
this group ; this undoubtedly depends on the degree of retraction
and under certain conditions precludes any possibility of nursing
of the breast. In not a few instances, with splendid cooperation
on the part of an interested nurse and a willing mother, enough
breast milk may be obtained in this manner to give at least partly
breast feedings. Cracked nipple is a frequent reason given. Not
enough attention is paid to the care of nipples during pregnancy.
Not a few women reach confinement with little or nothing said
to them about the care of their breasts. In many instances the
condition may be improved sufficiently to permit the baby being
placed again on the breast with sufficient perseverance and intel-
ligent care, and the putting up with more or less pain on the
part of the mother. In such instances, however, where the
mother's life is made miserable by the torture of nursing the baby
and every care and detail given to place the breast in good con-
dition has been unsuccessful, the baby may be weaned temporarily
or permanently. Not a few gave as reasons congested breasts.
This is obviously not an indication for permanent weaning of the
baby. There was a large group who gave as reasons, no milk,
weak milk, vomiting, baby refused to nurse, milk dried up, colic,
no gain, and eczema in the baby. Undoubtedly this latter group
is the one where certainly much can be done to extend the nursing
period. Sedgwick's series demonstrates that the wives of phy-
sicians of the United States in 80 per cent, of the instances nurse
their babies 3 months or longer. These women dififer from those
in this series only in the fact that they have been taught to
realize the importance of breast feeding, and have been en-
couraged in it by someone in whom they have confidence and by
someone who is in a position to exert a forceful influence.
Patients receive such conflicting information in regard to feeding
the infant, not only from well meaning neighbors, but often from
nurses who know nothing about the technique of breast feeding,
stripping of the breast or the various means which may be re-
sorted to in supplementing the breast, and also by doctors who
through ignorance or lack of time are unwilling to go into the
minute details and care necessary to make a thorough trial. Con-
tributing to this difficulty is the fact that there is no one way of
feeding the baby after it is off the breast. Every one has seen
some baby do well weaned onto some sort of feeding. The funda-
mental idea I wish to convey at this time as the most important
Manning : Duration of Breast Feeding in 1000 Cases 221
feature of this paper is to utilize all the breast milk there is, no
matter how small at the time, and tlven if necessary supplement
the breast with the bottle. This requires patience and cooperation
in which one must absolutely dominate the situation. In a group
of 127 reasons of this character, there were some 56 who said
that they had had no breast milk within the first few weeks and
for this reason weaned the baby, and 14 abandoned the breast
during the first week. The permanent discontinuance of breast
feeding, owing to insufficient supply or no milk during the first
week of life, is either due to ignorance or neglect on the part of
the attending physician. Colic is not an infrequent reason given
for weaning. Too much attention is paid to the character of the
stools in breast fed babies. Curds and mucus are a frequent ac-
companiment of colic and may often be an evidence of over feed-
ing. In most instances the less done the better to a colicky, breast
fed baby, which is gaining to regulate stools containing mucus and
curds. Vomiting is not an infrequent reason given for weaning the
baby. Suffice it to say that in most of these instances nothing is
gained by taking the baby ofif the breast. In most cases, where
vomiting of breast milk of the pyloric spasm type of vomiting per-
sists I have found the administrations of the thick cereal, one table-
spoonful four times a day before feeding, for a shorter or longer
period, a distinct contribution to the treatment of this sort of case,
making possible the continuance of breast feeding. Eczema is
occasionally given as a reason for weaning. As likely as not an
eczema may be worse and the nutrition much worse on weaning,
to the bitter disappointment of all. I believe with Zahorsky that
it is wrong to condemn physicians generally. Most physicians
do try to keep the baby on the breast. However, if 80 per cent,
of physicians' wives can nurse 1 or more babies, 3 months or
longer, and their private patients do not, more persistency on
the part of the physician together with a better understanding
of how to utilize what breast milk there is, is needed, no matter
how little it may be at the time. It is a vital problem in which
physicians must take the leading part. The general educational
publicity of a national character through various organizations,
which has so vigorously placed before mothers of the land the
value of breast feeding, has been of great assistance and must be
continued. It is gratifying in my own experience to encounter
a uniform desire on the part of mothers to nurse their babies
222 Manning : Duration of Breast Feeding in 1000 Cases
and a feeling of bitter disappointment when, in the early months,
it seems advisable to supplement it. In the entire series there was
but 1 mother who refused to put the baby to the breast,
BIBLIOGRAPHY.
1. Griffith: J. A. M. A., 1912, LIX, p. 1874.
2. Mitchell: J. A. M. A., 1916, LXVI, p. 1690.
3. Pinard: Williams' Obstetrics, p. 184.
4. Koplik: J. A. M. A., January 13, 1912, p. 75.
5. Sedgwick: Referred to by Jones, Archives of Pediatrics, January, 1912, p. 24.
6. Brown: Canadian Medical Assn. Journal, March, 1917.
7. Sedgwick: J. A. M. A., 1917, LXIX, p. 417.
8. Moore: Archives of Pediatrics, December, 1919, p. 609.
Autogenous Vaccines in Treatment of Chronic Nasal
Catarrh (British Medical Journal, Aug. 9, 1919). The cases on
which L. Mackey's paper is based concerned patients suffering
from (1) recurrent acute nasal catarrh, (2) chronic nasal catarrh
or (3) chronic postnasal catarrh. Mackey always uses an auto-
genous vaccine. The vaccines were made from the germ or germs
which he believed to be responsible, and always from the primary
cultures when these were pure. Mixed vaccines were made when
two or more germs grew profusely on the plates, or when, as
sometimes happened, a different infection was found in the two
nasal passages. The vaccine most frequently used was pneu-
mococcus, either pure or combined with some other germ, and the
next on the list was Pf eiffer's influenza bacillus ; then M. catarrha-
lis. Staphylococcus aureus, Streptococcus mucosus, B. mucosus-
capsulatus (Friedlander's), and, last of all, B. Septus and B.
coryzae-segmentosus. The vaccines were made in such strengths
that 20 minims represented the maximum dose. Mackey began
with 4 or 5 minims and gradually increased the dose, giving
twelve doses at intervals of a week. The maximum dose of
pneumococcus and streptococcus used was always 150 millions
for an adult and for the other germs 300 or 400 millions. In one-
half the cases the catarrh was cured and the nasal passages were
normally sterile. In about one-third of the cases the catarrh per-
sisted in a modified degree. — Journal A. M. A.
THE VALUE OF LUETIN IN AN OUTPATIENT
DEPARTMENT*
By Alfred Edward Meyers, M.D.
San Francisco
Because of the apparent difficulty in diagnosing many cases
of congenital lues from an outpatient standpoint, especially the
latent type, a luetin test was made on every child that gave the
slightest suspicion of the disease, either from the history or the
physical examination, and all were checked by the Wassermann
reaction. Errors in diagnosing this type of lues happen to all
who see a great many cases, especially if a routine blood-serum
examination is not done, and even then, too many negative re-
ports are returned to us from the laboratory. As if this were
not a sufficient handicap, we are now and then confronted by an
incorrect positive report, as is the experience of many who have
their Wassermann tests checked by anotlrer laboratory. When
we think of the many children of luetic parents struggling toward
manhood and womanhood against the ravages of this spirochetal
infection, these possible errors in diagnosis are appalling, espe-
cially in the light of the advances made in the therapy of this
disease. 9imply because their blood-serum is negative, we take
it for granted that they are non-luetic and pass them by, only
to be confronted by them a few years later with an acute inter-
stitial keratitis or other manifestations of active lues.
The day has arrived when we, who pose as being specially
interested in pediatrics, should not wait for a Wassermann re-
port before making a diagnosis of lues, or at least a tentative
one, just as a surgeon should suspect a fractured bone before he
sees the x-ray. It is quite true that many apparently show no
luetic stigmata, but a carefully recorded history, even in the
presence of what seems to be a negative physical examination,
will often throw enough light to cast some suspicion of lues.
However, it is my firm belief that every case of hereditary lues,
whether active or latent, will show some stigmata of abnormal
development, if we could only appreciate them. With this feeling
in mind, a Wassermann and luetin test were made on every child
who could not score 100 from a developmental standpoint. The
*From the Pediatric Department of the University of California Medical SchooL
223
224 Meyers: Value of Luetin in an O. P. Department
reason for their coming to the dinic, as well as the suspicious
points in their history or physical examination, were noted.
Divers opinions are held as to the value of luetin as a diag-
nostic aid in congenital lues. In 1912, Noguchi^ reported that the
luetin reaction was present in the majority of latent and heredi-
tary lues, and that it was of great prognostic value because of its
presence after the Wassermann and clinical signs had disap-
peared. Orleman-Robinson^ found that the luetin reaction was
more constant in tertiary and latent hereditary lues than the Was-
sermann. Cohen^ noted that the cutaneous test agreed with both
the Wassermann and the clinical signs. Nanu-Muscel* con-
cluded that the luetin reaction of Noguchi was positive in 71
per cent, of congenital luetics. S. Cannata^ observed that in 17
out of 51 cases less than a year old, and with positive signs of
lues, the skin test was negative, while the Wassermann was nega-
tive in 35. In older children, the 2 tests paralleled each other
more closely. Grulee" thought that the luetin test had a dis-
tinctly negative value, inasmuch as in all cases not luetic the re-
action was negative. Wolfsohn^ decided that luetin was especially
valuable in the diagnosis of parasyphilis, tertiary and latent hered-
itary lues. Cordon^ obtained a positive test in 81 per cent,
of his congenital cases and a negative test in all the non-luetic
ones. Noguchi,^ in a later article, reported that in primary lues
the reaction was positive in about 30 per cent, of the cases, the
reaction was mild; in secondary lues it was positive in 47 per
cent, of the cases, the reaction being very slight ; in tertiary lues
it was positive in 80 per cent, of the cases, the reaction was severe,
and usually pustular ; in congenital lues it was positive in 70 per
cent, of the cases, the reaction being more severe after treatment ;
it was more frequently positive in late congenital lues than in the
newborn ; in syphilis of the nervous system, it was positive in 60
per cent, of the cases ; in visceral lues it was positive in 90 per
cent, of the cases ; that the luetin reaction indicated an allergy,
while the Wassermann manifests an active syphilitic process.
Sherrick^*^ showed that a positive reaction could be obtained in 99
per cent, of all cases by the administration of potassium iodide
with, or shortly before, or after the intradermal test ; that other
substances, e. g., starch, agar, etc., will give the same reaction
when potassium is given ; that other drugs containing iodine have
a similar influence on the luetin reaction. Lyons^^ verified Sher-
Meyers: Value of Luetin in an O. P. Department 225
rick's work. Churchill and Austin^- found the luetin test to be
of little diagnostic value, although written directions from No-
guchi were carefully followed, DeBuys and Landford^^ believe
that the Wasserniann reaction is not so valuable as the luetin
test in cases of hereditary syphilis; and while they believe that
the luetin test is of more value in being more often positive than
the Wassermann, they do not believe that it should displace the
Wassermann, as both tests serve distinct purposes, the former
indicating an existing syphilitic condition, even though it be in-
active, while the latter gives evidence of the presence of anti-
bodies in the circulation, indicating an active process. Rytina's^*
conclusions are that in congenital, latent and tertiary syphilis the
luetin reaction is practically 100 per cent, positive. Brown's^^
observations on 134 cases resulted in nearly 90 per cent, of the
congenital luetics reacting j>ositively to luetin.
Of the 168 cases tested, 61 per cent, were males and 39 per
cent, females. Among them was a Chinese boy of 18 years. The
oldest child was 18 years old and the youngest was 7 weeks.
Several of the parents were injected, and the number of posi-
tive reactions was about 10 per cent, higher than the congenital
cases.
Comparison of the Luetin and Wassermann
Reaction in Children
Wassermann Luetin Per cent.
4- -f 17.8
— :+ 47.6
+ - .0
— — 28.5
Incomplete reactions 6.1
The total number of positive reactions was 65.4 per cent, as
compared with 70 per cent, which is about the average obtained
by most observers. Undoubtedly, our number would have been
closer to 70 per cent, had our number of incomplete reactions
been smaller, (I have recorded all who failed to return after
48 hours as "incomplete"). In practically every case that gave
a positive luetin test, there was something in the physical find-
ings or the history indicative of syphilis. The family history
suggested lues in over 35 per cent, of the cases, while 30 per
cent, were diagnosed from the clinical findings. Among the
226 Meyers: Value of Luetin in an O. P. Department
positive reactions, there were 4 cases of epilepsy, 1 case of mental
insufficiency, 1 case of orthostatic albuminuria, 1 case in which
the teeth did not begin to erupt until the fifteenth month, and 1
case in which there was a hernia through an abdominal scar.
Comparison. OF Parents' Wassermann and Luetin Reactions
Wassermann Wassermann Luetin Luetin
Mother + (17) — (22) + (12) — (4)
Father + ( 3 ) - ( 6 ) + ( 3 ) - ( 1 )
It is interesting to note that 75 per cent, of the luetin tests
done on the parents were positive, while only 41 per cent, of
the Wassermann tests were positive.
Comparison of Child's Wassermann and Luetin Reaction
With That of Parents
Child's
Child's
Parents'
Parents'
Wassermann
Luetin
Wassermann
Luetin
No,
+
+
+
+
3
—
+
+
5
—
—
+
2
—
+
—
+
5
+
+
—
+
3
—
+
—
6
+
+
+
1
—
+
+
+
1
Total 31
Case 40,911 came to the clinic complaining of a hordeolum,
ear-ache and anorexia. He was 9 years of age. The Wassermann
reaction of both father and mother was positive. The child was
26 kilograms in weight and 132 centimeters in height (about
2}4 kilograms underweight for his height.) He had a bilateral
ptosis, teeth were serrated, but not Hutchinson's type; the cer-
vical, posterior auricular, axillary and epitrochlear glands were
palpable. Mother's sister and cousin were said to have had
melancholia. His Wassermann reaction was negative. The
cutaneous test read as follows : "After 48 hours there was slight
induration and discoloration, but not papular." The child did
not report for a further reading, as was customary for all upon
Meyers: Value of Luetin in an O. P. Department 227
Suspicious Cases Giving a Negative Wassermann and
Luetin Reaction
1
jReason for coming
Reason for taking
Develop-
No. 1 Age
1 to clinic
W. and L.
■ Physical Findings ment
44348
7 yrs
IGen'l Exam.
Under weight
Negative
Normal
40880
5 "
iTo have blood
Father supposed to
Cerv. & axill. adn.
Normal
tested
have lues
prep, adhesions
37961
15 "
1 Tumor of palate
Necrosis of palate.
3 miscarriages
Impacted tooth
Orthostat. album.
Normal
40869
13 "
1 Headache, diplo-
History of paraly-
SI. int. strabismus.
Normal
pia, insomnia
sis of father
Albuminuria
40230
6 "
1 Mental and physi-
Physical retarda-
Int. strabismus;
Retarded
cal insufficiency
tion
cleft palate; 8
lbs. underweight
38522
5 "
|To have blood
tested
Father supposed to
have lues
Negative
Normal
40911*
— "
38661*
*•
41390
8 "
Nervousness
Convulsions up to
one year ago
Negative
Normal
46332
13 "
Temper
Mother had one
miscarriage
Negative
Normal
46341
14 "
Mentally back-
ward
Mental retarda-
tion
Underweight
Imbecility
Negative
Retarded
43181
7 "
«
Teeth irregular
Retarded
38645
7 "
Mother nervous
Mod. adenitis
Normal
and hysterical
40782
6 "
Vaginitis
Grandfather died
of softening of
brain
Vag. discharge
Normal
29191
7 "
Gen'I exam.
Mother had 4
miscarriages
6 lbs. underweight
Normal
42531
6 "
Gen'l exam.
Father treated in
nerve clinic
Negative
Normal
41604
15 "
1
Enuresis
Mental retarda-
Urine, acid
Normal
24986
13 "
Abscess of leg
tion
+ Wassermann of
brother 4 years
old
Abscess lower leg
Normal
39241
8 "
Gen'l exam.
Mother wished
tests done
Negative
Normal
37948
4 "
Mental retarda-
Imbecility. Petit
Reflexes sluggish.
Retarded
tion
mal
Irregular teeth
37067
10 "
Weakness
Underweight
Systolic murmur
Normal
34473
3 "
Cannot walk or
talk
Lack of sphincter
control; miscar-
Gen'l adenitis
Retarded
42783
1
9 "
Pain in temporal
riage
Mother wished to
Carious teeth.
Normal
1
region
have blood
tested
Convulsions.
Mod. adenitis
36141
9 "
Convulsions
Hyp. tons. adn.
Normal
Birth weight 3^
lbs.
Father had paraly-
41644
16 "
1
Epilepsy
Underweight 16
lbs.
Mod. adenitis
Normal
28245
8 "I
Nervousness
sis
Secondary anemia
Normal
39619
" ■• 1
Gen'l exam.
2 children died at
birth
Hyp. tons. & adn.
Normal
42956
6 " 1
1
Exam, for tons,
adn.
Began to talk at
3 yrs.
Hyp. tons. & adn.
Normal
42050
12 "
Inflamed eyes
Interst. keratitis
Interst. keratitis
Normal
37579
18 "
Discharging sinus
Bone destruction
Osteomyelitis of
digital phalanx.
Von Pirquet
Gen'l adenitis
Normal
43832
7 "
Mental retarda-
Mother has melan-
Retarded
tion
cholia. Grand-
father dead (in-
sane asylum)
36789
3 "
Lump on spine
Underweight
Dorsal Pott's
disease
Normal
40296
6 "
Below par
General adenitis
Hyp. tons, Adn.
Normal
41787
7 "
1
Gen'l exam.
Abortions: miscar-
riage (?)
Albuminuria
Normal
41889
10 " 1
Discharging sinus
Bone destruction
Osteomyelitis
Normal
40279
12 " 1
1
VIental retarda-
tion
Mother very ner-
vous. Pain in-
fraorb. region
Hyp. tons. adn.
Retarded
45314
8 " 1
nt. strabismus
Int. strabismus
Int. strabismus
Normal
43857
9 " i
1
Gen'l exam.
Suspicious family
hist.
Carious teeth
Normal
50251
13 •• 1
1
?oor memory —
4th Gr.
Father died
aneurysm
Negative
Retarded
10803
12 " 1
Joils
Irregularity pupils
Furuncles
Normal
7284
6 "
[Cannot talk or
Question of cere-
Partial reaction of
Retarded
walk
bral involvement
degeneration
228 Meyers: Value of Luetin in an O. P. Department
whom the test was made. It is quite possible that this may have
been a case of "delayed reaction."
Case 38,661 came for a physical examination because of a
triple positive Wassermann in the mother's blood. The mother
had 1 miscarriage (spontaneous) at 4 months after birth of
patient. He was 15 years old, 88 pounds in weight, and 61 inches
in height (16 pounds underweight for his height). His von
Pirquet and Wassermann reactions were negative. His luetin
test read as follows: "After 48 hours there was very slight
redness, induration and slightly papular." In 1 week the reaction
was distinctly negative. It was also negative after 3 weeks.
This was the only other case that gave a negative luetin test
where a positive Wassermann had been obtained in the parent's
blood, but when we consider the age of the child, it is more
than likely the parents were infected after the birth of the child.
This would then account for the negative reaction of both tests.
The cases giving a negative Wassermann and luetin reaction
are set forth below, also their reason for coming to the clinic, for
suspecting lues, their chief physical findings and their develop-
ment.
Case 42,050 might also be open to question because of the
diagnosis, but, while practically every case of interstitial kera-
titis in childhood has a luetic base, it is possible, as it is in the
case of adults, to be non-luetic. The Wassermann reaction of
both child and mother was negative. No blood test was done on
the father. One would also expect to obtain positive results from
the Wassermann and luetin in Case 24,986 because a younger
brother of 4 years reacted positively in both, but the same argu-
ment may be applied to this case as was given for Case 38,661.
A "delayed reaction" might account for the negative test in Case
50,251, whose father died of an aneurysm, and whose develop-
ment was retarded. The child did not report back to the clinic
for observation after 1 week.
Types of Reaction : The various reactions to luetin may
be grouped under 5 distinct heads; papular, vesiculo-pustular,
delayed or torpid, urticarial, and hemorrhagic. The majority
were of the papular type. After 48 hours there appeared at the
site of injection a definitely indurated papule, measuring from 5
to 12 millimeters in diameter, usually surrounded by a zone of
redness, which varied in size. During the next 3 or 4 days the
Meyers: Value of Luetin in an 0. P. Department 229
papule took on a venous blood color, which lasted for a number
of days. Notations of this type of reaction were about as follows :
After 2 Days
Definitely papular, red, and
indurated ; 10 mm. in diameter.
Definitely papular and slightly
vesicular, indurated. Size 7
mm. in diameter.
After 10 Days
Lesion still papular, but in-
duration, size, and zone sub-
siding.
Papular 6 mm. diam. slightly
papular and indurated. Color
fading.
After 5 Days
Papule a dark red color, in-
durated, zone of redness still
present.
Definitely papular and indur-
ated with central discoloration;
not tender or painful ; 7 mm.
After 25 Days
Papule about one half original
size, slightly papular and in-
durated.
Lesion barely papular, slightly
indurated. Size 5 mm.
Over one third were of the pustular type. An indurated papule
appears in 2 or 3 days, which soon takes on a vesicular appear-
ance. Central softening occurs and the lesion becomes a pustule,
which, after rupturing and discharging its contents, forms a scab.
Separation of the scab leaves a pigmented macule, which may
persist for a number of weeks.
After 2 Days
A vesiculo-papule, indurated,
zone of redness, size 6 mm. in
diameter.
After 10 Days
Lesion reptured, covered with
scab, slight induration.
After 5 Days
Central softening in lesion of
same size, seems pustular.
After 25 Days
Pigmented area about 7 mm.
in diameter.
Several cases gave the delayed or torpid reaction described
by Noguchi. The primary papule soon disappears, and simulates
a negative reaction. In about 10 or 12 days it reappears and
progresses to either a definitely indurated papule or a pustule,
after which time it behaves practically the same as the pustular
type.
230 Meyers: Value of Luetin in an O. P. Department
After 2 Days After 5 Days
Small, indurated papule, mod- Lesion very slightly papular,
•^rate induration, slight redness. no induration.
After 10 Days After 25 Days
Vesicle 8 mm. in diameter. Lesion covered with scab, and
filled with purulent fluid, si. slight zone of redness,
tenderness.
There were only 3 cases of the urticarial type. In about 9
days after the injection, the lesion took on a distinct urticarial
form, about 8 mm. in diameter. In a few days it changed to the
papular form, with a moderated amount of induration. Only
2 cases of the hemorrhagic type appeared. Instead of the lesion
filling with pus, as in the pustular form, it contained a hemor-
rhagic exudate, which, after breaking, formed a scab as in the
pustular type. Several reactions showed a desquamation about
the fading papule ; others were surrounded by a purplish zone ;
in one case, 15 days after injection, the lesion became absolutely
black, was papular and indurated. The papule of another was
encircled by a greenish area. A girl of 10, very nervous in tem-
perament, complained of pain in the chest; also that the lesion
was somewhat tender and painful. Another reaction remained
pustular for 30 days before rupturing. The most pronounced
reaction occurred in a case of phlyctenular conjunctivitis, whose
blood gave a positive Wassermann. In 2 days a papule appeared
which was about 8 mm. in diameter. This was surrounded by a
zone of redness 20 mm. in diameter. The center of the papule
had begun to break down, and the lesion was moderately tender.
In 1 week the zone of redness had disappeared, leaving a papule
about 5 mm. in diameter, which persisted for quite a while.
Clinical Manifestations as Shown by Outpatient
Records. Nervous System : It is interesting to note the com-
paratively small number of positive Wassermann reactions ob-
tained in conditions pertaining to the nervous system. There
were 24 cases of mental retardation, ranging from 3 to 4 years,
as shown by the Binet scale, to the stage of idiocy. Of this
number, 22 reacted positively to the luetin test and negatively
to the Wassermann reaction ; 1 had a positive Wassermann and
luetin, and 1 had a negative Wassermann and luetin. Of 5 cases
Meyers: Value of Luetin in an 0. P. Department 231
of epilepsy, 2 of which were petit mal, 4 reacted positively to
luetin and negatively to the Wassennann, One case of stuttering,
2 mongols, and 1 microcephalic reacted positively only to the
luetin, while 2 juvenile paretics and 1 mongol reacted positively
to both tests. There were no cases of multiple sclerosis or hemi-
plegia.
Eyes : The following is a list of the eye affections as noted :
inflammation of the eye (conjunctivitis), astigmatism, corneal
scar, nystagmus, optic atrophy, exophthalmos, retinitis, choriore-
tinitis, phlyctenular conjunctivitis, sluggish pupils and no re-
action of pupils ; there were 2 cases with a mongolian slant, and 2
with slight ptosis; 5 cases of interstitial keratitis; 6 cases of ir-
regular pupils; and 10 cases of marked bilateral ptosis. Cases
with ptosis reacted as follows :
Wassermann Luetin No.
Ptosis -\- +3
— — 2
- + 5
Interstitial keratitis -f- +4
« (( 1
Optic atrophy — — 1
Retinitis — — .1
Chorio-retinitis — — 1
Ears: The involvement of the ear was not a frequent occur-
rence. There were 4 cases of otitis media, 2 of which reacted
positively to both tests. One case of poor hearing and 2 cases
of otitis media reacted positively to luetin but negatively to the
Wassermann. One case of deafness reacted negatively to both
tests.
Skin and Mucous Membrane: The skin manifestations re-
corded were none of those typical of lues, the small and large nod-
ular syphilid. The lesions noted were furuncles, rash on the but-
tocks (a papular dermatitis), eczema of the face, ears and coccyx.
The fact that all but one of the cases were past the age of 1 year
accounts for the absence of bullous syphiloderms, usually seen
at or soon after birth, chiefly on the palms and soles. No
gummata were present. With the exception of an ulceration of
the tonsil bordering on the mucous membrane, and whose blood
232 Meyers: Value of Luetin in an O. P. Department
showed a positive Wassermann, no other involvement of the
mucous membrane was noted.
Bones and Joints : There were 3 cases of ulceration, 1 of the
finger, and 2 of the tibia and ankle, all reacting positively to both
tests. There was 1 case of osteomyelitis of the femur which
reacted positively only to the luetin, while 1 ulceration of the leg
was negative to both tests. A saddle or depressed nose was
observed in 8 cases, 5 of which reacted positively only to the
luetin, 1 reacted positively to both, 1 was negative to both, and
1 that had a negative luetin gave an anti-complementary Wasser-
mann. Early snuffles were noted in 3 cases, all of whom reacted
positively to both tests.
Teeth :
Type Wassermann Luetin No.
Hutchinson -[- -|- 7
Carious -|- -f" 2
Carious — -|- 3
Misshaped and irregular — -)- 1
Serrated — -{- 1
Pegged and separated incisors . . — -f- 1
Irregular — -|- 1
No attention was evidently given to the first molars for the
deformity described by Moon^*' or that described by Fournier.^^
It is such a common occurrence for the first molar to be carious
that no attention was evidently paid to any abnormality.
Palate : The following observations were made on the palate :
high (3 cases), cleft (1 case), a thick, median scar or ridge on
the hard palate (3 cases). While ulceration of the soft palate is
conceded to be invariably due to lues, very little attention, if any,
has been given to the hard palate. In not a few cases of con-
genital lues, there appears a thick ridge in the median aspect of
the hard palate, usually white in appearance, as if it were scar
tissue following a necrotic lesion. In 2 of the above cases, it was
this symptom upon which the diagnosis of lues was made, and
which was confirmed later by a positive Wassermann and luetin
test. Other cases of lues, to be reported later, having a positive
Wassermann and luetin reaction, showed this abnormality of
the hard palate.
Meyers: Value of Luetin in an 0. P. Department 233
Glands: Enlargement of the lymph-glands occurred as fol-
lows: cervical (19 cases); axillary (12 cases); epitrochlear (8
cases); inguinal (8 cases); parotid (1 case); submaxillary (1
case) ; posterior auricular (1 case). In all but 3 cases where
the epitrochlear glands were enlarged, the Wassermann was nega-
tive, while the luetin was positive; 2 cases reacted positively to
both tests. 1 (Case No. 40411) was negative to both tests.
Development : In 6 cases- the act of sitting up was delayed,
in 1 case until the fifteenth month. Dentition was slow in 16
cases, ranging from 8 to 18 months; many were recorded as
"dentition late." Inability to walk at the average time was noted
in 20 cases, a few being as old as 3^ years before being able to
walk. Speech was delayed in 23 cases, some as late as 4 years.
Miscarriages: A single miscarriage was recorded in 21 cases;
2 in each of 9 cases ; 3 in each of 3 cases ; 4 in each of 5 cases ;
12 in 1 case; a varying number of prematures in 10 cases; still-
borns were noted in 3 cases.
Insanity in the Family : One mother, 1 father, 5 aunts and 1
uncle were insane. There was feeble-mindedness on the mother's
side of one family. A mother's cousin was insane. The question
of feeble-mindedness or insanity or nervousness in the members
of a family is of inestimable value in deciding some of our border-
line cases. It is just as important to study the family in making
a diagnosis of congenital lues as it is the patient, and many a
doubtful case will be cleared up by an intensive study of the
patient's relations. This does not mean simply a child's father
and mother, but his uncles, aunts, cousins, grandparents, brothers,
sisters and all should come under the surveillance of the diag-
nostician.
Reasons for Coming to the Clinic: The most important
reasons for coming to the clinic were as follows : general exami-
nation, blood test, ulcerations, undernourished, retarded mental
and physical development, skin rashes, inflamed eyes, otitis media,
epilepsy, headache, microcephalus, mongolism, nervousness, Pott's
disease, corneal ulcer, gigantism, osteomyelitis, pleurisy, endo-
carditis, stuttering, lack of sphincteric control, phlyctenular con-
junctivitis, hematoma, secondary anemia, hypertrophied tonsils
and adenoids, scoliosis, enuresis, pyelitis, temper, thyroid insuf-
ficiency, indolent ulcer of the finger, vaginitis, ulceration of the
234 Meyers: Value of Luetin in an O. P. Department
tonsil, insomnia, furunculosis, impetigo, scabies, hemorrhage from
the nose and anorexia. Orthostatic albuminuria was discovered
in 2 cases and a condition of hypospadias in 1.
Von Pirquet Reaction : Fifty-eight of the series failed to re-
act to the tuberculin test; 21 reacted positively to the human, and
18 to the bovine tuberculin; 13 reacted positively to both.
Value of the Luetin Reaction : Luetin has a definite place
among the armaments of the clinical worker in ruling out con-
genital syphilis. Conflicting Wassermann reports often leave the
diagnostician in a quandary as to the proper handling of a doubt-
ful case. The performance of the test is a simple matter, if care
is taken to inject the luetin intracutaneously instead of subcu-
taneously. There should be no more trouble in reading a doubt-
ful luetin than there is in reading a 1 plus Wassermann, or a
serum that is positive with only a cholesterinized antigen. The
only advantage is the length of time necessary for the reading
of a delayed reaction.
I wish to thank Dr. Noguchi of the Rockefeller Institute for
his generous supply of luetin used in this work. Also Miss C.
Goodloe for her aid in carrying out many of the tests.
Conclusions :
1. The luetin test is more reliable in congenital lues than the
Wassermann.
2. At least 65 per cent, of congenital luetics will react posi-
tively to the test.
3. It causes no constitutional reaction.
4. It is more important to do a routine luetin test in the clinic
than the von Pirquet test, providing the material can be
obtained.
BIBLIOGRAPHY.
1. Noguchi: Jour. A. M. A., October, 1912, p. 1262.
2. Orleman-Robinson: Jour. Cut. Dis., July, 1912.
3. Cohen: Arch. Opth., 1912, xli, p. 8.
4. Nanu-Muscel, J., et al.: Mun. Med. Woch., 1914, Ixi, p. 1271.
5. S. Cannata: Pediatria, 1914. xxii, No. 7, p. 481.
6. Grulee: Amer. Jour. Med. Sc, 1914, clxviii, No. 5, p. 688.
7. Wolfsohn: Johns Hopkins Hosp. Bull., August, 1912, p. 223.
8. Gordon: Archives of Pediatrics, March, 1914, p. 186.
9. Noguchi: New York Med. Jour., August, 1914.
10. Sherrick: Jour. A. M. A., 1915, Vol. 65, p. 404.
11. Lyons: Southern Med. Jour., June, ix. No. 6, 1916, p. 487.
12. Churchill and Austin: Amer. Jour. Dis. Child., October, 1916, p. 355.
13. DeBuys and Landlord: Amer. Jour. Dis. Child., October, 1916, p. 387.
14. Rytina: Medical Record, 1913, Ixxxiii, p. 384.
15. Brown: Amer. Jour. Dis. Child.. September, 1913, p. 171.
16. Lucas, R. C: Brit. Jour. Child. Dis., 1908, p. 8.
17. Fournier: Recherche et Diagn. De L'Heredo-Syphilis Tardive, Paris, 1907, p. 87.
RESULTS OF THE EXAMINATION OF A GROUP OF
FRENCH CHILDREN
By C. F. Gelston, M.D.
Instructor in Pediatrics, University of California Medical School
San Francisco
In a former paper^ I dealt in a general fashion with the
results of the examination of approximately 38,000 French chil-
dren, representatives of the group of so-called "rapatries," or
repatriated civilian families returning from the invaded districts
of France during the recent war. It is now my intention to
analyze these findings in a more complete way, in the hope that
from this analysis such correlation may be drawn as may be of
value and of applicability to pediatric observation in the United
States.
Included in the series there will be but 24,505 examinations,
which constitute those performed by myself (exclusive of Belgian
children) and in which, as a result, any error is constant. The
remaining examinations were performed by several observers,
E. J. Labbe, M.D., Portland, Oregon and John Baldwin, M.D.,
Baltimore, Maryland, and such comparative data, in a rough way,
as were of value, namely the observations as to nutrition and
development, teeth, tonsils, cervical glands, etc. (a group of
38,000 children), appeared in the article to which reference is
made above. Further analysis from a standpoint of group-
observation would consist in a recording of the development and
nutrition, etc., according to age. Such an article would be of
great interest in regard to the comparative reaction of the various
ages to such privation as was endured during 3 years by this
group of children. This paper will appear later in collaboration
with these other observers. An analysis by age of one person's
findings would be of value for each one of the observations made
in this article but would entail too great space and will therefore
furnish the material for a further report.
As mentioned previously, the examinations were distinctly
superficial, and very hurried. They were intended simply to
eliminate the cases of infectious and contagious disease from ad-
mission across the frontier. Even the data obtained in this single
inspection, however, seemed to hold such possibilities of interest
235
236 Gelston : Examination of a Group of French Children
and of value that a record was kept of each one of the 25,000
cases, and the findings recorded by age. The group of cases
was distinctly abnormal in many respects which may thus modify
the feasibility of comparative study, and yet the children from
the slums of our large cities probably suffer as many drawbacks
in their development and in the progress of their nutrition as did
the children in invaded France. Poverty can closely stimulate
war in its relation to the restrictions placed upon the physical
advancement of a child.
In these observations, then, I recorded 6,946, or 28.4 per cent,
poorly developed, 5,710, or 23.3 per cent as fairly well developed,
and 11,831, or 48.3 per cent, as well developed. This category
and the one following, namely nutrition, are of course in their
classification capable of great individual variation and will depend
to a certain extent upon the class of patients, and the district of
the country as well as the community, in which the observer has
received his training. This was probably particularly true in this
series since my observation previous to residence in France was
practically entirely confined to western children who have been
demonstrated as being noticeably larger than, for instance, eastern
ones. On the other hand, the graphic representation of the com-
parative results of various observers in the larger group pre-
viously reported^ will show the averages at least to be approxi-
mately the same.
Granting a fairly accurate judgment then, and including the
records of nutrition, namely, 8216 or 33.5 per cent, poorly nour-
ished, 8616, or 35.1 per cent, fairly well nourished, and 7671 or
31.4 per cent, well nourished, we have as a result the observa-
tion that 51.7 per cent of these children were below par in de-
velopment and 68.6 per cent, in nourishment. This fact, namely,
that greater evil effects appeared in nourishment than in develop-
ment will unquestionably be borne out when the observations are
analyzed by age, but it will also undoubtedly be found that cer-
tain ages suffered much more than others. The reaction was
worse in the child under 3 and in the adolescent, the former be-
cause of an actual necessarily faulty and limited diet, the latter
because of sacrifice for his younger brothers and sisters. This
was of course an impression only and may not be proven, since,
in the total series of 37,500 children, only 3.7 per cent, ranged
in age from 1 day to 3 years, and 14.9 per cent, from 13 to 16
Gelston : Examination of a Group of French Children 237
years, while the remainder or 81.4 per cent, were practically
evenly distributed between the ages of 3 and 13 years, with a
maximum of 9.3 per cent, at 10 years.
In attempting to compare the findings in this group of French
children, it is extremely difficult to find an analogous group upon
which statistics have been published in this country. Consider-
ing them, however, as in the main (over 75 per cent.) school
children, we have the observations of Howes,^ in an analysis of
the physical findings in 2,449 school children in Framingham,
Mass. He found 16.6 per cent, anemic, 45.4 per cent, with cervi-
cal adenitis, 47.6 per cent, with tonsillar hypertrophy, 12 per
cent, with nasal obstruction, 1.2 per cent, with impetigo and 68.6
per cent, with dental caries. In the group of French children, I
found 24.6 per cent, anemic, 37.7 per cent, with "large cervical
glands," 33.5 per cent, with "palpable cervical glands," a total
of 71.2 per cent., which must be the figure for comparison with
Howes'. Forty-seven and four-tenths per cent, in my observa-
tions showed tonsillar hypertrophy (16.4 per cent, moderate, 31.0
per cent, large), which is surprisingly similar to Howes' figures.
Nasal obstruction was only noted to be present in 5.7 per cent, of
the cases, although there was nasal infection — coryza and rhini-
tis— in 18.4 per cent.. Impetigo was found in 2.7 per cent., but
the hygiene of these families was necessarily very bad. Among
the 25,000, dental caries was only present in 25.1 per cent, (com-
pared to Howes' figures of 68.6 per cent.), which is an interest-
ing commentary on our reputed advancement in the question of
mouth hygiene.
In Porter County, Indiana, as the result of an analysis of rural
conditions, the Public Health Service^ reports 55.6 per cent, with
carious teeth, 11.5 per cent, with adenoids, and 7.8 per cent, with
enlarged tonsils. There was also demonstrated 9.3 per cent, of
mental defect, the classification being made by the Binet-Simon
tests. This is an interesting figure when compared to the one
of 1.6 per cent, which was my impression of the amount of prob-
able definite mental defect in the French series (exclusive of gross
pathological conditions such as idiocy, etc.).
In the Bulletin of the Chicago School of Sanitary Instruction,*
is the report of 75,476 examinations performed on Chicago school
children. Of this number, adenoid hypertrophy was present in
5.3 per cent., diseased tonsils in 77 per cent., chronic otitis media
238 Gelston : Examination of a Group of French Children
in 1.6 per cent. (I found this condition in 0.9 per cent.), and dis-
ease of the eyes, exclusive of defective vision, in 9.9 per cent.,
to be compared to my figure of 5.9 per cent, (including certain
nerve lesions). In a report of the medical inspection of the
school children in British Columbia^ (Dr. C. J. Fagan), 37,591
examinations being made, 14.1 per cent, were found to have
enlarged tonsils and 33.6 per cent, dental caries, the latter a higher
figure than was noted in France, and distinctly lower than in
the United States. On the other hand, Dr. Andrew,® in Glasgow,
found 73.6 per cent, of boys with dental caries, and 90 per cent,
of girls, among the school children, while Sir Geo. Newman, in
London, found in an examination of 1,362,063 children 40 per
cent, with caries in London itself and 65 per cent, outside of the
city. A more complete catalog of conditions is to be found in
some statistics of the Berlin Medical School Inspector for 1913,^
in the compilation of which the results of 34,000 examinations
were used. There were found in this group, 5.9 per cent, anemic,
1.1 per cent, rachitic, 0.2 per cent, with bone tuberculosis, idiocy
in 0.2 per cent., feeble-mindedness in 1.2 per cent., and speech
defect in 0.2 per cent., which may be compared to my figures of
24.6 per cent, anemic, 7.5 per cent, rachitic, 0.3 per cent, with
bone tuberculosis, 0,1 per cent, with idiocy, 1.6 per cent, mentally
defective and 0.1 per cent, with speech defect. The findings of
these observers in regard to superficial conditions, such as skin
and eye infections, are so small that comparison cannot be made,
due to the probability of variation in classification.
Sir Geo. Newman's report for the city of London shows 40
per cent, afifected with dental caries, as noted above, 11 per cent,
with disease of the nose and throat, 6 per cent, anemic, 4 per
cent, with otitis media, and 4 per cent, with skin disease.
From these few reports it will thus be seen that the closest
comparison is found in the German children. American and Eng-
lish children on the whole are in better condition. It is of inter-
est that Genevrier and Heuyer,^ in May, 1919, report the present
condition of the school children, in the formerly occupied terri-
tories of Northern France, especially the Ardennes, from which
particular area a great percentage of the children in my series
was drawn, as being very poor, largely as a result of food defi-
ciency. Fifty or sixty per cent, are infected with skin disease,
all of them have been retarded at least 18 months in mental
Gelston : Examination of a Group of French Children 239
development, and all show a most noticeable evidence of adeno-
pathy.
The very wide range of scattered pathological conditions
found in these children precludes a table showing them. Never-
theless it may be of interest to specialists that I group certain
of the findings under systems or organs, thus giving the possi-
bility of comparison of the frequency of such conditions in this
country and in France.
For instance, under the Eye were found the following:
Blepharitis 524
Cataract congenital bilat-
eral 5
Conjunctivitis acute .... 133
Conjunctivitis chronic. . . 31
Conjunctivitis phlyctenu-
lar 10
Contusion eyelid 1
Cyst conjunctiva 1
Cyst lachrymal 1
Cyst palpebral multiple . . 3
Dacryocystitis 3
Destruction eye ophth.
neonat 1
Ectropion 7
Enucleation eye 11
Epicanthus 11
Opacity corneal 42
Fibroma conjunctiva ... 1
Exophthalmos 106
Hemorrhage sub-conjunc-
tival 4
Hordeolum 74
Iridectomy 4
Iritis traumatic 2
Keratitis acute 34
Keratitis interstitial 11
Keratoconia 5
Kerato conjunctivitis. ... 1
Microphthalmia 4
Nystagmus lateral 9
Nystagmus rotatory .... 2
Oedema conjunctival 1
Opacity Corneal 42 .
Pupils unequal 4
Pupils excentric 2
Ptosis bilateral 20
Ptosis unilateral 8
Sclerotics blue 2
Strabismus 378
Ulcer corneal 7
Gross fterve and brain conditions were as follows
Chorea, minor 1
Chorea, major 1
Chorea post-encephalitic . 1
Deaf mutism 14
Defective 421
Epilepsy 4
Herpes 96
Hydrocephalic head 74
Hydrocephalus arrested. 10
Hysterical 113
Idiocy 20
Little's disease 1
240 Gelston : Examination of a Group of French Children
Microcephalus 15
Mongoloid 5
Oligocephaly 1
Paralysis facial cause (?) 8
Paralysis birth, legs 2
Paralysis legs, poliomye-
litis 11
Paralysis legs post en-
cephalitic 5
Paralysis legs, pseudo
(rachitic) 1
Speech defect 24
Tic, facial 9
Under internal gland conditions were noted the following :
Achondroplasia 2
Acromegaly 1
Cretinism 2
Cretinoid 3
Fingers stubby 38
Fingers clubbed 26
Goitre 223
Hyperthyroidism 4
Infantilism lorraine 5
Macroglossia 1
Myxedema 1
Obesity 15
Over development...... 12
Prognathism 1
Under developmental
Absence 2nd phalanges. .
Equino varus bilateral . . .
Equino varus unilateral . ,
Cyst branchial
Cyst thyroglossal
Deformities, traumatic,
etc, .
Face asymetrical
Fingers malformation . . .
Fingers webbed
Hare lip
Hare lip operated
conditions, the following;
1
1
6
1
1
54
659
1
1
2
10
Under skin and subcutaneous
Abscess scalp 6
Abscess pinna 1
Alopecia areata 3
Alopecia burn 1
Burns superficial 37
Contusion eyelid 1
Contusion forehead 1
Cyst scalp I
Cyst seborrheic 2
Hypertrophy of gums. . . 1
Palate cleft 13
Palate cleft operated. ... 2
Spina bifida 1
Stigmata of degenera-
tion 1124
Uvula absence of 2
Uvula adherent 1
Uvula bifid 206
Uvula clubbed 22
Uvula deformity of 5
Uvula filiform 172
condition, the following:
Dermatitis impetigenous . 94
Dermatitis medicamentosa 1
Eczema 127
Furunculosis 12
Haematoma birth 1
Haematoma forearm .... 1
Ichthyosis 4
Infectious superficial .... 42
Lacerations superficial. . . 47
Gelston : Examination of a Group of French Children 241
Lupus 4
Lymphangitis 1
Naevi, all types 53
1
1
1
5
1
Edema conjunctiva....
Edema face cause ?
Edema hand traumatic.
Phlegmon face 1
Psoriasis circinata 2
Scars superficial 23
Seborrhea capitis 18
Seborrhea facialis 144
Tinea capitis 23
Urticaria 3
Verrucae all types (ex-
cept) 27
Verrucae infantile 19
Edema legs
Edema uvula
Paronychia 10
Phlegmon arm 1
In the observation of 2,503 abnormal children, in other words
cases voluntarily appearing at a dispensary for treatment of one
type or another, we found,'' using certain ones only, for the pur-
pose of comparison, the following conditions:
Potts disease 11
Verrucae 5
T. B. of the hip 9
Polio paralysis 11
Hordeolum 6
Hare-lip 2
Cleft palate. 1
T. B. of the knee 3
T. B. of the ankle 3
Anemia 15
Cervical adenitis 119
Tonsils & adenoids 1100
Impetigo 28
Scabies 33
Dental caries 243
Speech defect 43
Strabismus 46
Blepharitis 53
Conjunctivitis 43
In a crude way only, a comparison may be drawn therefore
between the findings in these different localities, and in tabular
fonn for clarity may allow of the formulation of certain deduc-
tions (see table on page following).
From this summary, it is seen that a wide variation exists in
the different parts of the world in regard to dental caries. This
variation is also apparent in the different parts of our own coun-
try. From the standpoint of anemia, not very accurate compari-
sons may be drawn from the figures cited — a comparable group
would necessarily be from a less hygienic environment than any
reported. Skin disease was more prevalent in the French series
because of necessarily poor hygiene — the same applies to eye
disease, which was much higher than that noted anywhere else
other than in the California figures, which are of pathological
cases entirely.
242 Gelston : Exammation of a Group of French Children
The large percentage of rachitic manifestations is unques-
tionably due to the dietary deficiencies during this formative
period — it is proven by the reports of the French physicians now
working among this same group. The same is true for the fre-
quency of adenopathy, although the role of tuberculosis will
appear later, in all probability. Bone tuberculosis had approxi-
mately an equal frequency in Germany and in France — the in-
United States
a
O
'•3
a
O
U
a
2
a
o
•n
a
o
6
c
u
U
M
o
y
'.a
U
a
a
'•B
a
a
25.1%
20%
81.8%
33.6%
55 6%
«S fiCK,
9.7%
Dis. of Nose and
throat
11%
Tonsils
47.4%
14.1%
7.7%
7.8%
47.6%
43.9%
Adenoids
1
5.3%
11.5%
Anemia
24.6%
6%
5.9%
0.5%
Ch. Ot. Media...
0.1%
4%
0.07%
1.6%
Skin Dis
7.3%
4%
0.05%
Imp.
1.2%
2.4%
Rachitis
7.5%
1.1%
•
Bone T. B. C
0.3%
0.2%
0.8%
.
0.1%
1
0.2% 1
1
Feeble minded-
1.6%
1
1.2%
B-S.
9.3%
Speech Defect...
0.1%
0.2%
1.7%
Eye Dis
5.9%
0.1%
9.9%
S.6%
Cerv. Ad
71.2%
45.4%
0.5
(True Cervical Adenitis.
Usually T. B. C.)
Gelston : Examination of a Group of French Children 243
crease of 0.1 per cent, may have been a result of the war condi-
tions. Idiocy and feeblemindedness were about equally frequent
in the German and French figures. No comparable data are
available for this country. The same applies to speech defect.
I think, on the whole, that it will be found a little surprising
that greater evil effects of the conditions undergone were not
noted — certainly they are not extraordinarily severe.
In conclusion I desire to acknowledge my indebtedness to
Dr. P. F. Armand-Delille of the Faculty of Medicine and Physi-
cian to the Hospitals of Paris, at one time Major, Medical Corps,
French Army, under whose general supervision these examina-
tions were performed.
BIBLIOGRAPHY.
1. A Public Health Problem in France: Am. Jour. Dis. Chil., October, 1918.
2. Howes, W. B.: Medical Supervision of Framingham Schools, Boston M & S..
Jr., October 2, 19, 181, p. 14.
3. Public Health Service Rule No. 77, 1917.
4. Quoted J. A. M. A., LXV, 15 (Oct. 9, 1915), p. 126.
5. Quoted J. A. M. A., LXI, 22 (Nov. 29, 1913).
6. Andrew: Health of Glasgow School Children, Glasgow M. J., July, 1918.
7. Quoted J. A. M. A., LXI, 9 (Aug. 30, 1913), p. 695.
8. Bull, de I'Acad. de Med., Paris, April 29, 1919, No. 81, 17.
9. Observations on T. B. C. in Childhood, University of California, Pediatric
Department — Unpublished Articles.
Paralysis of the Neck (Archives de Medicine des Enfants,
Paris, March, 1919). F. Figueira here presents 6 cases of the
"cephaloplegic syndrome" which affects infants and young chil-
dren, mostly previously healthy. On waking in the morning it is
found that the head cannot be held up; it lops forward or back-
ward. In some of the cases there had been a preceding pseudo-
grippal catarrhal affection. The tendon reflexes were usually at-
tenuated, and in most of the cases the electric excitability was
reduced. This acute and sudden akinesia disappeared in 4 to 10
days, without leaving a trace. All the cases were observed at Rio
de Janeiro, and the first coincided with an epidemic of 100 cases
of poliomyelitis (1910-1911). Since that time, about 10 or 15
cases of poliomyelitis have been reported there each year. Fi-
gueira is inclined to regard the "cephaloplegic syndrome" as an
abortive form of poliomyelitis, notwithstanding the lack of an
epidemic and the absence of several symptoms usually regarded
as testifying to poliomyelitis. — Journal A. M. A.
A STUDY OF THE GROWTH OF INFANTS IN SAN
FRANCISCO WITH A NEW FORM OF
WEIGHT CHART.
By Harold K. Faber, M.D.
Chief of Children's Clinic and Executive Head of the Subdivision of Pediatrics of the
Division of Medicine of Leland Stanford, Jr., University Medical School,
San Francisco.
Observation of normal babies over a period of several years in
the Children's Clinic and in the more recently formed branch for
well babies, the Baby Clinic, of Stanford University Medical
School, showed some time ago that the weights of the majority
of our well babies were well above the average line of our weight
charts (taken from Griffith) and that we were in need of a chart
more closely adapted to our own conditions. Accordingly a
compilation of weights from our own records has been made and
forms the basis of the present study. It has been made in 2
stages ; a preliminary compilation, completed 2 years ago, and the
present final one, which includes the data of the first. The results
of this work, showing that our average weight line is consider-
ably above that of the text books, led us to compare the original
figures of other investigators with our own. There is a very
large mass of statistics of weight in the first year. Most of these
are derived from the clinics and represent the lower economic
classes of society, but there are a few studies of weight in the
higher economic classes, notably those of Camerer and of Free-
man. Table I gives a number of examples.
From the various reports summarized in Table I, it is evident
that while birth weights in the classes especially favored by wealth
or by heredity (Warren's remarkable figures perhaps represent a
fairly pure native pioneer stock) are somewhat higher (about 500
grams) than those in the unfavored classes of mixed heredity
found in urban clinics, the weights at the end of the first year
present enormous divergences between the different levels. It
should further be noted that there are indications that average
weight in some places is now higher, at least in the latter half of
the first year, in the same economic level than it was a few years
ago'. The curve given as the average by Holt in the first edition
of his "Diseases of Infancy and Childhood," published in 1897,
244
Faber : Study of Growth of Infants by New Weight Chart 245
shows the weight at the end of the year as 20 pounds (9,065
grams) ; the curve of the sixth edition, published in 1911, shows
the weight as 21 pounds (9,520 grams). Our own data, plotted
in Figure 1, shows a distinct increase in average weight since
1917.
A word may be said about certain peculiar environmental
conditions which have a definite bearing on the well-being of
infants in San Francisco. While extreme poverty is unusual,
the economic level of our clinic families is not much above mini-
mum subsistence standards. Most of the families by special sac-
rifice can, however, obtain certified milk for their babies, and the
others are helped in this respect by charitable agencies through
the Social Service department. The seasonal variation in tem-
perature, the range of daily temperature and the fluctuations of
humidity are not extreme (see Figure 3). As a result our babies
TABLE I
Showing first year weights in different localities
Birth weight Six n
Author Country |City Boys 1 Girls Boys
onths
Girls
One
Boys
year
Girls
Robertson* England [Leeds (3300
3200)
6900
8525
7730
Robertson* England | London
3310
3210
7535
9700
8625
Broudic^
France [Paris
3130
3020
6800
6720
8950
8900
Gundobin'
Russia [Petrograd
3558
3380
6900
6300
9970
9300
Robertson*
S. Australia [Adelaide
3590
3410
7730*
7050*
9340*
9080*
Schmid-Monnard^
Germany [Frankfurt
3396
3315
8583
8600
Holt*
U. S. A. [New York
3400
3260
7260
7030
9290
8840
Freeman'
U. S. A. (New York
3965
!
1 1 1
7850 10535
■ [ 1 1
Camerer*
Germany [ Stuttgart
3480
3240
7650
6920
10210
9660
Warren*
U. S. A. [Portland, Me.
3965
3740
'Calculated values.
Note: Freeman's figures are based on patients in private practice, and Camerer's
figures on breast fed babies of the middle class.
Many of the quoted figures have been translated from the avoirdupois into the
metric system.
246 Faber : Study of Growth of Infants by New Weight Chart
can with safety be allowed outdoors at an earlier age and for a
greater portion of the day than is the case elsewhere. The mean
temperature is not high — about 56° F. — ice for refrigeration is
not essential and bacterial multiplication in milk even after the
bottle has been opened, even in the summer months, is not exces-
sively rapid. Through the efforts of the Milk Commission of
the County Medical Society, an extremely high standard of milk
purity has been established and strictly maintained. It is not
necessary to reduce the food intake in the summer, as it sometimes
is during the hot months in the East. The depressing effect of
Comparison of Weight Curves for 1906- 19 17^— land 1906- \m C"
-)
FIGURE 1.
hot weather on appetite is not a factor. Finally, there is an al-
most complete absence of the severer forms of diarrheal disease
of infancy.
Before 1917 the efforts to have well babies brought system-
atically and regularly to us for weighing and direction of feeding
were somewhat desultory and no special day was set aside for
them. In 1917, Dr. H. H. Yerington organized the Baby CHnic
as a branch of the Children's Clinic intended for well babies only.
Mothers of infants born in Lane Hospital or on the Outpatient
Obstetrical Service were urged to bring their babies to the Clinic
as soon as possible and the advantages of this were explained.
When the babies were brought to us they were weighed (without
Faber : Study of Growth of Infants by Netv Weight Chart 247
clothes) and the mothers were instructed in their feeding and
care. Breast feeding, or the use of certified milk for babies who
could not be nursed, was urged. Cases failing to return were
followed up by the Clinic nurse. The Baby Clinic has been
largely attended and it has given us a large amount of fresh
statistical material. Altogether 5,227 weighings have been col-
lected, of which about two-thirds belong to the period 1906-1917
and the remaining third to the period 1917-1919. These form the
basis for the graphic charts herewith presented. The weights
are those of all normal, full-term, gaining babies, both breast and
bottle fed, born in Lane Hospital or admitted to the Clinic since
1906 whose records have been sufficiently complete for statistical
study. Weights at birth and for the succeeding 10 days are
from the records of the obstetrical ward of Lane Hospital. The
birth weights are those of 644 infants, of whom 329 were boys
and 315 girls. The average curve for the first 10 days was made
from the charts of 112 babies, 53 boys and 59 girls, who made
an uninterrupted initial loss followed by an uninterrupted gain.
The maximum and minimum curves for the first 10 days
are hypothetical but include all observed cases with 1 exception
and follow Hammett's^" rule that the initial loss is roughly in-
versely proportional to the birth weight. After the tenth day all
weights were totalled and averaged and the maximum and mini-
mum noted for periods of 1 week and the results plotted up to
the 91st day. Thereafter, in order to obtain the "smoothing"
effect of a sufficiently large number of figures, the weekly totals
were combined and averaged as follows : for the 2 weeks period
from the 91st to the 105th day, and for 4 weeks periods from the
105th to the 364th days. The average figure was plotted in the
middle of the period and the maximum and minimum figures
where they actually occurred. The smooth line did not diverge
by more than 100 grams from any actual average so plotted. The
maximum and minimum curves include 5,205 of the 5,227 obser-
vations, or 99.58 per cent, the exceptions being about equally
distributed above and below. Outside of very exceptional or
"record" cases the curves represent a fair approximation to the
range of normal weights in this community. Table H sum-
marizes the weights and Table HI the rate of gain by 3 month
periods. Both tables are derived from the smooth curve of
Figure 2.
248 Fabek : Study of Growth of Infants by'New Weight Chart
TABLE II
Showing weights by three-month- periods
Boys
Birth
3 mos.
6 mos.
9 mos.
12 mos.
Minimum
1
2225
4' 14" 1
4200
9' 4"
6300
13' 14"
7775
17' 1"
8875
19' 9"
Mean
3495
7' 11"
5650
12' 7" 1
7650
16' 14"
9200
20' S" 1
10375
22' 14"
Maximum
5300 1
11' 11"
7725 1
17' 14"
10175
22' 7"
11600
25' 9"
12500
27' 9"
Girls
Minimum
2150
4' 12" 1
4000
8' 13"
6025
13' 5"
7450
16' 7"
8625
19'
Mean
1
3305
7' 5"
5400
11' 15"
7375
16' 4"
8900
1 19' 10"
10075
22' 4"
Maximum
4800
10' 10"
7400
16' 5"
9575
21' 2"
10900
24' 1" 1
11650
25' 11"
Girls
Minimum
TABLE III
Showing weekly rate of gain by three-month periods
Boys
Birth*
to 3 mos.
3-6 mos.
6-9 mos.
9-12 mos.
Minimum
168 G.
6 oz.
162 G.
5.7 oz.
117 G.
4.1 oz.
85 G
3 oz.
Mean
196 G.
7.2 oz.
154 G.
5.4 oz.
119 G.
4.2 oz.
90 G.
3.2 oz.
Maximum
234 G.
8.3 oz.
188 G.
6.7 oz.
HOG.
3.9 oz.
69 G.
2.4 oz.
160 G.
S.7 oz.
155 G.
5.5 oz.
110 G.
3.9 oz.
90 G.
3.2 oz.
Mean
192 G.
7 oz.
152 G.
5.4 oz.
Ill G.
3.9 oz.
90 G.
3.2 oz.
Maximum
232 G.
8.2 oz.
167 G.
5.9 oz.
102 G.
3.6 oz.
58 G.
2 oz.
'Calculated from low point after initial loss; period 12 }4 weeks.
Faber : Study of Growth of Infants by New Weight Chart 249
It is interesting to note that in the first 6 months the rate of
growth is in direct ratio to the birth weight, while in the third 3
months the rate is about the same for all babies, and in the fourth
3 months the rate of gain is in inverse ratio to the birth weight.
This may be construed as meaning that heavy infants bring into
the world a relatively strong growth impulse which gradually
diminishes toward the end of the year, while small infants have at
first a weak growth impulse which gradually grows stronger
orams I": ":::":±"---: : :.- . ::: : : ~ .--I'.-z^
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2(XȣS^ -t------
— »^(» , Comixwite VVei^ht Curye for First year. Qdmaies represent ^e,^hh
Showing Maximum, Mean and Mmmm Weights. /jtacssos rep-vsm/ /{ge ,n mka
FIGURE 2.
during the year. How long this compensatory process continues
after the first year would be a subject worth study.
The subject of seasonal variation in growth in infants has been
studied by Camerer, Bleyer" and others. Seasonal variation in
birth weight has received less attention. In our series a con-
siderable variation in the birth weights of boy babies has been
encountered, while those of girl babies have been found curiously
250 Faber : Study of Grozvth of Infants by New Weight Chart
TABLE IV
Showing seasonal variations in birth weight
Period
No.
cases
Boys
No.
cases
Girls
Jan. -Mar.
87
3576.0
75
3353.8
Apr.-June
55
3496.4
47
3358.0
July-Sept.
82
1
3425.0
60
3383.7
Oct.-Dec.
75
3516.4
99
3352.5
Oct.-Mar.
162
3549.0
1 174
3353.1
Apr. -Sept.
137
3453.7
107
3373.1
constant throughout the year. These pomts are shown in Table
IV.
Studying seasonal variations in the rate of growth of babies in
St. Louis, Bleyer came to the conclusion that there is a distinct
acceleration of growth in the summer months. San Francisco cli-
mate, with its small seasonal temperature variation and its rela-
tively cool summers, might be expected to show correspondingly
slight seasonal variations in growth. The following curves (Fig-
ure 3) were constructed from the rates of gain of a group of
about 200 babies, breast fed and bottle fed, and from the records
of the Weather Bureau, averaged for the period 1912-1916. The
fluctuations in growth are irregular and have no very close rela-
tionship with season, temperature or humidity. In the breast fed
group the maximum rate is attained both in February and in
August, while in the bottle fed group it is attained both in March
and November.
Brief mention may be made of certain other points which
were studied but which gave less definite or incomplete results.
An attempt was made to determine the frequency curve, or weight
distribution, for each weekly or 4 weekly period, but had to be
abandoned when it was found that an enormously greater mass of
statistics was required than we possessed. Percentile tables of
the Smedley type have been tentatively constructed, but are not
sufficiently complete as yet for publication.
Faber : Study of Growth of Infants by New Weight Chart 251
Comment: A comparison of the San Francisco curve with
other similar curves has more than a local interest. We have, it is
true, particularly favorable climatic conditions but on this basis
alone it hardly seems possible to explain the fact that our clinic
babies now run a course of first year growth like that of the babies
of the privileged classes elsewhere, ending the year nearly 2
pounds heavier than babies of the corresponding class in New
York. It is, indeed, quite likely that a revision of the figures in
other cities would show an upward movement of the curve, as has
our own. It will, perhaps, be worth while to attempt an analysis
of the conditions upon which growth in infancy is dependent.
CHART SHOWING- SEASONAL V/^^RIATION IN GROWTH OF BABIES
COMWREO WITH SEflSONfll VflRI/mONS IN HUM I PITY MHO TEM PERflTli RE
MK
FEB
MK.
APR.
MflV
JUNE
JUL1
jwa.
SEPT
OCJ
NOV.
otc.
«MM9
1
-
—
■■
■
DAILY
GBoirrM
.
.
_
-
^
*
Ij S ""
= 5
^
=
=
^
-i'
tt
-
-
;>*
s
-
-
;
-
"
'
=
__
~-
^
■^k*
^
*
(^
'
a
■^
' r
'
"
MEAN
%
«ajnvE
,
HUMIDITY
'i.
*
.
-
f
^
t^
^
■"S-.
,
• ,
-
• »
^ B '
■ ^
1
^
'
■II ■
^
^
n
MONTVIY
_
_
^
^
»d
hs
.
_
_
t
1
Z
_
_
_
_
_
-
^-
^
_
_
_
_
u
!>
_
_
_
__
iCNKannKes -,^
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= -a
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-
-
-
:
:
-
M
p
^
^
h
*
s
a<
^
:;
^
S
-_
-
I
S9
-i
^''x :
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-
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H
r
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f^
r
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-
r
-
-
-
-
s
-
i:
14 ^
u^
K,
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j-'T 1
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-
-
'^
^
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im
-
^
r-
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u
u
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u
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.
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.
■ 40
FIGURE 3.
The rate of growth in so-called normal infants is mainly de-
pendent upon (1) heredity; (2) favorable antenatal conditions;
(3) birth weight; (4) economic status of the parents; (5) purity
of the milk supply ; (6) climate ; (7) educational level of the com-
munity, particularly as regards hygiene. The relative importance
of these factors in our own community appears to be about as
follows. We have here a mixture of races (at least in our clinics)
which is much like that of other large urban centers in America,
and there has not been much change in this respect within the last
20 years. Prenatal clinics, such as that of the Stanford Women's
Clinic, have undoubtedly brought mothers to confinement in bet-
252 Faber : Study of Growth of Infants by New Weight Chart
ter physical condition and better trained in motherhood. They
have, however, so far as we have been able to determine, not in-
creased the average weight of babies at birth. The economic
status of the group we have studied varies little from year to
year, since an improvement in status sends patients to the private
physician. This factor then is a constant and does not account for
an increasing growth rate, except in so far as the ill effects of
poverty are better counteracted by the increasing efficiency of
Social Service. The purity of the milk supply has already been
discussed and is certainly reflected in the high level of the curve.
It has, however, been a constant for 5 or more years and, like the
favorable climate, probably has little to do with recent improve-
ments in growth. The cause of these must probably be sought for
in the remaining factor, education.
Education of the community in hygiene in general and in the
care of babies in particular has been an extremely intensive pro-
cess during recent .years. The annual Baby Week, the propagan-
da of the Children's Bureau, the establishment of prenatal clinics
and of clinics for well babies have all had their effect. Perhaps of
the most importance, at least in immediate results, has been the
clinic for well babies. Here every mother, by precept from physi-
cian and nurse and by example from the mothers and babies she
meets in the clinic, is made to know and to feel the real value of
breast feeding, of certified milk, of proper regulation of the
formula and diet, of regular weighings and so of the maintenance
of steady gain in her baby. In spite of all criticisms levelled at
the average weight line of the growth chart, we believe that the
net results of its use is good, if for no other reason than that it
undoubtedly stimulates the mother's interest in her baby's pro-
gress so that she comes to the clinic, and so to the doctor, at regu-
lar intervals. The dangers of overfeeding in an attempt to keep
the baby up to the standard are in our opinion much exaggerated
and can be easily obviated. By the use of a chart showing mini-
mum and maximum weights we hope to remove the main objec-
tions which can be made against the older form of chart contain-
ing but a single line.
It remains to be said that the growth curve has a distinct
potential sociological value since it probably is a fairly reliable in-
dex not only of the welfare of the infants in a community but of
Faber : Study of Growth of Infants by New Weight Chart 253
all the hygienic and economic conditions which influence the well-
being of the community in general. If this is true, it would be an
excellent thing if a weight curve were made for a representative
city in each major section of the country. The comparison of the
various local curves could not fail to act as a stimulus to welfare
work in those communities which found themselves backward. A
revision of the curve from year to year would give a graphic rec-
ord of the progress made. That such progress may be promptly
obtained through systematic and energetic effort can hardly be
questioned.
It is a pleasure to pay a tribute to the thorough and efficient
work of Dr. H. H. Yerington in organizing and conducting the
Baby Clinic." The very pleasing results in improving the welfare
of our babies as shown in the present study are due in very large
part to his efforts. I wish to acknowledge also the valuable as-
sistance rendered by Dr. Virginia Murray in the earlier compila-
tions.
CONCLUSIONS.
1. There are local variations in first year growth and there
should be a weight curve for each major section of the country.
2, A growth (weight) curve has been constructed from the
weights of San Francisco babies, showing maximum, average and
minimum weights for age and for both sexes. It is hoped that
this plan may obviate the disadvantages of the chart with a single
average line.
4. The average line of our babies of the clinics approximates
that of babies of the favored classes elsewhere. The reasons for
this are discussed.
5. The average weight, especially in the second 6 months of
the first year, has increased here during the last 2 years and there
are indications that the same phenomenon is occurring in the East.
Reasons for this are discussed.
6. Monthly variations in the rate of growth are compared
with temperature and humidity for the corresponding months.
7. The sociological value of the weight curve as an index of
the conditions in a community affecting infant welfare is pointed
out.
BIBLIOGRAPHY.
1. Robertson, T. B. : Studies on the growth of man. III. The growth of British
infants during the first year succeeding birth. Am. Jour. Physiol., 1916, 41,
254 Faber : Study of Growth of Infants by New Weight Chart
2. Broudic, L. : Contribution a I'etude de la progression du poids du nourrisson au
cours de la premiere annee. La Nourrisson, 1919, 7, 15.
3. Gundobin, A. P.: Die Besonderheiten des Kindesalters. Berlin, 1912.
4. Robertson, T. B. : Studies on the growth of man. I. The pre- and post-natal
growth of infants. Am. Jour. Physiol., 1915, 37, 1.
5. Schmid-Monnard: Ueber den Werth von Koerpermassen zur Beurtheilung des
Koerperzustandes bei Kindern. Jahrb. f. Kinderh., 1901, 53, 50.
6. Holt, L. E. : Diseases of Infancy and Childhood. Sixth edition. 1911.
7. Freeman, R. G. : Weights and measurements of infants and children in private
practice compared with institution children. Tr. Am. Pediat. Soc, 1914, 26,
202.
8. Camerer, W. : Gewichts- und Laengenwachstum der Kinder. Pfaundler und
Schlossmann; Handbuch der Kinderheilkunde, Leipzig, Vogel, 1910.
9. Warren, S. P.: The average birthweight in 2,000 confinements. Am. Jour. Obst.,
1917, 76, 932.
10. Hammett, F. S.: The relation between growth capacity and weight at birth. Am.
Jour. Physiol., 1917-18, 45, 396.
11. Bleyer, A.: Periodic variation in the rate of growth of infants. Arch. Pediat.,
1917, 34, 366.
12. Yerington, H. H. : Clinical supervision of the well baby during the first year.
Jour. Am. Med. Assn., 1918, 71, 1043.
NOTE
These three papers, specially contributed for this Pacific Coast
Number, have been crowded out because of lack of space :
The Food Requirement of the Breast Fed Infant. By Henry
Dietrich, M.D., Los Angeles.
Mental Examinations as an Aid to Pedagogical Methods in
the Public Schools. By William C. Hassler, M.D., and Olga
Bridgman, M.D., San Francisco.
Speech Disorders and Defects. By Mabel Farrington Gififord,
San Francisco.
They will appear in the next issue.
DEPARTMENT OF ABSTRACTS
Seham, Max : The Acidotic State of Normal New-borns.
(American Journal of the Diseases of Children, July, 1919, p. 42.)
Seham made 150 determinations on 50 babies whose ages
ranged from 1 hour to 32 weeks and concluded that alveolar
carbon dioxide tension is a practical index of acidosis. Fifty c.c.
of air in the bag, over a period of 30 seconds, for breathing gives
the most constant results. The modification of the Plesch-Hig-
gins' method of collecting air with the use of the pulmotor mask
is the most practical way of collecting air from new-borns. He
was not able to establish a lower CO" tension which is indicative
of the so-called "acidotic state." The ingestion of food, or starv-
ation and muscular exercise under these conditions, have no
constant demonstrable effect on the alveolar CO^ tension. The
urine of the normal new-born is nearly always acid. It takes
on the average 1.7 gm. of sodium bicarbonate to turn the urine
from acid to alkaline, giving 0.16 gm. every 2 hours by mouth.
His results with the alkali tolerance test for normal new-borns
do not indicate an acidosis. Practically no acetone was found
in the urine of normal new-borns.
C. A. Lang.
GiVENs, Maurice H. and McClugage, Harry B. : The An-
tiscorbutic Property of Fruits (an Experimental Study of
Dried Orange Juice). (American Journal of Diseases of Chil-
dren, July, 1919, p. 30.)
In this experimental study Givens and McQugage used orange
juice which was dried by two methods and both products were
fed to healthy guinea-pigs. These animals, fed on a mixed diet
containing plenty of green vegetables, developed scurvy similar
to that seen in humans, so are especially adapted for the experi-
mental study of the antiscorbutic vitamin. They demonstrated
that experimental scurvy in the guinea-pig can either be averted
or cured, by the use of a small amount of orange juice. Orange
juice can be dried so that it retains a significant amount of anti-
scorbutic vitamin. The most satisfactory process for drying is
the one in which the temperature of drying is not unduly high
255
256 Department of Abstracts
and the duration of drying very short. If orange juice is sub-
mitted to a temperature of from 55 to 60° C. for forty hours
or more, a part of the antiscorbutic vitamin is destroyed. The
dried orange juice investigated by the authors was active after
3 months' storage. Whether it will retain its potency for an in-
definite period remains to be determined. By desiccation of
orange juice it is possible to save a large amount of fruit hith-
erto wasted. Through such conservation of a waste product, it
ought to be possible to establish a price on dried orange juice
which is within the reach of a great many people who cannot
at present afford fresh fruit. They suggest the use of dried
orange as a convenient antiscorbutic in infant feeding, on polar
expeditions, in the navy, and for soldiers during war.
C. A. Lang.
Warwick, Margaret: Cerebral Hemorrhage of the
New-born. (The American Journal of the Medical Sciences,
July, 1919, p. 95.)
In a report of 36 routine autopsies performed on still-born
babies or those dying early in infancy, Warwick found 18, or 50
per cent, showed definite hemorrhages in the dura, over the brain
or in the ventricles. She gives a brief review of the literature
as to pathological findings and causes of the same and then sum-
marizes as follows:
1. The condition is brought about by trauma in normal or rapid
deliveries, by congestion or asphyxiation in slow deliveries,
or by disease of the child itself.
2. The so-called "hemorrhagic disease of the new-born" is a
much neglected but very important cause of cerebral hemor-
rhage in infants, occurring in 44 per cent of the deaths of
her series.
3. Forceps deliveries, advanced age of the primipara mother
and syphilis probably do not play as important a role in the
etiology of this condition as was formerly supposed.
4. More careful and complete routine autopsies on new-bom
infants as well as more accurate observations on the condi-
tions of the mothers and circumstances of the birth are needed
as a foundation for further studies.
C. A. Lang.
Archives of Pediatrics
MAY. 1920
HAROLD RUCKMAN MIXSELL. A.B.. M.D., Editor
CHARLES ALBERT LANG. M.B.. M.R.CS.. Associate Editor
COLLABORATORS :
L. Emmett Holt, M.D New York Fritz B. Talbot, M.D Boston
W. P. NoRTHRUP, M.D New York Maynard Ladd, M.D Boston
Augustus CAiLLft, M.D New York Charles Hunter Dunn, M.D. .. .Boston
Henry D. Chapin, M.D New York Henry I. Bowditch, M.D Boston
Francis Huber, M.D New York Richard M. Smith, M.D Boston
Henry Koplik, M.D New York L. R. De Buys. M.D New Orleans
Rowland G. Freeman, M.D. ...New York S. S. Adams, M.D Washington
Walter Lester Carr, M.D... New York B. K. Rachford, M.D Cincinnati
C. G. Kerley, M.D New York Irving M. Snow, M.D Buffalo
L. E. La FfiTRA. M.D New York Henry J. Gerstenberger, M.D. .Cleveland
Royal Storrs Haynes, M.D... New York Borden S. Veeder, M.D St. Louis
Oscar M. Schloss, M.D New York William P. Lucas, M.D... San Francisco
Herbert B. Wilcox, M.D New York R. Langley Porter, M.D..San Francisco
Charles Herrman, M.D New York E. C. Fleischner, M.D....San Francisco
Edwin E. Graham, M.D Philadelphia Frederick W. Schlutz, M.D.Minneapolis
J. P. Crozer Griffith, M.D.Philadelphia Julius P. Sedgwick, M.D Minneapolis
J. C. GiTTiNGS, M.D Philadelphia Edmund Cautley, M.D London
A. Graeme Mitchell, M.D. .Philadelphia G. A. Sutherland, M.D London
Charles A. Fife, M.D Philadelphia J. D. Rolleston, M.D London
H. C. Carpenter, M.D Philadelphia J. W. Ballantyne, M.D Edinburgh
Henry F. Helmholz, M.D Chicago James Carmichael, M.D Edinburgh
L A. Abt, M.D Chicago John Thomson, M.D Edinburgh
A. D. Blackader, M.D Montreal G. A. Wright, M.D Manchester
PUBLISHED MONTHLY BY E. B. TREAT & CO., 45 EAST 17tH STREET. NEW YORK.
ORIGINAL COMMUNICATIONS
THE INFLUENCE OF EPIDEMIC POLIOMYELITIS
UPON THE SUSCEPTIBILITY TO AND THE
SYMPTOMATOLOGY OF OTHER CON-
TAGIOUS DISEASES.*
By Joseph C. Regan, M.D.
Kingston Avenue Hospital, Brooklyn, N. Y.
The epidemic of poliomyelitis, which visited New York City
and vicinity in 1916, was notable for its extensive character and
high mortality. During the period of epidemicity, from the latter
part of June to the first part of October, 1798 cases were admitted
to the Kingston Avenue Hospital.
Owing to the large number of new patients who were literally
pouring into the hospital daily, it was a most difficult task to
exercise the same scrutinizing attention and routine which is
•From the Bureau of Hospitals, Department of Health, New York City, Dr. Robert
T. Wilson, Director.
257
258 Regan : Poliomyelitis and Other Contagious Diseases
customary in receiving other contagious diseases in order to avoid
the appearance of mixed infections in the open wards. Insomuch
as the majority of the admissions were children of an age in
which contagion is most common, it was considered probable that
a small number of poliomyelitis patients would be received who
were in the incubation period of a secondary malady, and that
subsequent to entrance to the hospital symptoms of the secondary
disease would appear, the children in the same ward would then
be exposed, and an outbreak of mixed infection on a small scale
would supervene.
It may be well to state before proceeding further that small
outbreaks of mixed infection constitute a common experience in
the treatment of all contagious diseases, especially in hospitals
with open wards. Such outbreaks originate from the importation
of infection into the hospital from without. Thus a patient suffer-
ing from a particular disease may be c^dmitted to that service
while in the incubation period of a secondary malady. Usually in
these instances the admission has occurred before diagnostic symp-
toms (rash, etc.) of the secondary disease have made their ap-
pearance; or on the other hand it may be a question of mistaken
diagnosis. Thus the sore throat and streptococcus exudate of an
early case of scarlet fever may be mistaken for diphtheria, the rash
not having as yet appeared, or the onset of measles, with catarrhal
croup, may be mistaken for laryngeal diphtheria, Koplik's spots
being indefinite or overlooked. At other times the outbreak
originates from the failure of the family to tell the ambulance
surgeon that the patient was exposed sometime previously to
another infection.
The result in any case is that the child, after admission to
an open ward, develops the secondary infection and as a result
all the children in that ward are exposed. It will therefore be
readily appreciated with what caution the examination of patients
must be carried out on entrance to the hospital to guard against
such occurrences. Yet even so, mixed infection at times origi-
nates. Scarlet fever, measles, varicella, etc., break out in the diph-
theria ward; diphtheria, scarlatina, varicella, etc., in the measles
ward, and so on. The diseases which are most apt to appear
thus are measles, varicella, diphtheria, scarlet fever and pertussis.
Of these, measles and varicella are the most contagious and more
generally lead to the largest number of secondary cases.
Regan : Poliomyelitis and Other Contagious Diseases 259
Once exposed, a ward must of necessity be quarantined from
the remaining part of the service in order to prevent the dis-
semination of the secondary infection. The executive care of the
service is thus increased, the segregation of patients is compli-
cated, the beds available for new admissions are diminished, the
mortality rate is occasionally augmented and the exposed ward
may have to be vacated in order to thoroughly clean and fumi-
gate it.
Therefore, reasoning from past experiences, outbreaks of
mixed infection, in the poliomyelitis wards were anticipated and
dreaded. Special care was taken to examine all children on en-
trance for signs of other contagious diseases, attention being par-
ticularly directed towards the buccal mucosa for evidence of
Koplik's spots, the throat for signs of exudate and the skin for
rashes.
A source of confusion at once arose. A small number of the
poliomyelitis patients presented minute macular spots on the buccal
mucosa resembling early Koplik's spots. These cases were iso-
lated for further observation. In no instance, however, did symp-
toms of measles develop. Then again, a number of the children
were admitted with a rash. As the eruption was in the majority
of cases scarlatiniform and as the tongue is often heavily coated
and the throat congested in both scarlet fever and poliomyelitis,
a differential diagnosis was sometimes not easy. The presence of
paralysis would, of course, indicate poliomyelitis, but the possi-
bility of a mixed infection of both diseases could not be excluded,
even after resorting to a lumbar puncture. The latter findings,
if positive, would often point towards poliomyelitis, but would
not prove anything regarding scarlet fever. Hence such cases also
required isolation.
As the epidemic progressed and none of the children isolated
developed further symptoms or complications of the suspected dis-
ease, these rashes were regarded with less suspicion, and the
writer was eventually compelled to conclude that patients with
poliomyelitis may have an eruption as part of the symptomatology
of the disease.*
One week after another of the epidemic passed without any
serious outbreak of mixed infection, and the poliomyelitis service
*The skin and throat manifestations of epidemic poliomyelitis have been described
by the writer in a previous article, Archives of Pediatrics, December, 1917.
260 Regan : Poliomyelitis and Other Contagions Diseases
remained virtually free throughout the epidemic of other con-
tagious diseases, with the exception of whooping cough.
Table I gives the total number of cases of mixed infection de-
veloping in the hospital among the 1798 patients admitted:
TABLE I.
Poliomyelitis developing pertussis 9 cases
measles 1 "
diphtheria 3 "
" " scarlet fever 1 "
varicella 1 "
Total 15 "
The percentage of mixed infection developing in the hospital
on this service was therefore 0.83 per cent. ; if pertussis be ex-
cluded from the series, it was 0.33 per cent., an extremely low
incidence, compared to that usual in other contagious diseases.
An analysis of the cases mentioned above is interesting. As
the table shows, 1 patient developed measles. The child was ad-
mitted in the incubation period and developed symptoms 10 days
following entrance to the hospital. The rash had made its ap-
pearance before the malady was recognized. No secondary cases
came down with the disease, despite the fact that the outbreak
occurred in an open ward with 32 other children, of susceptible
age, and not more than 20 per cent, of them were protected by
an antecedent attack. In the light of previous experiences with
outbreaks of measles in other contagious wards, this total ab-
sence of secondary cases was unusual. From such an exposure
sometimes, especially in diphtheria, 0.50 per cent, of those not
immunized by a previous attack will contract the disease.
Regarding the one instance of mixed infection with scarlet
fever a somewhat similar experience occurred. Not a single
secondary case developed, although the ward was filled with 30
young children and only a few had a history of an antecedent
attack.
The 3 cases of diphtheria originated in different wards. In
none of these 3 wards thus exposed did secondary cases follow.
This was rather surprising, for Zingher has shown that the Schick
reaction was positive in 81 per cent, of 954 children with poliomye-
litis between the ages of 1 and 4 years, compared to 30 or 40 per
cent, positives in normal children.
Regan : Poliomyelitis and Other Contagious Diseases 261
No secondary cases of varicella followed the exposure to the
one patient who developed that disease.
The only disease which was in the least prevalent among the
patients was pertussis. In several different wards patients de-
veloped symptoms of the disease. Several secondary cases ap-
peared in each ward, making a total of 9 in all.
Not only was the occurrence of mixed infections of polio-
myelitis with other diseases notahly slight in the hospital but the
number of patients admitted with double infections of any of
the acute contagious diseases plus poliomyelitis was also at a
minimum. Thus Table II shows the total number and type of
these admissions :
Table II.
Poliomyelitis and pertussis 14 cases
" measles 2 "
" mumps 1 "
Total 17 "
If Table I and II be added, it will be seen that out of the
1798 patients admitted only 32 had on entrance to the hospital
or developed later another contagious disease giving a percentage
of incidence of mixed infection in poliomyelitis among cases
treated during the 1916 epidemic of 1.72 per cent. If pertussis
be excluded from the series, the percentage of incidence is- re-
duced to almost one quarter of the total, namely, to 0.50 per cent.
This we believe is to be considered a very low figure for sev-
eral reasons. In the first place, most of the patients were children
of an age in which contagious diseases are most common and
many of them had little or no history of previous attacks. Then
again the epidemic was so extensive that the incidence of poliomye-
litis in the City per 1000 of population between the ages of 1 and
5 years was 28.26 cases.* Moreover, of the total of 4265 cases
that occurred in Brooklyn, the Kingston Avenue Hospital no
doubt received a high percentage of all those with mixed infec-
tion, as such cases would occur mostly in the poorer sections of the
city where hospitalization was more or less routine. Consequently
they would be sent to a hospital for treatment, and the only hos-
pital in the borough receiving contagion in addition to poliomyeli-
tis was the Kingston Avenue. Hence we feel certain that the per-
centage given above, 1.83 per cent, or 0.55 per cent, excluding
262 Regan : Poliomyelitis and Other Contagious Diseases
pertussis, would be greatly reduced if the total incidence of
mixed infection and poliomyelitis could be ascertained throughout
Brooklyn.
It might be possible to attempt to explain, on the basis of lack
of exposure, this low incidence of mixed infection if during the
first part of the epidemic contagious diseases in New York City
were at a very low minimum. That this was not the case, ex-
amination of Table III will show. At the time when the
epidemic began, namely the latter part of June, and subsequently
for several weeks, the prevalence of contagion was almost as high
as during the winter months of December 1915, January and
February 1916. Moreover, the districts in Brooklyn in which the
Table III — Cases of Infectious Diseases Reported in New York City
FROM December 1915 to August 1916.*
Dec, Jan., Feb., Mch., Apr., May, June, July, Aug.
1915 1916 1916 1916 1916 1916 1916 1916 1916
Measles 895 1,242 1,894 3,281 4,208 4,579 3,393 1,813 417
Scarlet Fever 520 680 753 948 842 791 489 300 78
Whooping Cough.... 463 465 526 930 1,094 1,140 1,033 %8 755
Diphtheria 1,390 1,572 1,485 1,570 1,329 1,715 1,570 1,064 511
Mumps 173 228 351 617 730 766 746 240 114
German Measles 50 86 113 225 346 475 395 132 29
Chicken Pox 661 956 874 1,439 1,623 1,747 1,331 430 70
Totals 4,152 5,229 5,996 9,010 10,172 11,213 8,957 4,947 1.974
*From the Monthly Bulletin of New York Health Department.
epidemic was the most severe were the more crowded quarters
and those where the people lived under very unhygienic surround-
ings and in which one usually also finds contagion most prevalent.
In this connection, one must consider the widespread dissemination
of poliomyelitis (for every 1000 persons between the ages of 1
and 5 years there were 28.26 cases). Therefore it would seem
probable that the factor of lack of exposure caii be ruled out.
The various facts mentioned above, regarding the in frequence
of the simultaneous occurrence of poliomyelitis and other con-
tagious diseases, are certainly of such an unusual character as
to permit a few logical deductions. Naturally it is not possible to
Regan : Poliomyf litis and Other Contagious Diseases 263
draw any hard and fast rules in a study of this kind and the con-
clusions which are eventually made will depend for their corrob-
oration upon future observations.
Either one or both of 2 suppositions are strongly suggested : —
(1) That children with acute poliomyelitis are not prone to
develop other contagious diseases with the exception of whooping
cough or (2) that children suffering from contagious diseases
are not usually prone to develop poliomyelitis.
That children with poliomyelitis are less susceptible to other
contagious diseases, with the possible exception of pertussis, would
be indicated by the following : ( 1 ) The small number of combined
infections of poliomyelitis and other contagious disease admitted
to the hospital during the epidemic; (2) the small number ol
patients who developed a mixed infection after admission to the
wards and the complete lack of secondary cases following si:cli
outbreaks (excluding pertussis) ; (3) these preceding facts to bo
considered in conjunction with the relatively large number of
cases of contagion existing throughout the city at the time of the
epidemic and the widespread character of this latter.
That patients with other contagious diseases are less apt to
develop poliomyelitis than normal children seems also a very
probable supposition, as is indicated by the small number of
patients with mixed infection admitted to the hospital, as well as to
a lesser extent by the fact that the only contagious service in
which cases of poliomyelitis developed was the diphtheria. Here
a few patients, 3 or 4, contracted the disease. This was the only
example of an outbreak of poliomyelitis that occurred on any of
the services during the epidemic, despite the fact that the hoopital
census of contagion on June 30, 1916, was 212 patients.
A Theory to Explain the Almost Complete Freedom of
Poliomyelitis from Mixed Infection, The literature dealing
with the influence of an attack of a disease prevailing in epidemic
form upon the susceptibility of the individual attacked to other
acute infections seems to be very meagre. No reference was
found relative to the influence of poliomyelitis in this respect.
Colin- states that it was the belief of some of the older students
of epidemiology, especially the "illustrious" Boudin^, that there
existed often a condition of antagonism between various diseases
which would explain the attenuation or suppression during an
epidemic of other infections. Colin does not think, however, that
264 Regan : Poliomyelitis and Other Contagious Diseases
this antagonism is so frequent as many observers have contended.
Thus he questions the opinion of the older writers that an antag-
onism exists between such maladies as variola and typhoid, typhus
and grippe, variola and bubonic plague, intermittent fever and
typhoid fever, etc. It is his belief that antagonism between epi-
demics is much less considerable than their affinity, as is indicated
by numerous places deprived of hygiene in which popular disease
of the most diverse type prevails.*
That the virus of poliomyelitis probably temporarily protects
the individual attacked from contracting other contagious diseases
(i.e. except pertussis), the writer believes. That this is an im-
munity of a temporary type would therefore be indicated, but as
it cannot be due to the presence in the blood of immune bodies,
either passively or actively obtained, it must be due to some other
condition. To understand the probable basic reasons^ we must
briefly refer to some fundamental facts of bacteriology. We shall
take the privilege of extracting some of these principles from a
book of standard authority (Park and Williams^) : — "When one
species of organism is grown on a food medium, the medium
usually becomes less suitable for the growth of its kind and of
other organisms. When different species are grown together, the
antagonistic action of one upon the other may be shown from the
beginning. Some species have a cooperative or symbiotic action
with other species . . . Microorganisms are also at times
directly influenced by the products of the associated organisms.
These may affect them injuriously or again the association of one
variety with another may increase its virulence i.e. streptococci
in diphtheria. . . . On the other hand the absorption of the
products of certain bacteria immunizes the body against the in-
vasion of other bacteria as shown by Pasteur, in that attenuated
chicken cholera cultures produce slight immunity against anthrax.
. . . The enzymes formed by certain bacteria have been found
to exert a slight bactericidal action not only on the germs which
have directly or indirectly produced them in the body but also on
other varieties."
From these fundamental principles of bacteriology, one may
attempt to formulate a working theory as follows: That upon
*Welch and Schamberg* believe that the presence of an acute disease is apt to
temporarily diminish the susceptibility of the patient to develop most of the ex-
anthematous maladies. Also that the susceptibility to measles may even be temporarily
abolished during the existence of another acute infection.
Regan : Poliomyelitis and Other Contagious Diseases 265
infection with the virus of poHomyehtis, certain changes occur in
the tissues of the infected individual, which as a rule render them
unsuitable for the growth of other causative agents of most of
the acute contagious diseases. In other words, a condition of
antagonism exists. It may be that the microorganism of polio-
myelitis is so thoroughly distributed and so numerous in the nose,
throat and upper respiratory or gastrointestinal tract, that other
organisms are quickly overgrown and the other infective agents
of the acute contagious diseases find it difficult to obtain an atrium
in which they can develop to a sufficient extent to invade the body.
Moreover, the products of growth (enzymes) of this particular
microorganism may render the tissues already infected unsuit-
able soil for these other organisms to develop upon. The only
germ which clinically seemed to have a symbiotic relation with
that of poliomyelitis is the bacillus of whooping cough.
Influence of Poliomyelitis Upon the Symptomatology
OF Other Diseases Occurring Coincidental with it, and Vice
Versa. That the symptomatology and prognosis of a disease may
be influenced to a greater or less extent by another concomitant
infection is well established by numerous observations. Owing
to the complete lack of literature on the subject relative to polio-
myelitis, it seemed that it might be of value to give in detail the
symptoms and clinical picture of the' various mixed infections
that occurred on the poliomyelitis service so that conclusions
might be drawn as to the effect that this latter disease exerts on
the clinical course of other concurrent maladies.
Poliomyelitis and pertussis. There were 23 patients with these
2 diseases treated and all recovered.
Symptoms of poliomyelitis — The type of the disease was mye-
litic in 7, myelitic and encephalitic in 12, meningitic in 1, ataxic
in 2. Bulbar symptoms were present in 3 of the encephalitic
cases and meningitic symptoms in 8. Paralysis involved both
lower limbs in 13, back muscles in 13, both upper extremities in
2, right upper extremity in 2, facial nerve in 7, muscles of deglu-
tition in 3.
Symptoms of pertussis — Most of the cases were of a mild
character. Whooping was present in 19, and vomiting in 17.
Four children, under 1 year of age, merely had a paroxysmal
cough with terminal expectoration of mucus. An interesting ob-
servation was that in several patients with paralysis involving the
266 Regan : Foliomyelitu and Other Contagious Diseases
muscles of the larynx, the character of the paroxysm was greatly
altered. The paroxysmal cough was not nearly so loud as it is
usually, and the loud crowing sound of the whoop was often so
indistinct that unless one was within a few feet of the patient
it would be missed entirely.
Poliomyelitis and diphtheria — The total number of patients de-
veloping diphtheria was 3. All recovered. The disease was mye-
litic in type in all 3 instances. The paralysis involved both lower
extremities in 2 cases and the right lower and left deltoid in 1.
Two of the patients had nasal diphtheria and one tonsllar. 1 hey
were all mild types of the disease requiring 5000 units of anti-
toxin for 2 cases and 10,000 units for 1. Cultures were positive
in all 3 cases. Symptomatology was uninfluenced.
Polioniryelitis and scarlet fever — Only 1 case was treated.
This was a boy, age 5 years. Patient presented typical symptoms,
mild angina with follicular exudate on tonsils, strawberry tongue,
and punctate erythematous rash. The type of poliomyelitis wa^
myelitic with involvement of lower extremeties, neck and back.
The disease pursued a mild course and patient recovered.
Poliomyelitis and measles — The total number of cases treated
was 3 ; of these 2 recovered and 1 died. Two cases were admitted
as poliomyelitis and measles and 1 case developed measles 10 days
after admission.
Case 1. Age 21 months, ill 21 days with poliomyelitis nnd
3 days with measles, when admitted. Rash was maculopapular,
and generalized. Koplik's spots were present, also slight coryza.
Myelitic tyi>e of poliomyelitis with paralysis of both lower ex-
tremities. Child recovered.
Case 2. Age 2 years, ill 13 days with poliomyelitis and 3
days with measles on admission. Rash was maculopapular,
coryza present. Koplik's spots fading. Myelitic and meningitic
type of poliomyelitis. Paralysis of both lower extremities, back
and intercostals, also rigidity of neck and positive Kernig. Child
died the third day after entrance of respiratory paralysis.
Case 3. Age 3 years, admitted as a case of poliomyelitis with
paralysis of both lower limbs, left facial nerve and intercostal
muscles. On 10th day developed Koplik's spots and coryza, and 2
days later a generalized maculopapular rash. Recovery occurred.
The symptomatology was typical in all 3 instances.
Poliomyelitis and varicella — One case, age 3 years. De-
Regan : Poliomyelitis and Other Contagious Diseases 267
veloped varicella 34 days after admission. No known exposure
within the hospital. Had paralysis of both upper extremities,
left lower, also of left facial nerve. Recovery ensued. Sympto-
matology typical.
Poliomyelitis and mumps — One case admitted with both
diseases. Patient was 2 years old. Had involvement of both
parotids. Myelitic type of poliomyelitis. Course was uneventful
and patient recovered. Symptomatology fairly typical.
Summary. 1. The occurrence of mixed infection constitutes
a possible source of danger in the hospital treatment of all con-
tagious diseases.
2. This danger was considered to be particularly acute in
the hospitalization of patients with poliomyelitis during the
1916 epidemic. Large numbers of children with this disease
were admitted daily to the Kingston Avenue Hospital, most
of them of an age which is most susceptible to the various con-
tagious maladies and many of them with an almost entirely
negative history as to previous attacks. During the early period
of the epidemic, when patients were pouring into the hospital
most rapidly, contagious diseases in New York City were as
prevalent as during the preceding winter months of December
and January. It was therefore considered probable that exposure
to other contagious diseases would occur in many instances.
3. Certain symptoms, such as rashes of scarlatiniform type,
heavily coated tongue, congested throat and occasional minute
spots on the buccal mucosa, which occur as part of the sympto-
matology of poliomyelitis, caused at first confusion and a number '
of patients were isolated as possible cases of measles and scarlet
fever. The subsequent clinical course of the disease proved that
the suspicious symptoms were to be attributed entirely to polio-
myelitis.
4. As the epidemic progressed, the notably small incidence of
mixed infection developing after entrance to the hospital was
noted. Considering the facts of the case, the figures we believe
are unusually small. Thus the total number of patients develop-
ing a mixed infection, subsequent to admission, was only 15, or,
compared to the total number received, 0.83 per cent, and, if 9
cases of pertussis be excluded, 0.33 per cent. (^ of 1 per cent).
5. These 15 cases were divided among the various diseases as
follows : — 9 pertussis, 3 diphtheria, 1 measles, 1 scarlet fever and
268 Regan : Poliomyelitis and Other Contagious Diseases
1 varicella. No secondary cases followed the outbreaks of the
cases of diphtheria, measles, scarlet fever or varicella, despite the
fact that the wards in which these diseases broke out were filled
with children, the majority of them unprotected by previous
attacks,
6. Not only was mixed infection of poliomyelitis with other
contagious diseases notably slight in the hospital but the number
of patients admitted with double infections of this and some other
contagious malady was also noticeably small — 17 in all or com-
pared to the total admissions, 0.94 per cent.
7. Thus out of a total of 1798 patients with poliomyelitis
treated there were only 32 cases who had, on admission or de-
veloped subsequently, another disease, giving a percentage of
incidence of 1.72 per cent. Of this total of 32, there were 22 with
pertussis; if these be deducted the incidence is reduced to 0.59
per cent. This figure is undoubtedly much higher than the actual
ratio of mixed infection in poliomyelitis in the City as a whole,
for while there were 4312 cases of the disease in Brooklyn only
1798 were received at Kingston Avenue. On the other hand, being
a contagious hospital, we no doubt received a high proportion of
all cases of mixed infection.
Conclusions.
1. The above facts indicate that children with poliomyelitis
are not as suspectible to develop other contagious diseases as nor-
mal children with the possible exception of whooping cough. This
latter was the only contagious malady prevalent among the polio-
myelitis patients during the epidemic.
2. A working theory to explain this temporary relative in-
susceptibility may, we believe, be based upon certain fundamental
principles of bacteriology : — Upon infection with the virus of
poliomyelitis, certain changes occur in the tissues of the infected
individuals, due possibly to the products of growth of the organism
of poliomyelitis, which render them unsuitable for the develop-
ment of the causative agents of other acute contagious diseases.
In other words, a condition of antagonism exists. It may be that
the causative factor of Heine-Medin's disease is so thoroughly
distributed and so numerous in the nose, throat and upper respira-
tory tract that the infective agents of other acute contagious dis-
Regan : Poliomyelitis and Other Contagious Diseases 269
eases find it difiicult to obtain an atrium in which they can develop
to a sufficient extent to invade the body. The only germ which
seems clinically to have a symbiotic relation with that of poliomye-
litis is the bacillus of whooping cough.
3. The influence of poliomyelitis on the symptomatology of
scarlet fever, diphtheria, varicella, measles and parotitis seems to
be negligible with the one exception that symptoms of the as-
sociated diseases were milder than usual. The only malady in
which symptoms were observed to be definitely modified was
pertussis. Thus in cases of poliomyelitis, with paralysis involving
the muscles of the larynx, the paroxysmal cough was often ren-
dered much less audible and the whoop so soft as only to be heard
if one was quite close to the patient.
4. The mortality rate of these mixed infections was remarkably
low, namely, 3 per cent, compared to 23.79 per cent, in the straight
poliomyelitis cases.
BIBLIOGRAPHY.
1. Monograph on The Epidemic of Poliomyelitis in New York City in 1916, published
by New York Health Department, New York City, 1917, p. 366.
2. Colin, Leon: Traite des Maladies Epidemiques, Paris 1879, pp. 475, 477, 485.
3. Boudm: Quoted by Colin, Ibid. p. 476.
4. Welsh, W; M. and Schamberg, J. F.: Acute Contagious Disease, 1905, p. 480.
5. Park, W. Fl. and Williams, A. W.: Text Book of Bacteriology, 1913, pp. 52, 137,
141, 158.
Essential Enuresis in Children (Pediatria, Naples, Sept..
1919). U. Provinciali reviews the various theories that have
been advanced to explain essential enuresis, and states that in
eight out of ten children of this category roentgen examination
revealed anomalies in the lumbar-sacral portion of the spine. In
only two were these parts of normal aspect. The children with
these anomalies did not show any other appreciable signs of de-
generacy or only in a proportion much less than in adults. As the
children usually outgrow the enuresis in time, he urges roentgen
examination of their spines to see if it might not be possible to
detect the nature of the anatomic changes which put an end to
the enuresis. He protests against the assumption of dysplasia in
the spinal cord or roots, as this would entail quite another set. of
symptoms, more in the line of neuralgia or paralysis. — Journal
A. M. A.
FROZEN MILK*
By Harold R. Mixsell, M.D.
New York
During- the past 3 years, and particularly during the severe
winter of 1917-1918, I have been asked repeatedly by patients
about frozen milk, and as to whether its use was harmful in
infant feeding. It frequently had happened that, owing to de-
layed deliveries, and to the extreme cold, milk would be received
in a more or less solid state necessitating its thawing out by means
of heat. In some cases, milk delivery was prevented for 2 or 3
days by snow drifts, and the milk would accordingly be from 4
to 5 days old when used, plus having been frozen. Naturally
the mother would hesitate to use this milk as there was a precon-
ceived prejudice against its use. At the time, and indeed ever
since, I advised against it, although I had only precedent to go
by. In this paper, therefore, I have endeavored to collect all the
facts of the case and to form conclusions as to whether or not
its use is injurious to infants or young children. This has not
been easy, for in reviewing the literature one is surprised at the
scarcity of material written on the subject. There is also a
confusing difference of opinion about various points which still
remains to be cleared up.
The first record of the use of frozen milk in commerce that I
have been able to find in the literature is contained in an article
by Duclaux\ written in 1896. Later (1907), milk frozen at
— 5° C. and reduced to a powder was shipped from Sainte Lau-
rent en Champsaur (Hautes-Alpes) to Marseilles^. Duclaux be-
lieves that the reason frozen milk has not been transported from
a region where it abounds to one where it is rare, is due to cus-
tom alone, and not on account of any valid objection to the method.
He admits though, that milk delivered in cold countries in a
frozen condition has a changed taste, without the ordinary flavor,
and that there is less cream. He believes, however, that with the
aid of refrigerating machines these difficulties are not insur-
mountable. The firm of Gillay of Lille, for example, over 24
years ago shipped from Lille to Paris, boxes lined with tin plate
on the inside with tightly fitting covers, containing loaves of
•Read at the New York Academy of Medicine, Section on Pediatrics, April 8, 1920.
270
Mix SELL : Frozen Milk 271
frozen milk in the form of flat tablets. These are prepared as
follows : The milk is first pasteurized, then plunged into a re-
frigerating bath of 25° F. in a flat metal case. This causes almost
instantaneous freezing. The crystalline needles implant them-
selves perpendicularly on the walls of the box, and extend down
to the middle of the mass, so that when the shape is drawn from
the mould, there is a hard cake, more crumbly in its median plane,
or where the 2 layers of crystals come together to form joists.
These cakes are placed side by side upright in the box, with an
intervening space so that they do not stick together.
Soon after their preparation these masses of ice undergo a
singular change in appearance. From an original yellow tinge
they whiten and become more transparent. It was Duclaux's
experience that the upper part of the cake was the first to change.
Accordingly he detached from the top and bottom of the cake 2
bands which were allowed to melt separately with the following
results :
UPPER PART LOWER PART
Elements in In In In
Suspension. Solution. Suspension. Solution.
Fats 2.73 .... 2.72
Milk sugar 4.19 .... 4.88
Casein 2.56 0.21 3.91 0.34
Phosphate of lime 0.17 0.12 0.24 0.16
Soluble sahs 0.28 .... 0.36
5.46 4.80 6.87 5.74
Total residue 10.26 12.61
I may say incidentally that these analyses agree with that of
other observers.
A comparison of the 2 analyses shows that the liquid coming
from the melting of the lower part is richer than the upper. Their
composition is normal, but one is more diluted and the other
more concentrated than the original whole milk. This is quite
obviously due to the concentrated liquid of the upper stratum by
force of gravity, gradually losing part of its contents which have
been entangled in the water crystals, very similar to a sponge.
The one thing to be noted is the fact that the fats have not
272 Mix SELL : Frozen Milk
followed in the descent of the concentrated milk (2.73 per cent.
as compared with 2.72 per cent.). This is due to the fact that
the fat is solidified at the low temperature to which it has been
subjected, and is firmly adherent to the ice crystals which they
only leave when these crystals melt. This is the reason advanced
by Duclaux for the changes in taste which one sometimes gets in
frozen milk, where it has only been either partially frozen or par-
tially melted. If the frozen milk is allowed to thoroughly melt,
and if it is mixed to insure its homogeneity, he found no particular
taste or change in taste.
C. Mai^ had rather similar results to those obtained by Du-
claux. He had samples of normal milk frozen, each at a different
temperature, and for a different length of time, and then all
thawed out under the same conditions. Analyses of the mushy
top ice, the solid cakes on the sides and bottom, the unfrozen
portion in the middle, and of the whole milk after being again
thawed and thoroughly mixed, indicate: 1. Even when the out-
side temperature is 18° F,, a large part of the cream will rise
before the milk freezes; 2. The calcium chloride, serum, acidity
and solids (not fat) of the residual unfrozen portion are much
higher, and of the solid ice lower than the same factors in the
original milk; 3. That there is no permanent change in the
composition of the milk due to freezing and thawing. He feels
that there is no reason why samples of milk should not be col-
lected in the winter if the frozen mixture can be thoroughly
melted and mixed before the samples are used.
A fact which has been utilized in milk preservation in cold
storage warehouses, is that the growth of organisms in milk is
delayed by cold, and that there is, accordingly, a retardation of
those processes which eventually would make the milk unfit for
consumption. In the past it has been popularly supposed that all
bacterial life is dormant during this period of extreme cold.
This is probably due to the fact that with milk, which has been
packed in ice, the rate has been extremely slow. In fact, during
the first 24 to 48 hours there is a definite loss of organisms. Conn
and Esten* report 3 experiments where milk was kept at 1° C.
They found that scarcely any bacterial development took place
for from 6 to 8 days, after which time there was a steady increase
until very great numbers were present, though the usual lactic
acid organisms were not in the majority, therefore the milk did
Mix SELL : Frozen Milk 273
not curd. They also found a comparatively large number of
gelatin-liquefying organisms, and a number of the "neutral" milk
organisms; that is bacteria which produce neither acid or alkali.
In their summary, they state that milk is not necessarily whole-
some because it is sweet, especially if it has been kept at low tem-
peratures. It may contain enormous numbers of bacteria, among
which are species more likely to be unwholesome than those that
develop at 20° C.
Pennington^ has made an extensive study of the bacterial
changes which occur in milk at low temperatures. The experi-
ments were conducted upon certified milk and ordinary market
milk, the 2 being run side by side and the results compared. It
was found that the bacteria increased markedly in numbers after
the first 48 hours. The milk used in some instances was kept
almost 2 years at 29° to 31° F. in packages. Incidentally the
freezing point of milk is 30.9° to 31.02° F. Bacteria growth at the
end of a week, even in the cleanest milk, which contained 300 bac-
teria to the cubic centimeter, was pronounced. Within 6 weeks it
often passed the billion mark per cubic centimeter.
Within 3 weeks milk kept at this temperature froze in the form
of small ice crystals in the vessels containing them. In spite of the
freezing an enormous increase in the bacteria occurred, and it
was found that there was neither odor or taste to indicate that this
had happened. Another interesting point was that the milk did
not curd, even on heating, and it was not until the putrefactive
organisms had multiplied was its use to the casual observer con-
traindicated.
Pennington's technique was as follows : The number of organ-
isms in the milk was found by plating in suitable dilution and
counting the colonies in the usual way. In order to have some
idea of the qualitative as well as the quantitative relation of these
organisms, plates were made on several different kinds of media.
A plain nutrient agar was used for the total count. A lactose
agar, containing sufficient litmus to color it a clear blue was used
to pick out, more especially, the acid forming organisms; and a
lactose-litmus gelatin served for the detection of those organisms
which form proteolytic enzymes.
A classification on a chemical basis of the organisms occurring
at these low temperatures showed that there were constantly
present bacteria which formed acid, and bacteria which acted
274 Mixsell: Frozen Milk
on proteid. There were also neutral organisms which formed
neither acid or alkali and did not act on gelatin. The acid forming
organisms were generally in relatively smaller numbers than are
found when milk is kept at higher temperatures, and the lique-
fying organisms were more numerous. Certain species, such as
B. forrhosus, R. solitarius, and B. Ravenel were especially resist-
ant to cold. The predominating acid forming organisms found
were the micrococcus aurantiacus and the micrococcus ovalis.
Coincident with the bacteriological study of milk samples
there was made a chemical analysis of the changes occurring in
the proteid. This showed that the casein was rapidly digested
until finally more than 50 per cent, of it was changed to soluble
compounds. Caseoses, amino-acids, and probably peptones in-
crease rapidly at the expense of the digested casein. This was
pronounced at the end of 2 weeks.
More recently Pennington and her collaborators", having de-
termined that raw milk held at, or a little below a temperature
of 0° C, undergoes a marked proteolysis in 2 weeks or less, have
endeavored to ascertain whether this is due to the enzymes of the
milk, or to the bacterial flora, or to both combined. They have
come to the conclusion that the proteolysis of the casein is pri-
marily of bacterial origin, and that the proteolysis of the lact-
albumin is due, primarily, to the native enzymes of the milk.
They have also determined that the milk enzymes and the bac-
terial flora combined, give rise to more rapid proteolytic changes
than are produced by either agent alone. This involves a break-
ing down of the true proteins and their passage through peptones
and caseoses to the amino-acids.
The determination of the acidity by the decinormal sodium
hydrate-phenolphthalein test showed that there was a much higher
acid content after 2 weeks than is ordinarily required for curding
—which seldom happened. Milk having this high acidity, even
when placed in an ordinary ice chest did not curd even when
exposed to the higher temperature.
In regard to the effect of extreme cold on the carbohydrate
constituents of" milk very little is known. That there is some
change is indicated by the quite marked increase in acidity which
has been determined by the decinormal sodium hydrate-
phenolphthalein test. Hepburn^ has also shown experimentally
that the lactose content decreases after milk has been frozen.-
Mixsell: Frozen Milk 275
Pennington has determined that the fermentation of the lactose
with the resulting formation of lactic acid is largely, if not ex-
clusively, due to bacterial action.
Pennington conducted a series of experiments on the fat
content of frozen milk. She found that the iodine number* and
the index of refraction of the butter fat remained unchanged, while
the Reichert-Meisslt value showed no marked change. The
hydrolysis of the fat and the increase in acid value was found
to be due to the action of bacteria. This agrees with the findings
in the digestion of the protein, the fermentation of lactose and
the increase in acidity. All these progressive changes are caused
by the vast increase in the bacteria, and are accompanied by pro-
gressive lowerings of the freezing point of the milk.
In regard to the action of frozen milk on the digestion of an
infant or a young child, there is a wide divergence of opinion,
although the weight of evidence seems to be that there is no reason
for the belief that frozen milk elaborates toxic substances which
will disagree with the average bottle-fed baby. Experimentally
we have seen that there is no increase in the number of bacteria
in the first 48 hours, and it is seldom, if ever, that milk has been
frozen even as long as that time. The action of freezing on the lac-
tose and the fat is seen to be very slight, the protein is split into
peptones, caseoses and eventually amino-acids, and that only after
a period of 2 weeks or more. I have frequently had babies who
were taking frozen milk with no bad results. Kerley* speaks in
his text book of having fed many thousand quarts of frozen milk
to infants under his care during the past 30 years. Duclaux
reports on the practicability of utilizing it commercially, and Mai,
that there is no permanent change in the composition of milk due
to freezing and thawing. The crux of the whole matter seems
to be in insuring its homogeneity by properly melting and mixing
it before it is used. Heineman^, however, says that under no
conditions is thawed milk exactly the same, in every respect, as
unfrozen milk. This, he states, is due to the fact that the water
*The iodine number — This is the percentage of iodine or equivalent halogen with
which an oil is capable of combining. The modern modification of this method was
perfected by Hubl, who used a mixture of solution of iodine with a solution of mer-
curic chloride, the amount of the absorption being calculated in terms of iodine.
tReichert-Meissl value — This is the measure in cubic centimeters of decinormal
alkali solution of the proportion of volatile fatty acids distilled in a current of steam
under constant conditions from 5 grams of the fat saponified and acidified under
specific conditions.
276 Mixsell: Frozen Milk
freezes at first at the outside on the wall of the vessel ; the solids
are forced towards the center, the fat rises and is partially churned
when the milk freezes. The natural emulsion of fat is never com-
pletely restored after thawing, and the casein appears in flakes
rather than in the original colloidal condition. The emulsion of
fat is destroyed more rapidly than the colloidal condition of the
casein. It is probably on account of this that thawed frozen milk
may decompose more rapidly than normal milk. It is therefore
essential that it should be used immediately, if at all. Heineman,
however, does not state that this interference with the emulsifica-
tion of the fat prevents the ready digestion of the milk.
Rosenau'" also states : "'Milk cannot be preserved indefinitely
simply by the use of cold. Even at the freezing temperature some
of the bacteria continue to grow and multiply, and putrefaction
slowly takes place. Milk kept very cold does not sour, but turns
putrid because the lactic acid bacteria do not grow at low tem-
peratures, whereas the putrefying bacteria do. While milk should
be kept cold, it should not be permitted to freeze, for freezing
alters its composition and may render it undesirable, especially
for infant feeding. . . . Freezing does not destroy the
pathogenic bacteria. If milk contains the germs of typhoid,
diphtheria, scarlet fever or tuberculosis, the danger is not
eliminated even if the milk be frozen. Cold therefore, while a
preservative, is not a germicide."
Owing to the marked difference of opinion, I have made it a
rule in the past to advise the use of either dry milk or unsweet-
ened condensed milk in cases where the milk has been frozen, —
especially among young infants. I have heard indirectly, but not
in detail of cases of severe diarrhea 'following the use of frozen
milk, and it is on account of this that I have recommended the
above milk preparations as alternatives. It is perfectly possible
that a putrefactive diarrhea may ensue, owing to the growth
of the putrefying bacteria at low temperatures, and the breaking
down of the proteids into amino-acids,' or a diarrhea due to
lactic and fatty acid formation. I may go on record, however,
as stating that personally I have never seen any bad efifects from
the ingestion of frozen milk, and would gladly welcome additional
data on the subject.
Conclusions
1. There is no increase in the number of bacteria in 48 hours.
MixsELL : Fro::en Milk 277
2. After 48 hours the increase is marked, although the usual
lactic-acid forming organisms are not present in sufficient quan-
tities to form a curd.
3. There is a rapid proteolysis which is pronounced at the
end of 2 weeks.
4. The acidity is markedly increased, owing to bacterial
action on lactose, changing it to lactic acid.
5. No marked change in the fat has been noted except that
caused by bacteria.
6. It is believed by many that frozen milk, if melted and
thoroughly mixed, may presumably be used with impunity,
within 48 hours after freezing.
7. Owing to divergence of opinion it is better for the pediat-
rist to substitute a temporary formula of either dry milk or
unsweetened condensed milk for milk which has been frozen,
especially in feeding very young infants.
BIBLIOGRAPHY.
1. Duclaux, E.: Sur le Lait Congele. Annates de I'lnstitutc Pasteur, 10, 1896, p. 393.
2. L'Hygiene de la Viande et du Lait, 1, 1907, p. 37.
3. Chemical Abstracts, 6^ May-September, 1912. C. Mai. Z Wahr Genussim 23,
250-4.
4. Storrs' Agricultural Experiment Station Report, 1904.
5. Pennington, Mary E.: Journal Biological Chemistry, 4, 1908, p. 353.
6. Pennington, et al. : Ibid. 16, 1913-1914, p. 331.
7. Hepburn: Journal of the Franklin Institute, CLXXII, (1911), p. 187.
8. Kerley, C. G.: Practice of Pediatrics, 1917, p. 78.
9. Heineman, Paul G.: Milk, 1919, p. 128.
10. Rosenau, M. J.: The Milk Question, 1912, p. 293.
11. Rischoff: ttber Eisniilch. Arch fiir Hygiene, 47, 1903. n. 68.
12. Morse and Talbot: Diseases of Nutrition and Infant Feeding, 1920.
13. Farrington, E. IL: Wisconsin Station Report, 1902, pp. 136-137.
14. Mai, C: Molk. Zeitg., Berlin, 22, (1912), 18, pp. 207-208. Reviewed in the New
York Produce Review and American Creamery, 34, (1912) 6, p. 262.
15. Engling: Landw. Vers. Stat, xxxi, (1888), 391; Siegfried and Bischoff: quoted
by Raudnitz in Sommerfeld's Handbuch, 201.
Cod-Liver Oil for Rickety Children (Medical Officer,
1918, i, p. 47). — G. A. Brown states that the administration of
cod-liver oil is an essential and powerful factor in the treatment
of these cases. From his observation of the improvement in the
general nutrition of rickety children after a course of cod-liver
oil, judiciously administered over a long period, he is convinced
that the oil is one of our most powerful allies in combating the
effects of this wide-spread disease. At the same time excellent
food and the good hygienic condition of special schools play an
important role in the treatment of the disease. — British Journal of
Diseases of Children.
THE FOOD REQUIREMENT OF THE BREAST FED
INFANT
By Henry Dietrich, M.D.
Los Angeles.
When we consider that the infant in all parts of the world is,
and has been, fed at the breast since the creation of the world,
we must be struck by the scarcity of observations in regard to
the amount of food taken by a child during the period of lacta-
tion. Most of the reports cover a period of a few days or weeks,
only a very few recording the amount taken from birth until the
child was weaned. A very large part of the data comes to us
from the foreign literature. In no instance was a daily examina-
tion of the breast milk carried out. This would be of scientific
interest but less important practically, and we wish to discuss the
subject from a practical standpoint.
The chemical composition of mother's milk varies from day
to day, and often from nursing to nursing, and as is well known,
at different periods of the same nursing. Furthermore, the
amount of inorganic constituents is rarely determined, and yet
they play a very important role in the body metabolism. Sub-
stances such as nucleins, glycoproteids and lecithin may be more
or less important factors in body growth. The value of the ex-
amination of mother's milk as it is ordinarily carried out is there-
fore over-estimated, and in many instances leads to false deduc-
tions and treatment. We feel, therefore, that a volumetric esti-
mate of the child's food requirement is in the average case a more
practical one. Heubner and others, in addition to stating the
amount of breast milk required for growth at a given age, have
expressed themselves in terms of calories. This is of some value,
but on the other hand also is only approximate, as with the varia-
tion in the composition of mother's milk its caloric value also must
change, and different authors disagree as to the average caloric
value of 1 kilogram of milk. If we express ourselves in terms
of calories, we must state whose figures we use in computing the
calories. The caloric value of 1 kilogram of milk is given as
follows : Rubner and Heubner, 650 calories ; Gans, 722 calories ;
Schlossmann, 721 calories; Rehyer, 765 calories; Engel, 765 calo-
ries ; Morse and Talbot, 782 calories.
278
Dietrich : Food Requirement of the Breast Fed Infant 279
Heubner's figures were used in computing the caloric require-
ment in the cases here cited, and we will use the same figures in
order to facilitate comparison.
Energy quotient is the term applied by Heubner to the number
of calories per kilogram of body weight per day that are neces-
sary for growth. Remembering that after all each child is an in-
dividual, and that the caloric value of mother's milk in each in-
stance was not calculated, we are not surprised to again find wide
diflferences in the energy quotient quoted, as noted in different
children observed. Heubner gives 100 calories as the quotient
for the first 3 months, Schlossmann 110, Siegert 80, and Dennett
110 to 120 calories. Cramer observed an infant for the first 9
days, who gained well on 50 calories. Cans, quoted by Reuss,
reports a case with a quotient of 44 calories for the first 10 days.
Beck quotes the following as average figures :
1 — 12 weeks = 107 calories
13_24 " =: 91
25—36 " irr 83 "
37_^4 " r= 69
Finally we wish, as far as possible, to state the child's re-
quirement of food in terms of grams of milk taken per meal per
day. For a detailed account of the cases reported we will refer
the reader to Czerny and Keller, Vol. 1, pages 392-406. The
children observed varied considerably in weight, in other in-
stances the number of feedings is not stated, and in 2 instances
the report states that both breasts were fed at each feeding (Ahl-
feld, Haehner i). We will here quote only the averages ar-
rived at and conclusions which may be drawn from the figures
published. The amount of milk taken at the individual meal,
even on the same day, varies considerably, not infrequently as
much as 50 to 100 grams after the first month. The amount
taken at a single meal depends on the amount of milk in the
breasts and the number of feedings per day. The total amount
taken in 24 hours, however, for a given period of life is fairly
constant, increasing of course with increase in weight and age.
Engel claims that the infant, after the first few weeks, takes its
largest meal in the morning, a lesser amount in the middle of the
day, and again an increased quantity at the evening meal. We
find in our case that this was quite often the fact but can not say,
however, that we find it to be the rule. Gregor also has shown
280 Dietrich : Food Requirement of the Breast Fed Infant
that the total quantity taken at a single meal and over a period
of time is somewhat dependent upon the percentage of fat in the
milk. The amount of breast milk taken per day increases rapidly
the first week, so that during the second week an infant will
average 400 to 500 grams, then a gradual increase to about 800
grams by the eighth week, and approximately 1,000 grams by
the fourth month. Rarely does the quantity exceed 1,000 to 1,100
grams. The quantity taken per kilogram weight per day usually
increases up to the eighth week, reaching a maximum of 150 to
180 grams, rarely 200, and then gradually decreases to 110 to
125 grams per kilogram weight per day. Czerny says the young
infant requires an amount of breast milk equal to 1/5 of its body
weight per day ; 1/6 to 1/7 from the 6th to 18th or 20th week ;
and 1/8 at 6 months of age; or in other words, at first it con-
sumes the equivalent of its body weight in breast milk in
5 days, later in 6 or 7, and still later in 8 days. Camerer observ-
ing a series of 9 to 13 children over a period of 20 weeks gives
us the following average figures for 1 day.
Day
Amount
Week
Amount
The figures stated up to this point are all averages obtained
in children who varied in weight, but were all within normal
limits and healthy. The figures I am about to report were ob-
tained from weighings of my own child, Robert, whose birth
weight was over the average (4,020 grams). He never showed
an initial loss of weight. The weighings after the first 2 weeks
were all done by my wife or myself. As the findings are those
obtained from one individual child they will naturally not always
coincide with the foregoing figures. The figures of other ob-
servers as well as my own merely show that these children did
thrive on the given amounts of breast milk. They do not, how-
ever, demonstrate that the amounts given were the minimum
amounts necessary for growth and well being. The following
chart is self-explanatory, and gives the data obtained during 20
weeks of observation.
1
1 2
1 3
1 4
'5
! 6
1 7 1
17
1 91
1 193
1 309
1 352
1 391
1 467 1
1 2 1 4 1 7 1 14 1 20 1
1 480 1 600 1 770 1 830 | 890 |
Dietrich : Food Requirement of tJie Breast Fed Infant 281
CHILD— ROBERT DIETRICH
BIRTH WEIGHT 4020 CMS.
to
Si
it
1
-J
is
II
c
O C
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rt ^
IS
a «
Average per day
Average per day
per Kg., weight
u
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o.
(A
V
B
O
u
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'3
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c
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to
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gms.
cal.
gms.
cal.
M
V
60
l4
>
<
1 1 4280 II 1995 II 8S 1 25 11 285 1185.25
1 II II 1 II 1
66.5
43.2
7
260 37.1
1 II II 1 II
2 1 4560 II 4920 II 120 1 60 || 702.8 45C.8
154
1
100.1
6J4
280 40
1
3 1 4690 II 4255 II 130 1 50 || 607.8 395.07
1 II II 1 II
129.6
84.2
6
130
18.6
4 1 4870 1 1 4590 || 140 | 80 1 1 655.7 | 426.2
134.6
87.5
6
180
25.7
5 1 4950 1 1 4490 1 1 150 | 110 || 64l'.4 416.9
1 II II 1 II
1
129.5
84.2
5
80
11.4
6 1 5120 1 1 4680 1 1170 | 100 1 1 668.6 434.59
130.5
84.8
5
170
24.3
7 1 5280 II 5055 II 170 1 90 || 722.1 469.36
1 II II 1 II 1
136.7
88.8
1
160
22.9
1 II II 1 II 1
8 1 5470 II 5405 II 200 i 100 |l 772.1 | 501.86
1 II 1! 1 II 1
140.8
91.5
5
190
27.1
1 II II 1 II 1
9 1 5750 II 6030 II 250 1 90 || 861.4 1559.9
1 II II 1 II 1
149.8
97.3
' =
280
40
10 1 5890 II 6130 II 230 1 100 || 875.7 | 569.2
148.6
96.5
,1s
1
140
20
III 1
11 1 6100 1 6140 240 100 | 877.1 570.1
III 1
143.7+
93.4
II
5+
5
1
5
210
30
12 1 6300 1 1 6420 1 1 240 | 120 1 1 917.1 596.05
145.5
94.5
200
28.5+
13 1 6340
II 5925 II 230 1 120
II II 1
II 6510 II 280 1 130
II
1 846.4 548.16
133.5
86.7
40 1 5.74-
14 6450
1
II
II 930 604.5
144.1
93.6
1
5
1 1
110 15.7+
IS 1 6690 II 6590 || 270 | 140 || 941.4 | 611.9
146.6
95.4
Is
1
240 34.3
II 1 1
16 6900 1 1 6690 | 300 | 100
II 1 1
1 955.7 621.2
138.5
90
1
5
210 30
I 1 J Jl
17 17070 7230 II 280 100 1 1032.8 671.3
II II 1 1
146
96.9
5
170 24.3
18 7240
1
6790 1(260 100
970 630.5
120.1
78.06
1 5
170 24.3
1
19 7290 7210 | 300 150 || 1030 | 669.5
1 1 II 1 II 1
141.1
91.7
1
5
50 7.1
20
741C
1 1
) 7330 1 300 150
II
1
1047 680.5
141.3
91.8
1
1'
!
1 120 17.1
PREMATURE SEXUAL DEVELOPMENT.
{Report of case)
By John Phillips, M.D., and George L. Lambright, M.D.
Cleveland, Ohio.
It is quite evident from the number of experimental and
autopsy rejx>rts on clinically studied cases that diseased condi-
tions of the pineal gland and adrenal cortex markedly alter the
development of the sexual organs.
The pineal gland is a small organ situated in the brain just
below the splenium of the corpus callosum and careful studies
have shown its structure to consist of ill defined glandular sub-
stance, muscle and nerve fibers with a small amount of neuroglia.
In the lower animal, it in all probability serves the purpose of a
third eye. The gland undergoes involution changes before
puberty and has been removed without any appreciable effects
on life. Some able investigators doubt seriously if it has any
effect on the development and maintenance of health. This is
debatable ground and perhaps will remain so for some time, but
a review of the literature will show many interesting cases, in
which structural alterations have been found in this gland at
autopsy,, with changes in the sexual, somatic and appendage sys-
tems. Growths of the gland have not been noted in a large
number of instances. Heubner in 1898 reported a case of a boy,
4^ years of age, who showed precocious sexual development
and sornatic growth. The body of this child was that of one
8 or 9 years of age ; the genitalia corresponded to the proportion
of those found at puberty. The pubic hair was 1 centimeter long.
A year later an autopsy showed a teratoma of the pineal gland.
Marburg in 1907 was able to collect 40 histories of cases of
this type. He sought to establish a clinical entity for such ab-
normal function. The term "macrogenito-somnia precox" was
introduced but probably forgotten by this time. In a more recent
paper he attributed the following characteristics to this con-
dition r
1. General. This includes all the signs of intracranial pressure
secondary to an internal hydrocephalus.
282
Phillips-Lambright: Premature Sexual Development 283
2. Neighborhood, from pressure on the quadrageminate
bodies, leading to ocular palsies and disturbance of the pupils, also
disturbances from encroachment on the cerebellum such as ataxia.
3. Constitutional. This includes early sex maturity, enlarged
sexual organs, pubic hair, general body hair, early changes in
voice, precocious mental development, evidence of maturity in
thought and speech, general overgrowth of the body to the extent
that a 5 year old child may resemble in stature that of a child
10 years of age. Most of the cases reported by him occurred
before puberty and in the majority of cases in boys.
The subject of the adrenal gland in relation to its internal
secretion has received a great deal more attention than that of
the pineal gland. Most of the investigation has centered around
the medulla. For awhile it seemed that the cortex was completely
forgotten. Much that was supposedly proven in connection with
the medullary portion of this gland has had to be retracted, and,
no doubt, further investigations are needed to clear up many hazy
questions relative to the presence and effect of suprarenalin in the
blood stream. We are not concerned particularly in this respect
but more with the influence that the cortical system may have
on the development of the sexual organs and the cortex of the
cerebrum. From an embryological standpoint we are certain
that there is an intimate association with the development of the
genitalia. There is no longer any doubt from experimental work
that during breeding the cortex increases in size. Hoskins has
shown that feeding the cortical substance to animals has increased
the size of the testicles. Quite a number of reports are found
of cases with tumors of the adrenals with hermaphrodism, hyper-
trophies of the genitalia, precocious sexuality, early and excessive
growth of the hair on the body and increase in size of the body
growth. The following table will be of interest to show reports
of cases in which tumors of the adrenals have been discovered :
No. Observer Agk Sex Clinical Manifestations Nature Tumor
1. Bulloch & Hair on chin and upper lip, pubis, Hypernephroma
Sequera 11 F. axilla, fully developed mammae,
menstruation.
2. Colcott & Pubic hair. Large celled
Fox 2 F. sarcoma
3. Dickinson 3 F. Pubic hair and harsh voice ?
284 Phillips-Lambrigiit: Premature Sexual Development
No. Observer Age Sex Clinical ^.ANIFESTATIONS Nature Tumor
4. J.Ogle 3 F. Hair all over body, mustache, pubic Large enceph-
hair. aloid cancer.
5. Linser 5 M. Pubic hair, precocicfus develop- Malignant hy-
ment of sexual organs, great pernephroma
growth of whole body.
6. Orth 4J/2 F. Beard, precocious development of Hypernephroma
external genitalia.
7. Dobbertin 1 F. Hair on genitals. Hypernephroma
8. Tilesius 4 F. Pubic hair, premature development ?
of mammae.
9. Wm. Cook 7 F. Obesity, facial and pubic hair. ?
10. Bevern & Premature development of sexual Large celled
Romhilk F. organs. sarcoma
n. Ritchie 4 F. Facial hair, notable muscular de- Carcinoma
velopment.
The above table is not compiled to represent a complete review
of the literature, but in the 11 cases reported shows the char-
acteristic symptoms present and types of tumor found. It is
equally important to note the fact that reported in the medical
literature are quite a number of cases in which tumors of the
adrenals have been found in early life with no abnormal influence
on the growth and sexual development of the individual.
That the adrenals are in some way connected with the growth
of the cerebrum is shown by the well known fact that in a con-
siderable number of cases of anencephaly a hypoplasia of the
adrenals is present. Zander enlarged upon the ideas of Morgagni
in this respect and came to the conclusion that the proper develop-
ment of the adrenals could only proceed normally with the brain
intact. The viewpoint of Alexander is, however, the reverse of
this, viz. : that the adrenal hypoplasia is primary while the cerebral
defect is secondary. It has long been known that the adrenals
at the end of 3 months are larger than the kidneys ; at the birth
the kidneys have gained the advantage, while in adult life the
proportion is 44 to 1. Glynn has given an excellent account of
tumors and rests of the adrenal cortex with their relationship
to sex abnormalities. The following is a brief abstract of his
classification :
A. Benign Tumors, Cortical, Group 1. Diffuse hyperplasia
Piiillips-Lambright: Premature Sexual Development 285
passing into : Group 2, Adenomata, which may be bilateral. The
cells contain considerable amount of fat and their arrangement
is like that of the zona fasciculata.
B. Malignant Tumors, Cortical, Group 1, Sarcomata-round
celled, often lymphosarcoma, i.e., small cells with alveolar arrange-
ment. These occur in children between the ages of 2 and 3.
Group 2, Hypernephroma, a tumor having large polyhedral cells
resembling: the structure of the adrenal cortex.
Fig. 1. — Case V. D. . Tliese pictures, taken two years ago, show the premature develop-
ment of the child. Since then there has been a develojjmeiit of pubic hair,
the waist line has narrowed and the hips have broadened, accentuating
the female type of pelvis.
Recently a case came under our observation with symptoms
closely resembling the findings which have been classified above
and attributed to internal secretory disorders of the pineal and
adrenal glands. It emphasizes many of the points stated by other
authors, but leaves much to be explained. The patient had con-
vulsions and premature development of the sexual organs. An
outline of the case is as follows :
Case, V. D., aged 7 years, female, referred by Dr. G. W. Crile,
for examination on account of generalized convulsions and an
explanation of the premature development of the sexual organs.
286 Phillips-Lambrigiit: Premature Sexual Development
From the parents the following information was obtained: The
child at birth appeared to be unusually healthy and robust in
contrast to the other 4, who were frail. At 2 years of age the
breasts were noted to be unusually large and this opinion was
confirmed by a physician called at that time. At 5 years of age
pubic hair and well developed external genitalia were present.
The child maintained a good state of health, but was above the
average in height and strength for her age. Between 3 and 4
years of age light convulsions were noted which have increased
in severity until they occur from 3 to 8 times in 24 hours, both
diurnal and nocturnal. The menstruation was fully established 3
months ago and since then the parents are sure that the seizures
have grown much stronger. The attacks are typical of those so
often seen in epilepsy and are ushered in by a cry; loss of con-
sciousness follows with clonic and tonic contractures of the ex-
tremities and right side of the face. Incontinence of urine usually
occurs. The paroxysm ceases in from 1 to 3 minutes and the
child awakens fatigued and scratches and pulls at the nostrils.
Such an attack as above described was witnessed by one of us.
Physical Examination. Weight. 73^2 pounds.
Height. 4 feet 4 inches.
General. The child when stripped had the appearance of being
in excellent condition and her height and body development were
above the average for her age.
Head. The cortex was flattened and the head increased in
size in lateral and anterior posterior diameters. The left frontal,
malar, and maxillary bones were much heavier in appearance
than the right ones.
Hair. The hair on the head had grown luxuriantly and was
dark and healthy in appearance. The axillary and pubic hair
had reached its full growth. The eyebrows were normal and no
hairy growth on the surface of the body noted.
Teeth. Nutrition was very poor ; the teeth were widely spaced
and practically all decayed.
Eyes. No exophthalmos. All ocular movements normal. No
limitation in the fields of vision was present. Optic disks not
examined.
Skin. No unusual dryness or moisture was noted. No edema
Phillips-Lambrigiit: Premature Sexual Development 287
present. Skin was dark in appearance but was not bronzed or
gypsy in appearance.
Glands. Thyroid normal in size. Mammary glands show the
development of an adult woman.
Thighs and Buttocks were fully developed. The pelvis was
broad and the child resembled a fully matured woman. The shaft
of the femur was heavy in character.
Mentality is below the average. The child cannot read nor
write. The memory is fair. Hearing and obedience are excel-
lent. Speech greatly limited and articulations are like that of a
mute.
Sexual Organs. The mons veneris is fully developed and the
hair is limited to the space above the symphysis. The vulva is
fully developed and the vagina easily admits one finger. The
uterus and adnexa are of normal adult size.
All other organs not noted were examined and found to be
normal. X-ray of the skull was negative, as was also blood and
urine; 150 grams of glucose was given with no appearance in the
urine. Circumstances made it impossible to give larger amounts
and test tolerance.
COMMENTS AND CONCLUSION.
Hyperpituitarism with its influence on other glands is a pos-
sibility to be considered on account of the heavy character of
the bones of the right side of the face and thigh. There was no
chin prominence, no pressure signs in the cranium and the hands
and feet in contrast to those of acromegaly are not dispropor-
tionately large. The sugar test in addition has shown no de-
crease in tolerance and the x-ray of the skull is negative.
In view of the limited knowledge concerning the pineal gland
we are not inclined to attribute the findings to disturbance of
that organ. This is especially so with the absence of pressure
signs on the quadrageminate bodies, normal eye movements, no
hyrocephalus or pressure on the motor tract. The convulsions
could be explained on the basis of the faulty development of the
cerebral cortex. The cortical portion of the adrenals is probably
the most likely to be at fault. No palpable tumors in this region
were noted. Just what association can attach to the convulsions
which appeared in this child's life after sexual organs had de-
veloped is an interesting point and brings up the question of
288 Phillips-Lambrigitt: Premature Sexual Development
whether a hypoplasia of the adrenals has not been followed by
some changes in the cerebral cortex, such as has been previously
noted in anencephaly.
BIBLIOGRAPHY.
1. Bulloch and Sequera: Transactions of the Pathological Society of London, Vol.
56, 1905.
2. Bell: Sex Complex. 1912.
3. Gushing, Harvey: The Pituitary Body and Its Disorders, 1912.
4. Fenger, F.: Jour. A. M. A., Vol. 87, 1916.
5. Glynn: Quarterly Medical Journal, Vol. 5, 1912.
6. Heubner: AUg. Med. Central Zeitung, cited by C. Vogel.
7. Hoskins: Arch. Int. Med., Vol. 17, 1917.
8. McCord, C. P.: Sur. Gyn. and Obst., Vol. 25, Dec, 1917.
9. McCord, C. P.: A. Jour. Obst., Vol. 86, 1917.
10. Phillips, John: Medical Record, Vol. 75, 1909.
11. Vincent, Swale: Surg. Gyn. & Obst., Vol. 25, Dec, 1917.
12. Wegener: Jour. Nervous and Ment. Dis. Vol. 44, 1916.
13. Warren & Tilney: Jour. Nervous and Ment. Dis., Vol. 74, 1917.
The Union Building, 1836 Euclid Avenue.
InDICAN AND THE SULPHATES IN InFANTS' UrINE IN HeALTH
AND Disease (Rivista di Clinica Pediatrica, Jan., 1920, p. 1).
Maccone remarks that on account of the difficulty of obtaining
the total twenty-four hours' urine of infants he had to be content
with specimens collected at different hours. There is probably not
as much difference between the day and night urine of infants as
later in life. Of the eighteen infants whose urine was systemati-
cally examined, twelve were less than a year and the oldest was
only 17 months old. The children fed on cow's milk had a much
larger indican and ethereal sulphates content than the breast fed,
and the dyspeptic children had much more than the healthy chil-
dren. The maximum was found in the children of the alimentary
decomposition type, and those with grave digestive disturbances.
Not a trace of either indican or ethereal sulphates was found in
the healthy breast fed infants, and healthy artificially fed infants
presented only traces of them. With severe digestive disturbance,
up to 1 or, exceptionally, 2 eg. of indican was found per day,
but the amounts were reduced to traces in the children with
extreme athrepsia. With inflammatory processes in the intestines,
the output of aromatic substances rose and fell parallel to the
severity of the inflammatory symptoms except when there was
much diarrhea. In three infants with athrepsia, he found traces
of glucose in the urine. — Journal A. M. A.
MENTAL EXAMINATIONS AS AN AID TO PEDAGOGI-
CAL METHODS IN THE PUBLIC SCHOOLS
By William C. Hassler, M.D., Health Ofificer,
and
Olga Bridgman, M.D., Medical Psychologist,
Department of Public Health, San Francisco.
Mental examinations are coming into such wide use as aids
in caring for various classes of children that a discussion of their
scope, their value, and, finally, illustrations of their practical ap-
plication to special school problems must be of interest to all who
are concerned with the care of children, as well as of very special
interest to those whose main concern is public health in its wid-
est sense.
A mental examination, as ordinarily given at the present time,
includes far more than the actual testing, by more or less stereo-
typed methods, the performance of children in response to a set
group of mental tests. To be sure, the so-called "intelligence test"
is an important part of the whole procedure and is justifying day
by day the confidence which Workers have placed in it. Some
form of a mental age scale is employed usually as a routine meas-
ure and serves as a fair indication of the child's ability to per-
form certain simple acts which serve as an index to his general
ability. By such a scale the child's mental level is roughly deter-
mined— that is, his mental age is found — or, to be more explicit, a
comparison is made of the child examined with the average child
of his age. For example, if a child of 12 years can do only those
things which the ordinary child of 8 years can accomplish, that
child is said to have a mental age of 8 years. He is actually 12
years old, but his mental ability is only that of an 8 year old child.
Experience in the examination of thousands of children has gone
to show that when a child is more than 3 years retarded in his
mental ability, that backwardness is serious and permanent and
that the child in question will never be able to compete with nor-
mal persons under ordinary conditions.
But an age scale, such as has been briefly described, of which
the Binet scale is the most commonly used in some of its forms,
289
290 Hassler-Bridgman : Public School Mental Examinations
is not in itself sufficient to determine the actual mental status of an
individual. Certain factors may enter in and serve to make this
method alone inadequate or misleading. For example, a child in
whose home a foreign language is habitually spoken will probably
fail to use the English language as readily as will the child from
an English speaking household, and hence will appear less ca-
pable if tested without taking this one fact into consideration.
Again, there are many children found among the failures in life
whose main difficulty consists in a serious nervous instability and
a lack of mental and physical control. These children frequently
fail in tests because of restlessness and poor attention, and hence
give the impression of having poor intelligence, whereas the real
difficulty lies in their failure to make use of such ability as they
have. Then, too, ill health may make a child apathetic and slow
mentally, so that the results of a mental examination may be quite
unfair, unless supplemented by a careful consideration of his con-
dition otherwise. And, finally, the home training of the child has
an undoubted effect on the quality of his performance. The dull
child from the careful home may have been drilled and coached
systematically until he makes a far better impression than his
real ability deserves, while an untrained child may make a poor
impression because of the lack of formal opportunities in his
home. So if a mental examination is to be of real assistance to the
individual child's problem, it is necessary to consider all of the
other factors involved in making him what he is. Hence, the
child is further questioned as to his interests, his amusements
and as to the special advantages which he may have enjoyed
outside of the school. He is also tested by being given mechani-
cal and manual tests, so that, if a foreign language is interfer-
ing with his ability to answer questions well, he will still have
an opportunity to show what he can do without the use of lan-
guage. It is also of the greatest value for the examiner to have
had experience in the observation of individuals from the physi-
cal standpoint. It is a remarkable opportunity for a physician to
observe, during an hour's performance, the appearance, attitude
and manner of the child being examined. Many a small point
becomes noticeable which may be overlooked even in a physical
examination, and it is rare that a child will be suffering from
much of a physical handicap without its giving distinct evidence
in his work or behavior. Then, added to the facts obtained from
Hassler-Bridgman : Public School Mental Examinations 291
the child, there must be information from others with whom he
comes in contact as to his general character and his relation to
other children and as to his home surroundings, with special ref-
erence to the social and moral standards of his parents or rela-
tives. So it will be seen that the individual mental examination,
to be satisfactory and fair, is a comprehensive thing, correspond-
ing more and more with the tendency to judge of feeble minded-
ness by social standards rather than by mental or intellectual
methods alone.
Such a mental examination as has been described here must
necessarily consume a considerable amount of time, not only in
the matter of obtaining the necessary facts, but also in correlating
and weighing them in making plans for the child. Ideally, every
child in the schools should be given just such a thorough study,
but while this work is still new and where the workers available
are so few in number, it is, of course, quite out of the question for
the majority of school children, and hence must be reserved for
those who are failures or who present such obvious peculiarities of
one sort or another that special plans are quite necessary for their
care. There are occasions, however, when wholesale examina-
tions of entire schools or districts are desirable, when a rough
determination of the extent of serious mental deficiency is the end
to be sought. For this purpose, briefer and much more rapid and
mechanical methods may be used, and although the results in the
case of certain individuals may be inaccurate, still the situation
as to actual feeble-mindedness in the entire group can be de-
termined with fair accuracy. If all children who make a satis-
factory record in these more superficial surveys are then excluded
as being presumably normal, those who fall below a certain rank
may be examined in the more careful and intensive way and
special plans may then be made for their necessary care or treat-
ment. Such a study would constitute a satisfactory survey of the
school children of any community.
The value of standard and more or less exact methods of com-
paring the performances of children is obvious. A careful men-
tal examination will help greatly in setting standards to which
the individual child should be held. The complaint is sometimes
made that children are lazy, that they could do certain tasks if
they would, and hence a child may often be blamed by a teacher
292 Hassler-Bridgman : Public School Mental Examinations
for wilful lack of effort, when, in reality, he may have some spe-
cial disability or inability which effectually prevents his acquiring
certain types of knowledge with ordinary ease. A child may fail
of promotion again and again because one or two subjects are
difficult for him, even though his ability is for the most part quite
as good as the average. A careful examination of his real ability
along other lines and an adjustment of the school program to
care for his needs may help to add another responsible citizen
to the community, rather than to develop an individual whose
mind has been trained to accept the idea that he is a failure. It is
a very unfortunate thing for any child to get into the habit of
failing and of accepting the fact that only failure is to be ex-
pected of him.
A mental examination will also aid greatly in pointing out
those children who are beyond question feeble-minded and who
should be under close supervision for the rest of their lives. Such
a child as one of these is entirely out of place in the ordinary
schoolroom. He uses up a great proportion of the teacher's time,
and as a result those other children who are later to become re-
sponsible, self-supporting citizens are neglected. This is not only
quite unfair to the normal children and their parents, but is ob-
viously foolish and extravagant.
Another and an important value of mental examinations is in
their use for the purpose of refuting hasty judgments as to the
presence of mental defect on the part of children who may be
troublesome in the schoolroom. When a teacher is worried by a
badly crowded school it must be a great temptation to wish to get
rid of troublesome children, and it seems to be becoming quite cus-
tomary to judge a child as mentally incompetent as soon as he
becomes a disturbing element. It is undoubtedly an important
advantage to point out the fact that such a child is not a defective.
He may be erratic and untrained or his home life may be having
a bad effect on his ability to do any effective mental work, but
although these troubles may often be associated with the presence
of mental defect, still a child may be a misfit without being feeble-
minded, and it is then the responsibility of the teacher to remedy,
in so far as is possible, those things which cause failure, rather
than to feel that the child must be gotten rid of because, if he were
not defective, he would not be so troublesome.
Hassler-Bridgman : Public School Mental Examiniitions 293
Thus far, in San Francisco, the plans for caring- for defective
or unusual children have not been developed very extensively, but
such provisions as have been made are on a sound and permanent
basis and the possibilities of expansion from time to time are good.
There is one ungraded school, under the Board of Education, sit-
uated in a poor and foreign part of the city, to which children
from all parts of the city have access. This school is a thoroughly
modern institution for defectives of the more serious type, and
contains for the most part children who will be inevitable social
failures unless given permanent supervision. This school, with
four rooms and a capacity for training 60 defective children, gives
a most excellent opportunity for close observation and study of the
children attending its small and intensive classes. It can scarcely
be possible for a youngster to leave such a school without its hav-
ing been estimated fairly accurately what his capacities are and
what can be expected of him as an adult. Besides this school,
there are special classes which care for defective children in other
parts of the city, where the greatest need arises. The ungraded
school and the special classes are under the same general supervi-
sion and control and the same methods are used in all. In fact,
the main ungraded school is used as a training- school to prepare
interested teachers to take charge of special classes for defectives.
In this way provision is made for a satisfactory increase in the
number of workers who will be able to teach abnormal children.
In all, approximately 140 children attend the ungraded school and
the special classes, and nearly all of these children are very seri-
ously retarded mentally.
In addition to these classes, which care for the institution
type of defective children mainly, there are several other classes
which go by the name of "opportunity classes." In these classes
there are to be found children of a much higher grade of mental
ability, but for whom the regular work of the upper primary
grades is too difficult. Many a child begins to hold back when
he has gone as far as the fifth or sixth grade in school, and if held
to the standard possible for the average child and the bright
child will absolutely fail to finish his grammar school work and will
leave school, branded as a failure. For just this type the oppor-
tunity class has been developed, and its aim is to give to the child
special elementary drill in those subjects which will be of the
294 Hassler-Bridgman : Public School Mental Examinations
greatest practical value to him later in life, so that he will have the
fundamentals of a grammar school education, and to omit such
special subjects as music, drawing, foreign languages and the
like, all of which have their great value, but can better be omitted
than can such subjects as reading and arithmetic. The child may
in this way be carried along and may learn in his slower way
much more than he could possibly get when surrounded by bright-
er children and confused by the more complicated curriculum
which makes school work most interesting to the child without
mental limitations.
The actual systematic work of caring for the mental examin-
ing of special and defective children in the San Francisco public
schools has been undertaken by the Department of Public Health
and is under the supervision of a medical psychologist, trained
both in medicine and psychology. Thus far the work has of ne-
cessity been on an experimental basis and has been more in the
nature of emergency work, rather than actual systematic study
of conditions over the city. The ultimate object will, of course,
be a survey aiming to study conditions over the entire city, but
the workers are still very few in number and the population of San
Francisco is large, so that such a task is still somewhat in the
future. At present, careful mental examinations are being made
of such children as constitute a special problem or who are fail-
ing systematically to make such progress in school as is possible
to the average child. Lists of such children are made out by the
teachers and turned over to the psychologist and mental examina-
tions are then made as speedily as possible. On the basis of the
psychologist's recommendation, children may then be placed in
one of the ungraded classes for low-grade defectives or in one
of the opportunity classes for the dull but on the whole normal
children. When the bulk of this emergency work has been com-
pleted, plans will be made to make a more systematic study of
all of the children in some of the poorer districts where the great-
est amount of school retardation exists. Then, gradually, it is
planned to increase the work as opportunity arises until a study
of the public schools of the whole city has been completed. Plans
are already in the process of making toward this end, although
the actual work has not as yet been begun. There is fairly close
cooperation with all other .public agencies, and when necessary
or desirable the assistance of the juvenile court, of the clinics and
Hassler-Bridgman; Public School Mental Examinations 295
hospitals of the city is asked and given freely. Work of this sort,
to be far reaching in its results, must be well known and under-
stood in the community, and the larger the number of individuals
and agencies concerned in the care of defective children the
greater will be the understanding of the problem and of the need
for care and protection of these unfortunates, both for the sake of
the abnormal child and for the protection of the community from
unnecessary poverty, vice and criminality.
During the first year of work in this department, there were
363 children examined in 10 of the public schools. With the
exception of the children examined in one of the large inter-
mediate schools, all were referred as defective or very peculiar
children whose removal from the ordinary grade room was
deemed by the teacher as being very desirable.
Only 1 survey which could be called at all systematic was
attempted, and that was at 1 of the large intermediate schools
whose population is nearly 1,000 children, all of them in the sixth,
seventh and eighth grades. This school was selected at the sug-
gestion of the Board of Education, because of the very great
interest of the principal in mental examination.
Psychological Examinations Given 3 Grammar Grade
Classes in an Intermediate School: The general purpose of
this particular investigation was to throw some light and to offer
some practical suggestions, if possible, upon the problem of
eliminating the wastage to the teacher, to the child and to general
educational efficiency which occurs in all school work where those
to be instructed include so many types of mental makeups, so
many strata of mental capabilities.
The specific purpose of the investigation was fourfold :
1. In the first place, to find those children who are so far
mentally retarded or deficient that they are unable to profit by the
regular work of the classroom. These children — and every
teacher who has taught in the elementary or grammar grades
has run across this type — are wasting time and energy in a
variety of ways :
(a) They are trying to do what they are Incapable of doing.
(b) They are not receiving the special training which they are
capable of taking.
(c) They are a drain on the teacher, who must of necessity
296 Hassler-Bridgman : Public School Mental Examinations
give disproportionate attention to these unfortunates who, men-
tally below par, have no alternative other than being a drag on
the class.
(d) Their presence in the regular class is a great disadvan-
tage to those children who are able to profit by regular school
work, but who do not get the maximum of benefit from their
school experience because the teacher cannot give them due con-
sideration.
The obviously economical thing, financially and educationally,
from the point of view of the teacher, the normal child and the
mentally defective child, is to locate and segregate defectives or
subnormals into classes where they may receive such practical
instruction as they are capable of receiving profitably.
2. A second aim was to discover those children who are
capable of profiting by their regular school work, but who because
of some peculiar defect or because of being innately slow or dull,
cannot keep up with the average speed of the regular class, and
who need special help to carry them along. Often it develops
that a child of this type who can never do regular academic work
well shows relatively good mechanical ability. If, in addition
to this, the financial status of the home requires that the lad shall
go to work when finishing the grammar grade, his schooling
will mean most to him if it has given him training along mechani-
cal or vocational lines. In his case, less emphasis can be laid
upon abstractions which are extremely difficult for him to grasp
and more emphasis upon practical concrete problems and train-
ing. Again, it would appear that a maximum degree of benefit
would accrue by grouping this type of children, giving the boys
the advantage of additional shop work and the girls additional
sewing and cooking, and to both special drill in such academic
work as would be of value to them. And among this group, as
in the other groups, special help could be given to the boys or
girls who showed some peculiar disability. For example, in the
case of a child who had a very poor auditory memory and a fairly
good visual memory, it could be suggested to the teacher that a
greater preponderence of visual explanation would enable the
child in question to grasp the idea more quickly and to hold it
more accurately. And again, special help and stimulation could
be given to those children who showed on investigation some
Hassler-Bridgman : Public School Mental Examinations 297
peculiar or special ability which might be stressed to the advan-
tage of the child.
3. A third purpose was to locate those children who were
doing poorly in their school work, but who had no mental dis-
abilities or deficiencies. That is to say, if the school report
showed unsatisfactory scholarship and the psychological examina-
tion showed the chjld to be of normal intelligence, an effort could
be made to locate the source of the difficulty.
Perhaps the trouble might have a physical basis, as for ex-
ample, defective vision or defective hearing, or adenoids or in-
fected tonsils. Again, the unsatisfactory school report might be
due in part to an incomplete recuperation from some severe ill-
ness, such as influenza, or again it might be due to some debili-
tating habit which had a physical effect. Any child who showed
obvious need of a physical examination or whose mental per-
formance suggested that a physical examination might throw
helpful light on his case was recommended for such an examina-
tion.
Again, the cause of the trouble might lie in irregular home
conditions, such as poverty, viciousness, improper supervision.
For example, take the case of one girl in the sixth grade who said
that she went to the movies or to the beach every night. Lax
home supervision of that type would necessarily react on her
school performance.
4. Again, it was a purpose of this investigation to discover
those children with intelligence above the average that they
might be given instruction according to their abilities and not be
held back to the speed and type of work that fitted the average.
The work was undertaken with the feeling that psychological
examinations, including intelligence tests, performance tests and
the gathering of information concerning the child's home con-
ditions in conjunction with his school report could help in making
these above-mentioned segregations which seem so educationally
desirable. But so that others, not familiar with this shortcut
method of classification, might share this assurance, it was neces-
sary to show the practicability of the tests, to compare the teach-
er's estimate of the child's success in his school work with the
psychologist's estimate on the basis of intelligence tests.
To make this comparison as accurate as possible, the three
298 Hassler-Bridgman : Public School Mental Examinations
classes examined were selected from one school. Similar school
conditions, gradings, and methods of instruction, would main-
tain; hence, results would be more accurately comparable. The
school was the Horace Mann Intermediate, located in the Mission
District, in which no special foreign element predominates, as
in some sections of San Francisco. Departmental work — dififerent
subjects taught by different teachers — being the method of in-
struction, meant that the scholastic estimate wTiich would be used
as a basis of comparison would not be one teacher's judgment,
but the combined judgment of several teachers.
Group i: The first class to be examined was a special class
of 50 children, ranging in age from 13 to 17 years, the majority
of whom were either 14 or 15 years old. This group of 50
children had been segregated into a special eighth grade class by
reason of the fact that in some respect their school performance
was below average. For the purpose of giving them more in-
dividual help and coaching, by teaching them in small sections,
they had been grouped together, and then subdivided into small
reciting groups, one group stressing arithmetic, another gram-
mar, etc., according to the subject which required additional
study on their part. This segregation had been in process since
as sixth graders these children had entered the school. It covered
a period of 2 or 2^ years and was based on the definite failure
of the child in the regular schoolroom.
There were 2 reasons for selecting this group to examine:
(1) The discovery of the causes of their poor scholarship
and of each child's peculiar abilities or disabilities.
(2) Being problem cases, they had demanded special obser-
vation on the part of the teachers, and hence were better known
than the average child. Therefore, the teacher's estimate and
that of the psychologist would form a particularly interesting
comparison.
A few words of explanation as to the nature of the examina-
tion :
Each child was examined individually.
The following information other than that elicited by the in-
telligence tests themselves was obtained in every case, in order
that the recommendation might be based upon as full a knowl-
edge as possible of the child's complete environment — his home,
school and social relations :
Hassler-Bridgman : Public School Mental Examinations 299
(1) Nativity of child. Special considerations in the case of
the immigrant child are necessary.
(2) Nativity of the parents. The child of the foreign-born
parent who does not become Americanized as quickly as the child
presents an abnormal home condition.
(3) Occupation of the father and mother. This is often sug-
gestive of the economic status of the family, whether there is
plenty or actual want in the home.
(4) Information as to whether the home is normal, in that it
is not broken by the death, desertion, or separation of the parents.
If the father is dead, it often means that the mother must work
away from home and that the children of necessity are left un-
supervised and without proper care. The loss of a mother may
mean that the home is broken up or that a girl in the family has
to bear the burden of the housework in addition to going to
school. Home conditions are bound to influence tremendously
the child's school performance. With this information in the
hands of the teacher, she may ease matters considerably and let
her helpful influence be carried into an unfortunate home.
(5) Information as to the health of the family. A record of
tuberculosis in the home, for example, in the case of a child who
shows early signs of mental fatigue during the examination would
indicate the need of a physical examinatioii for a possible infec-
tion in the child.
(6) Information was also secured as to what the child in-
tended doing upon finishing the grammar grades. Did he intend
to go to high school, to business college, or to work? If to work,
wthat sort of work? A child who either by force of economic
necessity, or because of disinclination to go further, intends to
quit school when he finishes the grammar grades or when he
reaches the age of non-compulsory school attendance presents
a somewhat different educational problem from that of the child
who intends to go to high school and college and become a brain
worker rather than an artisan.
(7) The child was also questioned as to his interests, occupa-
tional and recreational ; inclination or interest in doing mechanical
work where native mechanical ability existed might advantageous-
ly be focused into actual intention. On the other hand, a girl
who wanted to become a stenographer and showed no maiuial
300 Hassler-Bridgman : Public School Mental Examinations
dexterity and a marked inability to react quickly should be dis-
couraged from attempting a line of work at which she could not
succeed.
This information, together with the results of the intelligence
tests and several mechanical performance tests, was used as the
basis of discussion with the teachers and the principal, as to what
would be the best educational suggestion for each child consid-
ered individually. As a result of these conferences the pupils
were regrouped and rearranged.
Results of a Comparison of the Teacher's Estimates and the
Scoring of the Tests in Regard to this Special Group of 50 Chil-
dren: Of the children who graded relatively low by the tests all
were doing poor work in this special class. There were in this
class some 5 or 6 who showed intelligence of a good order. One
of these, and the only pupil of the entire group concerning whom
the teachers and the examiner differed absolutely, was a lad who
was doing extremely unsatisfactorily in school work. His per-
formance in the intelligence tests showed that he could not do it.
He was examined last term. This term the teachers report that
he is doing very good work. Some other factor, probably a lack
of interest in his school work typical of the adolescent lad some
time or other in his school career, was keeping him from doing
the type of work of which he was mentally capable.
The other children, who by the tests graded somewhat above
average, were children who were having special difficulty in one
subject, and that subject was arithmetic.
Conclusions: The investigation of this special group showed
clearly enough, that —
(a) The backward child in school could easily be picked out.
(b) That the same results, for which the teachers and prin-
cipal were compelled to s{>end from 1 to 2^/2 years, could be done
on the basis of psychological examinations at the rate of one
pupil per hour and a quarter — the average length of an examina-
tion.
(c) This was possible without the necessity of the child's
suilfering the discouragement of failure and coincidently the
actual loss in not receiving the type of training which he was
capable of taking.
Group ii : The next group to be examined was a regular
Hassler-Bridgman : Public School Mental Examinations 301
eighth-grade class which pedagogically was adjudged to be an
average class. This class was chosen for the purpose of ascer-
taining whether or not the intelligence tests would be as accurate
in locating the child who was doing excellent work in school as
it had been in locating the backward child. The same program
was followed as in the special class. The same span and type
of information was ascertained in each individual case.
The tabulation below shows the interesting relation between
the intelligence score and the gradings given by the various teach-
ers. The psychological gradings have been roughly divided into
three groups.
(1) Those having a mental age of 15 years. (Above aver-
age. )
(2) Those having a mental age of 12 years. (Average.)
(3) Those having a mental age of less than 12 years. (Be-
low average.)
COMPARISON OF MENTAL STATUS AND SCHOOL REPORT.
Unsatis- Pro- Not pro- Promoted
Mental age Number Excellent Good Fair factory moted moted on trial
15 17 11 3 2 1 17 0 0
12 19 1 6 7 12 12 2 5
12 (minus) 10 0 0 19 17 2
Remarks: (1) Seventeen out of a class of 46 had a mental
age of 15 years.
(a) Eleven out of the 17 were doing excellent work.
(b) Three were doing good work.
(c) Two were receiving one or more "fair"' marks.
One of these was a lad having difficulty with arithmetic ; the
other, a girl, was a discipline case and her poor marks were
definitely due to her deportment.
(d) One lad of this group was receiving unsatisfactory marks
in arithmetic and deportment. The low grade in arithmetic was
absolutely traceable to his poor conduct, because he was able to
do, when tested individually, relatively difficult arithmetical
problems.
The important thing to note is that out of this group of 17
all were promoted unconditionally.
(2) Of the second group^ grading 12 years by the Binet
scale, there were nineteen.
(a) Only 1 of these was an excellent student — a lad of 13.
302 Hassler-Bridgman : Public School Mental Examinations
(b) Six were rated as good in their work.
(c) Seven were fair.
(d) Twelve were doing- unsatisfactory work in arithmetic
according to their grades. Five of these were receiving unsatis-
factory marks in some subject other than arithmetic.
Twelve out of the 19 were regularly promoted. Five were
promoted on trial. Two were held over and not promoted. These
2 were Italian girls, natively slow but not sub-normal, who had
missed considerable of the term's work on account of influenza.
On the whole then, this group was doing passable work.
(3) Of the third group, those who graded less than 12, there
were ten.
(a) There was not an excellent pupil in the group.
(b) There was not even a good pupil in the group.
(c) There was only 1 who graded as fair, a girl of 13 who
graded slightly under 12.
(d) All but 1 of the 10 were doing unsatisfactory work, and
that 1 was just above the line.
Only 1 of this group was promoted. Two were promoted on
trial, and these 2 are doing such poor work that they will have
to be held over this term. Seven could not be promoted, even con-
ditionally. All but 1 of this group, then, who graded below 12
years mentally were not doing passable work.
Conclusions on the results of a comparison of the teacher's
estimates and those made on a basis of psychological examina-
tions:
1. The correlation between the 2 estimates is extremely
high, almost a perfect correlation, save for some 3 or 4 cases.
2. Those cases which do not closely correlate can definitely
be explained by some factor other than intelligence entering to
interfere with the performance of which the child is mentally
capable, as, for example, sickness, or some peculiar mental dis-
ability. Those cases where there is an absence of correlation
point to the need of further study of the particular child to find
ivhy the child's performance in school falls below what one should
expect on the basis of his showing in the intelligence tests. Is
it due to physical condition? Is it due to irregular attendance?
Are there unsatisfactory home conditions? Is there some tem-
peramental or emotional peculiarity ?
Hassler-Bridgman : Public School Mental Examinations 303
3. The practical significance of the correlation means that
segregation and grouping necessary to educational efficiency,
which by present schoolroom methods requires 1 or 2 or more
years and is based on the actual failure of the child, can be made
on a basis of intelligence tests w*hen the child enters the grammar
grades, or preferably before then, without submitting the child
to the discouragement of failure and the concurrent waste of
energy on the part of the child and the teacher.
Group hi : The next group to be examined was composed
of 50 children who had been sent from various primary schools
to a special class for backward children in this school. They
were classed as fifth and sixth graders. The teachers in charge
discovered soon after the term began that they had almost a
hopeless mixture — children who could get nothing out of the
work, children who were backward and could be helped, chil-
dren who could do satisfactory work in a regular class and who
had evidently been shoved by other schools into this class be-
cause they were discipline cases.
Psychological examination showed the following mental
classification :
Seventeen were feeble-minded. That is to say, they showed
4 or more years mental retardation.
Nineteen were classed as borderline cases — some of them
potentially defective. These showed 3 years' mental retardation.
Six showed a mental retardation of 2 years.
Four showed a mental retardation of 1 year.
Four w'ere children of normal intelligence.
The chronological ages of the group ran from 12 to 16; by
far the larger percentage of the class were 13 and 14 years.
The report of the teachers showed that all the children who
graded less than 10 years mentally were complete failures in this
class for backward children. They were incapable of' doing even
the most diluted fifth or sixth grade work. If they are to get
anything out of their school training they must be given manual
work, not mental work. There were 16 of this group who graded
less than 10 years mentally, and hence should be transferred to a
class for subnormals.
The 4 children who graded as normal were hard to manage
in this class because the teacher could not keep them busy. They
were boys who obviously were discipline cases, and should never
304 IIassler-Bridgman : Public School Mental Examhtations
have been put into a class with backward children.
The children who showed only 1 year's retardation mentally
should be, and since then have been, transferred to a class of
average ability.
Those children who are seriously backward are now in a class
by themselves, and can be given the type of work which they
are able to grasp, and at such a rate as they are capable of tak-
ing it.
Finally, we feel that the results of 1 year's work along the
lines indicated herein prove conclusively that there is a place
for the medical psychologist in school medical inspection and
justify the extension of the work we are trying to do, besides
presenting a strong argument against the promoters of our new
state statute, which allows parents and others to protest against
examination of their children, any number among which might
be defective, and retard the greater mass of normal children.
Rickets in Relation to Housing (Glasgow Medical Jour-
nal, 1918, i, p. 268). — L. Findlay during the past three years
carried out an extensive research into the conditions, dietetic,
hygienic, etc., of actively rachitic and non-rachitic children be-
longing to the same social class. The most important factors, in
order of significance, were: (a) Improper housing; (b) absence
of facilities for open-air life; (c) imperfect parental care. It was
found that the rachitic families did not spend as much on rent as
the non-rachitic families and they would thus be supplied with
inferior houses. The frequency of rickets was directly propor-
tionate to the air-space in the house available per person and also
to the opportunities of open-air exercise. An interesting com-
parison is drawn between conditions in Port Sunlight and in Glas-
gow. The author thinks that the want of care on the mother's
part is usually not due to indifference to her responsibilities, but
simply to the fact that as a result of her unfavorable surroundings
she has lost all interest in life and the vitality to contend against
them. — British Journal of Diseases of Children.
SPEECH DISORDERS AND DEFECTS
By Mabel Farrington Gifford,
Director of the Speech Clinic, University of California Medical School and Hospitals;
Supervisor of Speech Improvement in the San Francisco Schools.
The department of Speech Correction in San Francisco was
first opened as a Speech Clinic in the Pediatric Department of
the University of California Medical School in 1915. This clinic
has been held Saturday mornings for the accommodation of school
children. The cases are divided into groups, according to the
type of the defect, and are given class instruction wherever pos-
sible and individual treatment in unusual cases. In general the
speech defects are classified under 4 heads. The first to be con-
sidered are the speech disorders, found more among the psycho-
pathic types of children. These include stammering, stuttering
and cluttering. For convenience in recording these cases, stam-
mering is defined as a spasmodic action of the speech muscles;
stuttering as repetition of the initial sound of a word ; and clut-
tering as rapid, choppy, indistinct speech.
The second group have neurotic, organic or sluggish articula-
tion of the elements of the language. Many of these are infantile
mistakes such as lisping and other substitutions of sounds. By
organic is meant the malformations of the speech organs such
as teeth, palate, and jaw defects and nasal or throat obstructions
which efifect speech. Still another group of children are trained
in this division who have not defective speech in the same sense
as the others but who mispronounce the English elements because
of a foreign language environment.
The third group have sluggish enunciation due to a careless
use of the jaw and lips. These have disagreeable voices. Among
these are the nasal, harsh, high pitched, weak, hoarse, tense or
thick voices.
Outside these regular types are the cases of aphasia, aphonia
and mutism. Cases belonging to the last type are examined first
for hearing defects, next the mental tests are given to determine
whether mental deficiency is the cause or whether the absence of
speech is due to aphasia. The aphonia cases may be due to hys-
teria, to a partial paralysis of the larynx muscles, or to tumors in
305
306 GiFFORD : Speech Disorders and Defects
the throat. In cases of marked retardation of speech, a careful
investigation is made of the environment and heredity of the
children. Tests are made to see if this retardation is due to
arrested mental development or to other causes. Some children
have a combination of 2 or more of these defects or disorders.
A careful history and record of progress is kept of each case.
Children who need the attention of a physician, surgeon or ortho-
dontist are referred to these departments before any speech cor-
rection is attempted.
Referring again to the first group, the psychopathic type of
children, an entirely different line of treatment is pursued than
that given to the other cases because of the peculiar nature of the
disorder. In former years, the outward manifestation was mis-
taken for the cause. Accordingly various operations were per-
formed, nerve tonics were given and mechanical devices were
worn in the mouth. All of which proved to be ineffectual. Neu-
rologists now classify this manifestation as one of the neuroses
caused by a severe fear shock, which was in some way associated
with the effort to speak. The original experience may be for-
gotten but by the unconscious association of ideas the disturbance
in speech continues. In some instances there is a history of a
particular shock followed by the appearance of the speech dis-
order. Among these might be mentioned a case where a child
saw a companion burned to death. In another instance a child
just escaped drowning. In most cases the parents are unable
to account for the disorder.
In the treatment of these cases a careful study has to be made
of each child, as heredity, environment and experience are im-
portant factors to be taken into consideration. Some children
are keenly sensitive to ridicule and very early develop self-con-
sciousness and a feeling of inferiority. This has a warping effect
upon the child's psychological development. Often his general
health is greatly impaired because of worry over his inability to
recite in the schoolroom. In some cases he prefers to be con-
sidered stupid and pretends that he does not know his lesson
rather than subject himself to the agony of conflicting emotions
which result from the attitude of thoughtless schoolmates. There-
fore it is necessary to build up confidence and poise and in every
way to counteract the effects of the humiliating school experi-
ences. The physiological speech drills bring about a conscious
GiFFORD : speech Disorders and Defects 307
control of the entire speech mechanism and serve the purpose of
giving the child a concrete proof of his abilitj'^ to control himself.
The emotional training is very important if these children are to
be fitted to meet the difficult situations away from the home pro-
tection.
The articulation cases mentioned in the second group, require
individual instruction. In many cases children may have perfect
hearing and yet fail to perceive the sharp distinctions in sounds.
The acquirement of normal speech is the result of 4 processes.
The first is the recei\'ing of sounds by means of the ear, the sec-
ond is the registration of these sounds in the auditory speedi
center of the brain, the third is the association of ideas with these
sounds and the fourth is the reproduction of these sounds by
means of oral language. The first step in treating a case is to
examine the hearing. If that is normal, the next step is to use
ever}' means to quicken the perception of the differences in sounds.
The mirror and pictures sho\%nng the contact of the tongue with
the palate will give a visual impression of the physiological
formation of a sound. Wlien the new position of the tongue is
taken, the child gets the tactile and a muscular sensation in the
speech organs which is necessarj^ to produce the required sound.
Considerable drill is given until the new habit is formed- The
lessons are g^ven in steps of progressicm frcmi the simple sound
to all its combinations in words and sentences. The element that
gives most trouble is the hissing sound found in words like salt,
cell, or box. Some children substitute the "th" sound, as
thalt for salt, thell for cell and bokth for box. Others make a
thick cluttered sound instead of the sharp hiss. All cases show
improvement from the careful drills. Even the mentally defi-
cient make ccmsiderable progress.
Often a child's speech has so many substitutions of sounds
that it is almost unintelligible. Frequently such children are classi-
fied as mentally deficient and unequal to any school recitation.
But in many cases a few months of instruction and home co-
operation completely clear up these defects. In the mentally de-
ficient these articulation defects are frequently found in degrees
ranging from no speech, unintelligible jargon, substitution of
many sounds up to ordinary infantile mistakes known as "liaby
talk."
308 (]iFFi)Rn: Speech Disorders and Defects
Voice defects are sometimes due to nose and throat obstruc-
tions or to a sluggish condition of the muscles after an operation
for their removal. Often, however, the fault lies in a lack of ear
training and proper tone placing. To meet these conditions,
exercises are given to develop breath and diaphragm control, a
voice free from tension, well modulated, having resonance and a
pleasing quality. In some instances the fault lies farther back.
Environment may bring about a chronic state of irritability which
is reflected in the voice. Other emotional states are reflected in
the voice, also. If a pleasant speaking voice is to become a habit
the imagination must be awakened and the desire to interpret
selections of the best literature should be stimulated, showing the
possibilities of such interpretation through the medium of a beau-
tiful speaking voice.
Sluggish enunciation is often due to carelessness and the lack
of training in good speech. Exercises for developing the habit
of a free jaw and lip action result in a clear distinct enunciation.
The same work is being carried on in the public schools under
the direction of the writer who is also training teachers to assist
in the handling of hundreds of speech defects. General speech
improvement is being introduced as fast as the training can be
given. In proportion to the school attendance, the San Fran-
cisco schools have the largest speech department in the country.
The work begins in the primary grades and extends through the
high school. The city is divided into districts and the classes
sent to centers where the director and an assistant meet a dif-
ferent group each day, covering the city in a week. This is re-
peated each week and the instruction is followed up by a teacher
from each school who attends the center, observes the corrective
lesson and gives it to the pupils who need help in her own school.
Under the University Extension division, classes for the train-
ing of teachers in this field are being conducted. In addition to
these practical courses, lectures on the theoretical background
of speech defects with the pathological and therapeutic aspects
are given by the Neuropsychiatry Department of the University
Medical School.
Heretofore, very little attention has been given to the peda-
gogical phase of the correction of speech defects because no one
had brought together all the correlated subjects and worked out
Gifford: Speech Disorders and Defects 309
a plan of classified instruction. But now this has been done.
Material has been prepared to meet practically every case of de-
fective speech. Therefore, no child should be allowed to grow
up handicapped by a defect in speech.
Drugs in Treatment of Children — Klotz (Therap.
Monats., BerHn, March, Vol. XXIX., No. 3, pp. 129-192)
comments on the complete failure of treatment of rachitis to
date on the basis that it is the result of disturbances in some
one internal secretion. Neither thyroid nor epinephrin treat-
ment has displayed the least efficacy, nor hypophysis nor thymus
extract. Of course if any treatment is begun just as the rachitis
is spontaneously subsiding, "astonishing results" may be obtained
with or rather in spite of the treatment. Calcium alone is equally
ineffectual, but given with phosphorus and cod-liver oil, the de-
sired result is realized. Recent studies of the metabolism by
Schloss indicate that the phosphorus can be dispensed with. The
calcium can be given in the form of i or 1.5 gm. of calcium
acetate (calc. acetic.) daily. Another field in which calcium is
useful is in melena of the newborn. Whatever the scientific ex-
planation, the melena may be arrested by subcutaneous injection
of 3 or 5 c.c. of a 5 per cent, solution of calcium chlorid (CaCL,
with gelatin. Or serum or gelatin may be injected and calcium
acetate (10 c.c. of a 5 per cent, solution) or calcium chlorid crys-
tals ( 10 c.c. of a 10 per cent, solution) be given by the mouth every
two hours, lengthening the intervals after 3 gm. has thus been
taken. Klotz has never witnessed any benefit from calcium salts
in prophylaxis or treatment of catarrhal affections or serum sick-
ness. The main field for calcium treatment is in arresting a ten-
dency to spasms and convulsions. From 8 to 15 gm. of the cal-
cium chlorid must be given in the first twenty-four hours, and
most of it during the first hours. With calcium acetate this
dosage should be reduced one-third. The drug is then continued
for three days, giving 1.5 gm. calcium chlorid or 1.25 calcium
acetate six times a day, gradually reducing this until by about the
tenth day 4 gm. is the daily dose, and this is kept up indefinitely.
In case of a relapse, the course is begun anew with three of the
initial doses and then five doses a day of 1.5 gm. of calcium
chlorid or 1.25 of calcium acetate. — Journal A. M. A.
MISCELLANY
A MOTHER'S INSTRUCTIONS TO A NEW NURSE.*
You are probably finding it rather difficult to get the children
to obey you at once. I am, therefore, going to write the follow-
ing hints, which may help you and give you an idea of my own
methods. I look upon it as vitally important that they should
obey at once even in unimportant things such as "come into the
garden now," because if they get into the habit of hesitating to
obey one can imagine an occasion when it might mean death to
one of them. For instance, if "come into the garden" is not
obeyed at once, "don't step off the pavement" might equally be
disobeyed with terrible results :
1. Never give a tentative order such as, "I think it is time
you came in," say "come in now." Always conclude that your
order will be obeyed at once until you see it is not. For instance,
don't say "come in now" and at the same time walk towards the
child to take its hand to lead it in, but say "come in now" and
turn yourself towards the house.
2. If possible never show annoyance. For instance, repeat
an order if necessary in exactly the same voice, because other-
wise they will wait until you are annoyed before they will obey.
3. Never show surprise at wrong doing. For instance, "Oh !
Pauline, you are not pouring water on Molly, are you?" Say,
Pauline, stop pouring water on Molly."
In case of disobedience. 1. I give the children 25 cents each,
good conduct money, on Monday morning if their conduct has
been perfect for the preceding week. I keep in a book the number
of marks, each 1 cent, taken off for little things, such as dawdling
when told to do something, touching things that don't belong to
them when they know they shouldn't, saying "why," not to gain
information but to delay obeying, etc. You can also take off
marks and let me know every evening whether you have taken
any off or not, so that I can enter them into the book.
To give an instance, if you should say "come into the garden
now" and they should not have obeyed by the length of time it
takes to count about 10, just say, in a quiet tone of voice, "one
mark off"; then repeat your order, using the same words and
voice as before. If disobeyed the second time say "four marks
*These simple hints to a nurse, devised by a young English woman, have appealed
to the Editor as well worth being printed. They are modeled on military standing
orders and are designed for the benefit of a woman who had never been a nurse
before.
310
Miscellany: A Mother's Ifistructions to a New Nurse 311
off," and if disobeyed a third time say, "no cake for tea," or
"stand in the corner for 5 minutes," whichever is most convenient
at the time.
2. You must always win no matter what uproar it creates,
but never under any circumstances slap or have recourse to cor-
poral punishment. (I feel that it is quite unnecessary to say this
to you, but I am putting it down with the rest.)
3. The "no cake," or "corner," may lead to a bad outbreak
of temper. The best thing to do then is to put the child to bed
and leave her there till she is quiet. This has only had to happen
very rarely.
4. Always be firm and get your own way wherever you are
and whoever is there. Giving way to a child to save a scene in the
street or on the stairs only lays up trouble for a future occasion.
Children can see so quickly whom they can get the better of, and
they are in the long run happier with, and fonder of, the people
who can control them. Pauline and Molly never bear resentment
for just punishment.
5. Never give an unnecessary order. Remember, it is more
important that they should be jolly and happy than that they
should have clean clothes and perfect manners. The object of
all the foregoing notes is in order to cut down "don'ts" and
"mustn'ts" to the minimum. I think that their very exuberant
spirits have been greatly helped by this system.
General Notes. 1. The children have no idea about being
frightened in the dark because it has never been suggested to
them, directly or indirectly, that there is anything in the dark to
be frightened of. For instance, they have never been asked if
they were frightened or praised for not being frightened. Never
say "it's all right, I am in the next room."
2. They have no fear of anything supernatural, as they have
never been told stories about spooks, bogies and ghosts, which
terrify children so. When I tell them fairy stories I always say
they aren't really true but just imagination stories, such as Father
Christmas. Never tell them an untruth such as "the policeman
will come and fetch you," or "angels bring babies."
3. Never say when they are naughty "I'll tell your mother."
They ought to realize that I will be told as a matter of course. It
is apt to make children deceitful.
312 Miscellany: A Mother's histructions to a Nezv Niirse
4. Before stepping off the curb into the street, or stepping
on to a carriage way in the park, or when a motor vehicle comes
in sight on a country road, I make Pauline hold my arm and I
hold Molly's hand. You should do the same. On the pavement
make them walk beside you, do not let them straggle all over the
pavement. Never take them under any roof without my knowl-
edge. No one else must be in charge of them for one moment
without my permission, except their father, you or me.
5. Do not think it necessary to amuse them the xvhole time.
They are accustomed to amuse themselves. This is a good thing
for them. By this I do not mean you sliould not play with them
when you feel so inclined.
6. Strangers take a great deal of notice of them and I am
anxious that they should not grow up thinking themselves of
more importance than any other member of the general public.
General Health Notes. I must be told everything, however
trivial it is, about their health, conduct or funny remarks. When
you notice a symptom of ill health, however small, let me know at
once, whether it is in the middle of the night or whether I am at
a dinner party. When you cannot speak to me or telephone to
me put the child to bed, send me a telegram and send for the
doctor. Money where health is concerned is no object. This
also applies to yours. If your suspicions prove to be unfounded,
it would only give me more confidence in you. If they complain
of any pain always conclude they really have one until both you
and I agree that they have not.
Both children must go to the W^ C. every morning after
breakfast regardless of whether they want to or not. If a whole
day goes by without the bowels moving inform me and give an
aperient. You need not inform me by telegram if they miss one
day, but you should if they miss two. They should be made
to go to the W. C. to make water whether they want to or not at
the following hours : first thing in the morning, before luncheon,
when they come in in the afternoon, and at bed time.
All wet clothes, especially wet shoes and socks (this includes
faintly damp) should be changed at once on coming into the house,
and if they are damp they should not sit down out of doors.
They should never sit on anything damp or on cold stones. It is
no good asking them if they are cold or hot. You can really only
MiscELT-ANv: A Mother's Instructions to a Nezv Nurse 313
tell by feeling them or the look of them. At home we always
have an outside thermometer and you should get into the habit
of consulting this when deciding what out-door clothes they should
wear.
They must never eat anything, including chocolates or sweets,
between meals. They know that they must tell people who oflfer
them anything to eat that "mother doesn't let me."
It does not matter if they drink out of each other's glasses
or use each other's cutlery but they must never use a glass, etc.,
used by somebody else before it has been washed.
You may have to limit the amount they eat of any particulaj
thing but never press them to eat against their will. Give them
small helpings so that they do not get into the habit of wasting
food by leaving it on their plates. Let them drink as much
water as they like at any time.
Unless their father or I am present you are completely respon-
sible to me for them without any exception, and I will always
back you up.
Pfeiffer's Bacillus in Influenza (Lancet, London, Oct. 4,
1919). The investigation made by Wilson comprises the examina-
tion of forty-three separate specimens of blood. Ten of the speci-
mens were from cases that were definitely not influenza, but
included such conditions as vaccinia, mumps, bronchitis, etc. In
all of these no agglutinins for the B. Influenzae were found. The
remaining thirty-three cases were typical examples of influenza
of a severe type and all of the patients were suffering from or
were convalescing from bronchopneumonia at the date of the
examination. Of the thirty-three the blood serum of eleven
showed distinctly the presence of agglutinins for PfeifFer's bacil-
lus. The important point was that the positive cases still mani-
fested elevation of temperature, while those that were negative
had been afebrile for periods varying from six to thirty-two days.
The study of three cases showed that the agglutinins very rapidly
disappear from the blood when the patient becomes convalescent. —
Journal A. M. A.
DEPARTMENT OF ABSTRACTS
Bruce, W. : A Simple Method for Determining the Re-
action OF Feces. (Journal of Laboratory and Clinical Medi-
cine. October, 1919, p. 61.)
The author suggests the following method for testing the
reaction of feces : Prepare 1 per cent, aqueous solution of ali-
zarine. Place 2 small drops of the indicator on a glass slide one
inch apart. Dip a glass stirring rod into the liquid part of the
specimen or puncture the mass if formed. Mix thoroughly in one
of the drops using the other as a control. An alkaline reaction
is indicated by a reddish violet to violet color, neutral no change,
and acid to a light yellow color. The density of these colors will
depend on the amount of acid or alkali present. The use of
white porcelain is recommended.
The indicator can also be used for urine and human milk.
Although some biochemists and physiologists state that the re-
action of feces has little value, the author believes a great deal
of this feeling is due to the present unsatisfactory methods of
obtaining it. A. Bret Ratner.
Herrick_, W. W. and Dannenberg, A. M. : Observations
ON THE Cerebrospinal Fluid of Acute Disease. (Journal of
the American Medical Association, November, 1919, p. 1321.)
The authors state that a review of the literature and a per-
sonal study of 76 cases not resulting in meningitis show beyond
question that the cerebrospinal fluid often gives evidence in in-
creased pressure, pleocytosis and heightened globulin content of
a reaction on the part of the leptomeninges to the infective agents
or toxins of a large number of miscellaneous acute diseases not
ordinarily causing true meningitis.
These diseases are lobar pneumonia and bronchopneumonia,
influenza, tonsillitis, the exanthems, herpes zoster, parotitis, typh-
oid fever sepsis, arthritis, pleurisy-migraine, reaction to typhoid
inoculation and others. Most but by no means all of the patients
with subarachnoid reaction have clinical meningismus.
The greatest caution should be used in making a diagnosis of
meningitis or poliomyelitis from fever, meningism and the changes
in the cerebrospinal fluid mentioned. Cases with less than 100
314
Department of Abstracts 315
cells should be viewed with skepticism unless clinical, epidemio-
logical or other laboratory evidence is decisive.
The meningococcus finds access to the subarachnoid space in
95 per cent, of meningococcus septicemias — 25 per cent, of pneu-
monia cases. The T. B. and spirocheta pallida also readily pass
the meningeal-choroidal barriers, less readily the bacillus typhosis,
influenza and gonococcus. Staphylococcus and streptococcus
rarely penetrate the subarachnoid system except by direct exten-
sion from some focus of suppuration adjacent to the meninges.
The agent of poliomyelitis penetrates the structures with great
facility.
After an experience of 5000 lumbar punctures in all sorts of
conditions, the authors think it absolutely a safe procedure.
A. Bret Ratner.
Cohen, M, B. : The Choice of Sera in the Treatment
OF Meningococcus Sepsis. (Journal of Laboratory and Clinical
Medicine, December, 1919, p. 176.)
The author reminds us that a number of observers have
noticed variations in the therapeutic result following the use of
different sera for the treatment of meningococcus meningitis.
Studies by the Royal Army Medical Corps in England, the
Pasteur Institute in France, and the Rockefeller Institute in the
United States have shown that the group of meningococcus is a
heterogeneous one and divided at least into 4 groups. The
various commercial polyvalent antimeningococcic sera are made
from a number of strains of meningococcus isolated from the
spinal fluids of cases of meningitis, and are supposed to contain
immune bodies for the 4 main groups. In spite of the polyvalency
of the sera, many cases have not responded properly to serum
treatment. Clinicians have been in the habit of changing sera
when proper results did not obtain and frequently with clinical
improvement.
Now that we can grow the organism on suitably enriched
media in 24 hours the following should be practiced. When a
patient is brought in the meningitis ward, a lumbar tap is done,
the fluid sent down to the laboratory and a preliminary bacterio-
logical report is made. Serum is injected and the following day a
saline suspension of the patient's organism is tested against vari-
316 Department of Abstracts
ous dilutions of the different sera. The serum giving the highest
titer is then used for the further treatment. This is practical and
insures proper treatment. A. Bret Ratner.
Putnam, Tracy Jackson: The Calorie as a Unit in
Figuring Milk Modifications. (The Boston Medical and Sur-
gical Journal, January 29, 1920, p. 107.)
In concluding the author states : —
1. The method of calculating milk modifications according to
the absolute caloric values of the respective food elements is as
rational as the present methods of percentage composition and
volume, or by total caloric value.
2. The use of the calorie as a unit in expressing the compo-
sition of milks is of advantage, in that all food elements are re-
duced to a common standard.
3. Such a view of the infants diet might lead to a clearer com-
prehension of the subject by some practitioners.
4. It would allow an easy manipulation of the fluid volume
apart from the food value of various mixtures ; and might lead to
the accumulation of more data concerning the effects of altera-
tions in fluid volume.
5. It would facilitate the extension of the calculation of the
diet into late infancy, when desirable.
6. The calculation of modifications would be simpler in many
ways, and more easily understood, than under many of the present
systems. Alterations of one constitutent without changing the
others would be particularly simplified.
7. But the possible advantages gained by such a method of
calculation are probably scarcely sufficient to warrant its adoption
in place of the present well-tried and well-known procedures.
L. L. Shapiro.
Guerbet, M. : Lead Poisoning from Nursing Bottles.
(La Nourrisson, June, 1918.)
Tests for the presence of lead were made on milk pasteurized
for 20 minutes in nursing bottles with the result that the milk
was found in some cases to contain as much as 9 mmg. of lead
to the litre. The milk assumed a yellowish tint. The author
offers the explanation that alkalies or chlorides combined with
Department of Abstracts 317
heat during the pasteurization may attack the glass. Minute
quantities of lead would be thus set free and changed into
sulphide. C. D. Martinetti.
Kjrmisson, E. : Epithelioma of Appendix in a Child.
(Bulletin de la Societe de Chirurgie, July 3, 1917.)
An emergency appendix operation was done on a girl of 14.
Peritonitis had set in from a long ulcerated appendix. The
appendix contained no fecal matter nor foreign body but at its
extremity was a yellowish mass of the size of a cherry. This
had formed in the mucus and had not invaded the muscular
tissue. Microscopic examination disclosed its nature to be an
epithelioma of the mucus. Recovery was uneventful and the
girl after two years was still in perfect health.
C. D. Martinetti.
Wallace, J. Sim : Saliva and Oral Hygiene. (The Med-
ical Press, June 18, 1919, p. 469.)
The author combats the theory that the saliva is primarily
a digestive juice. He says it is generally accepted that the di-
gestion of uncooked starches by the ptyalin in human saliva is
almost negligible and further states that it has not even been
contended that it digests sugar, although the ingestion of sugar
stimulates a fairly strong flow of ptyalin-rich saliva. He points
out how strange it is that almost immediately after the food
is mixed with ptyalin it is sent on to an acid medium where the
digestion of starch by ptyalin is immediately arrested. It seems
ridiculous to him to try to argue further for this digestive action
of saliva by stating that the food is in bolus form in the stomach
and not disintegrated for some time, thus permitting the action
of the thoroughly mixed saliva to go on more nearly to com-
pletion. He does not believe food enters the stomach in one big
bolus, but is at once rather intimately mixed with the gastric
juices as it enters the stomach.
The author believes that one of the functions of the saliva,
which becomes markedly alkaline when food is taken, is to re-
move the food particles from the mouth. An alkali separates
adhering mucus and clears away all the food connected with it.
318 Department of Abstracts
Also an acid reaction would tend to decalcify the teeth. Sugar
taken into the mouth favors this acid reaction, but it also stimu-
lates the free flow of the alkaline saliva which neutralizes the
acid and preserves the~ teeth. Another duty of saliva is to pro-
vide ameboid phagocytic cells — the so-called salivary corpuscles
which may be regarded as the scavengers of the mouth.
Thus he believes that it is much more accurate to consider
the prime function of saliva as one of oral hygiene than one
of carbohydrate digestion. Hugh Chaplin.
Pelfort, C. : Tubercular Meningitis in Infancy. (Ar-
chives Latinos Americanos de Pediatria, Nos. 1 and 2, 1917.)
This paper, read before the Pediatric Association of Monte-
video, was based on the study of 20 cases under 2 years belong-
ing to the Clinic of Prof. Morquio. The following conclusions
were reached :
1. Tubercular meningitis in infants is rather frequent and is
observed chiefly in the male sex (14 cases out of 20).
2. Clinically the disease appears of primary origin, but the au-
topsy invariably shows it to be secondary, the first lesions
being in the peri-tracheal bronchial ganglia.
3. Infection occurs usually from relatives.
4. Cold weather predisposes to infection. Practically all the
cases observed occurred in winter or spring.
5. Symptoms vary and progress of the disease is insidious.
6. The commonest forms are those associated with somnolence
and convulsions.
7. Spinal rigidity and Kernig's sign are constant.
8. Lumbar puncture confirms diagnosis.
9. Death occurs in 100 per cent of cases.
C. D. Martinetti.
Hatfield, Hugh K. : A Preliminary Study of the Effect
OF Rickets on the Jaws. (The International Journal of Ortho-
dontia and Oral Surgery, July, 1919, p. 367.)
The article includes, first, an outline of some of the character-
istic features of the disease seen in other parts of the body;
second, a reference to observations upon its deforming action
upon the jaws; and lastly, photographs showing models of the
Department of Abstracts 319
teeth and jaws of the group of rachitic children under observa-
tion.
Concerning the second portion of the article the following
orthodontic conception of the disease is given : Rickets, charac-
terized by a faulty development of bone, is a very important
etiologic factor and deforming agent in malocclusions. It delays
the eruption of the deciduous teeth which are in turn lost early
with resulting malocclusion in the second dentition. There is
faulty development of the alveolar process and of the bones of
the mandible and maxilla. The marginal ridges of process are
thickened and rounded. Incisors of the upper jaw usually small,
soft and friable. Permanent teeth damaged before their ap-
pearance, showing erosions on body and cutting edge. The upper
jaw narrowed or V-shaped in form. Palate high vaulted and
teeth crowded. Lower jaw shortened or trapezoid in form.
Upper alveolar processes have a tendency to turn out ; lower
alveolar processes, to turn in. Of these signs the narrow or
V-shaped upper arch with high vaulted arch palate seems to take
first place as a characteristic deformity of rickets.
The author draws no definite conclusions from his studies,
as they are not completed, but ventures the interesting specula-
tion that as the disease seems to be essentially an epiphyseal
disturbance of the bones and as the growth of the mandibles is
not of an epiphyseal character, the prognosis in these cases would
seem to be more favorable than in the case of long bones with
epiphyses. Hugh Chaplin.
Scott, A. J., Jr. : Boiled vs. Raw Milk in Infant Feeding.
(Southern California Practitioner, February, 1920, p. 11.)
Very young infants, according to the author, do better, gain
faster, and have fewer digestive disturbances upon the use of
boiled than raw cow's milk, for the following reasons :
1. Raw milk forms tough, leathery, large curds in the stomach,
many of which pass, not completely digested, through the stomach
and intestines and are found in the stools.
2. Boiled milk forms soft flocculent curds, and the stool is
softer and smoother.
3. Raw milk curds take more calories of heat from the child
320 Department of Abstracts
to digest than boiled milk, because the latter curds are smaller
and softer.
4. Raw milk fat forms large soap stools, the curds of which
are like lima beans, while the heating of the milk causes chemical
changes in the fat and while a considerable amount is passed by
the stools as evidenced by the smooth oily appearance, only in
exceptional cases do we find the bean like masses.
To prevent the child developing scurvy or rickets when feed-
ing a cooked milk, one which has all the vitamines destroyed, use
some fresh fruit juice, preferably orange, which may be given to
infants as young as one month without untoward eflfects.
L. L. Shapiro.
Unger, Lester J. : The Therapeutic Aspect of Blood
Transfusion. (Journal of the American Medical Association,
September 13, 1919, p. 815.)
Unger in his article discusses the 2 methods of transfusion,
the dosage and indications. He then summarizes as follows : —
There is a far greater number of reactions following transfusions
with citrated blood than with unmodified blood. This is due to
alterations in the blood cells. The platelets undergo early coagu-
lative changes. Sodium citrate acting as a harmful foreign sub-
stance renders the red cell more fragile and more easily hemolyzed.
This undesirable result is of especial importance in hemolytic dis-
eases. Transfusion of whole unmodified blood is the procedure of
choice when blood is required as a tissue. When it is wanted
merely to replenish an impoverished circulation with an adequate
supply, citrated blood may serve as a substitute. For the selec-
tion of donors, a simplified and rapid microscopic method is desir-
able. Repeated withdrawal of blood for transfusion may produce
in the donor an intense secondary anemia with an increase in the
leucocyte count. The onset of hypertransfusion is evidenced by
the patient's giving vent to short, sharp coughs. This signal has
been of decided value as a warning of impending danger. The
giving of more than about 200 c.c. of blood after the occurrence
of "the signal cough" may prove fatal. Transfusion yields moder-
ately good results in infections and debilitating conditions. The
best results are obtained in toxemias, in shock, in cases of hemor-
rhage, and in diseases of the blood, in which it is frequently of
life savins: value. C. A. Lang.
Archives of Pediatrics
JUNE.
1920
HAROLD RUCKMAN MIXSELL, A.B.. M.D., Editor
CHARLES ALBERT LANG, M.B.. M.R.CS.. Associate Editor
COLLABORATORS:
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ORIGINAL COMMUNICATIONS
EPIDEMIC OR LETHARGIC ENCEPHALITIS IN CHIL-
DREN*
By Josephine B. Neal, M. D.
New York
The present outbreak of epidemic or lethargic encephalitis
seems to have started in Vienna in the winter of 1916-1917. In
the spring of 1918, it appeared in England and France and in the
fall of 1918, in the United States. A large number of articles
have appeared, to which it is unnecessary to refer at this time.
Anyone desiring a very complete bibliography of the present
epidemic, as well as of earlier outbreaks, will find it in the article
by Barker, Cross and Irwin in the American Journal of the
Medical Sciences, February and March, 1920. This study in-
* Read before the Brooklyn Pediatric Society, March 31, 1920.
* From the Meningitis Division, Research Laboratory, Department of Health,
New York City.
321
322 Neal: Lethargic Encephalitis in Children
eludes also a very comprehensive and detailed discussion of sev-
eral typical cases of encephalitis.
In only a few instances has the subject of encephalitis in chil-
dren been especially discussed, probably because the disease seems
to be one of adult life rather than of childhood. Batten and Still
reported 4 cases in 1918 under the heading of "Epidemic Stupor
in Children." Netter described cases in Paris giving headache
and lethargy as the prominent symptoms. Comby, in 1919, re-
viewed the literature referring especially to the disease in chil-
dren, and Heiman, in 1919, described several cases calling the con-
dition, "Post Influenzal Encephalitis." Tilney and Riley, in a
study of encephalitis in 1918, reported several cases in children
and mentioned 4 or 5 infants which they had seen at the Babies'
Hospital.
The fact that the meningitis division has seen a relatively large
number of children is due, I think, more to the distribution of our
work than to the age distribution of the disease. Moreover, more
cases may escape diagnosis in children than in adults, since, as
will be mentioned later, the disease is likely to run a milder course
in early life. Therefore, in places where lumbar puncture is not
freely resorted to for diagnosis, these cases may easily be un-
recognized. Of 54 cases studied by Netter, 77 per cent, were
more than 15 years of age and in London 86 per cent, of the
cases were more than 10 years of age. We have seen approxi-
mately 125 cases and of these 58 were 15 years or under.
It seems to me unfortunate that there is a tendency at present
to call encephalitis by a variety of names. Such a multiplicity of
terms can only add confusion to the general practitioner, who will
probably see but few cases of this disease and who should not be
asked to burden his mind with several names. It also seems to
me unnecessary to attempt to classify the condition too minutely.
When we remember that we have an agent that may attack any
one or several parts of the central nervous system and in varying
degrees of severity, it is obvious that we shall have symptoms of
the greatest variety, both in kind and intensity. The study of a
large number of cases impresses one more and more with the
protean manifestations of this interesting disease.
Some writers, especially McNalty, make a point of prodromal
symptoms but inasmuch as they are usually a milder form of the
Neal : Lethargic Encephalitis in Children 323
later symptoms and since, as he himself admits, it is difficult to
tell when the prodromal period leaves off and the real disease
begins, it seems superfluous to make such a distinction. The
characteristic picture in either adults or children is usually as fol-
lows: A gradual onset; marked lethargy and asthenia; head-
ache ; low, irregular temperature ; frequently cranial nerve palsies.
Other paralyses may occur. A mask-like expression is often
present. The onset may be sudden and is so more frequently in
children than in adults. Other striking features that may be
present are catatonia, marked tremors, choreiform movements,
profuse sweating, insomnia, delirium, a marked twitching of cer-
tain groups of muscles. A slurring, hesitating speech, with a very
slow response is quite characteristic. One asks the patient a
question. There is a long pause. Finally, after one has become
certain that the patient has not heard or will not respond, he
answers correctly in a low monotonous voice. Disturbances of
vision, either diplopia or blurring are fairly common, and are very
diagnostic symptoms. These occur or are elicited more frequent-
ly in adults than in children. We have found these disturbances
of vision in a much larger percentage of cases in the last few
months than in the preceding year. Whether they have really
been present in greater numbers or whether we have elicited them
more carefully, I do not know. However, I read with interest
that Netter has found such disturbances less frequently this win-
ter than last so it seems that their occurrence does vary at dif-
ferent periods. Captain Smith of the Public Health Service told
me that in New Orleans, where a considerable number of cases
occurred in the winter of 1918-19, the oculists saw a surprising
large number of cases of transient diplopia, or strabismus occur-
ring without other symptoms. Vomiting is common especially in
children. Constipation, rather than diarrhea, is the rule. At
Mount Sinai Hospital, it is reported that a considerable number
of cases show retention of urine. This has been present in only
a small percentage of our cases. An. interesting point has been
demonstrated in the First Medical Division at Bellevue by Dr.
Norrie and Dr. Cotter, who have shown that the oculo-cardiac
reflex has been present to a marked degree in practically all the
cases that have occurred on the division. This reflex, one will
324 Neal; Lethargic Encephalitis in Children
remember, is brought out by pressing the eyeballs and shows
itself by a marked slowing of the pulse.
The course of the disease is often remarkable for the sudden,
transient changes in the condition of the patient, either for the
better or worse. These changes show themselves most in the
mental condition and are often very temporary so that one must
be guarded in making a prognosis until he has studied the case
for a time and gained some idea of the patient's average condi-
tion.
The most striking feature of the disease, especially in adults,
is the prolonged course. Cases will run 2, 3 or even 4 months
with so light changes from week to week (disregarding the tem-
porary changes to which I referred) that they are the despair of
the physician as well as of the family. Many seen at the height
of the disease appear so desperately ill that one who is not fairly
familiar with such conditions would be quite hopeless as to the
ultimate outcome. These prolonged cases are very unusual in
children. In only 1 instance have I observed it. That case will
be discussed in detail later. The average duration in children is
under 6 weeks. The onset, as I said before, is more frequently
sudden; there are fewer paralyses, and fewer disturbances of
vision. Table I shows the salient features in the 58 cases that I
have studied. An interesting point is the sex distinction. Of the
58 cases, on which this study is based, 44 were boys and 14 girls.
Differential Diagnosis: A differential diagnosis in chil-
dren must be made from tuberculous meningitis, brain tumor,
meningism with some unknown underlying cause, syphilitic in-
volvement of the central nervous system, and poliomyelitis or
polioencephalitis and meningitis. In adults, especially, cerebral
hemorrhage or thrombosis and uremia must be considered.
The diagnosis from tuberculous meningitis is by no means
easy in the more typical cases. After studying a number of these
cases one may hazard a guess from the clinical picture judging
by the patient not seeming so ill as a case of tuberculous meningi-
tis would be, assuming that it is a, case of 2 or 3 weeks' standing;
vomiting is a less constant feature,- and the pulse is more likely
to be regular in encephalitis than in tuberculous meningitis. The
final diagnosis v^ill reist on thie examination of the spinal fluid
and even here the first examination may leave us in doubt. The
NeaL : Lethargic Encephalitis in Children 325
spinal fluid findings in encephalitis are discussed under laboratory
findings and are not given at this point.
Therefore, if the case is seen early, we may, even with the
examination of the spinal fluid, be in doubt as to the diagnosis and
must await the further development of the case and the examina-
tion of the fluid at a later stage.
Brain tumor is comparatively rare in children and usually
shows a more protracted course than does encephalitis. Choked
disc, which occurs in brain tumor, does not occur in encephalitis,
though some edema may be present. The spinal fluid findings are
not constant in brain tumor, sometimes showing an increase in
cells, though rarely an increase in albumin and globulin, so that
it will not be of great help in making the diagnosis. Brain
tumor is more often a stumbling block in the diagnosis in adults.
Several cases which had been diagnosed as encephalitis at Belle-
vue proved on autopsy to be brain tumor.
Meningism, in mild cases, is sometimes suspected, occurring
perhaps with the gastrointestinal upset that sometimes accom-
panies encephalitis, but this will be ruled out by the normal fluid
found in meningism. Certain cases of meningism, to be sure, do
not show a perfectly normal fluid but may show an increase in the
proteid content or cells or both. These cases usually fall into 4
well-defined groups : cases with severe and prolonged convulsions
as the convulsive type of whooping-cough; cases in which the
meningism has been persisting for a long time without relief of
pressure, especially in cases that are moribund when seen; cases
with an inflammation near the meninges as otitis media, mas-
toid or sinus involvement, called by Strauss "meningitis sym-
pathetica" ; and a miscellaneous group of special conditions —
mumps, typhus, etc. I feel strongly that when changes are found
in the spinal fluid one must search carefully for some such under-
lying cause as those mentioned above before one assumes that it
is a simple case of meningism.
Syphilis of the central nervous system is less common in chil-
dren than in adults and, therefore, is seldom a problem in differ-
ential diagnosis. For sometime we have been doing as routine a
Wassermann of all our clear spinal fluids showing pathological
changes and we assume that a negative Wassermann rules out a
syphilitic condition of the central nervous system. The diflferen-
326
Neal: Lethargic Encephalitis in Children
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328 Neal: Lethargic Encephalitis in Children
tial diagnosis from the encephalitic form of poliomyelitis is, in
certain mild cases, quite impossible, I believe. Since at the present
time we are having so few typical cases of poliomyelitis and
since, even in the epidemic of 1916, we saw very few of the ence-
phalitic type, it seems more logical to consider these cases ence-
phalitis though I am perfectly free to confess that had they oc-
curred in the summer of 1916 I should have diagnosed a small
number of them as the encephalitic form of poliomyelitis. Prob-
ably neutralization tests are the only method of making diagnosis
and these tests are not always satisfactory.
The diagnosis from the various forms of acute purulent men-
ingitis is usually not difficult though certain cases of encephalitis,
with an acute onset, have been considered cases of epidemic
meningitis. The clinical symptoms in atypical cases may be suffi-
ciently similar to cause confusion. The examination of the spinal
fluid affords the most reliable means of differentiation, the spinal
fluid of purulent meningitis being of varying degrees of cloudi-
ness and showing an excess of polymorphonuclears, a diminished
or absent Fehling's, and the causative organisms.
The diagnosis from cerebral thrombosis or embolism may not
be easy, as sometimes a monoplegia or a hemiplegia may be
present in encephalitis and of course, cases with cerebral hemor-
rhage or embolism usually show drowsiness and a slowness of
response. This diagnosis, as well as that from uremia, must, of
course, be made chiefly in adults.
A description of certain cases may be of interest.
Case 1. L. S., a boy of 9 years, is of interest on account of
the long duration of his disease. He was admitted to Willard
Parker Hospital on February 13, 1919, with a history of being ill
for 3 days and a diagnosis of epidemic meningitis. He was then
comatose, had a slight rigidity of the neck and Kernig's sign,
exaggerated knee jerks, positive Brudzinski sign, and Babinski
reflex. He ran an irregular temperature from 100° to 103'^ F.
until February 19, after which it was below 100° F. until March
14. At times his pulse and respiration were irregular. He be-
came progressively worse and by February 20 had rigidity of the
entire body, and a mask-like, expressionless face. He became
unable or unwilling to swallow and had to be tube-fed. The
white blood count was 15,000 of which 81 per cent, were poly-
Neal: Lethargic Encephalitis in Children 329
morphonuclears. The first lumbar puncture, February 13,
showed a clear fluid with moderate increase in cells, 60 per cent,
polymorphonuclears, moderate increase in protein elements, nor-
mal reduction of Fehling's and a negative Wassermann test.
• Fluid withdrawn February 14, was slightly blood-tinged so that it
had a somewhat hazy appearance. Therefore, with the clinical
picture resembling meningitis so strongly, and an excess of poly-
jtnorphonuclears in the first fluid, serum was given. Of course,
this obscured the spinal fluid picture for some time. During all
this time the child did not speak and has not up to the present
time. There were frequent muscular twitchings. Early in March,
he began to move his head and a little later his legs and arms, and
seemed to be progressing toward recovery. On March 14, how-
ever, the temperature rose to 106° F., he perspired profusely and
seemed to be in a desperate condition. A blood culture at this
time was negative. Twenty c.c. of spinal fluid were withdrawn
under some pressure, showing a moderate increase in cells, 80
per cent, mononuclears, increase in albumin and globulin, and a
normal reduction of Fehling's. On March 15, he began to im-
prove, his temperature dropped to 100° F., after that time his
condition showed some progressive improvement, and he gained
in weight. A peculiar hairiness appeared on the trunk, legs and
arms and forehead. He looked about and had an intelligent ex-
pression but did not respond in any way when spoken to. He had
,to be tube- fed up to January, 1920, but was able to swallow if
one was dexterous enough to insert food when his mouth was
open. His arms, and especially his legs, were somewhat spastic
and the right leg showed contracture, though it was possible
nearly to straighten it without his evidencing much discomfort.
He was transferred to the Children's Medical Service at Belle-
vue Hospital in December, 1919, where he improved somewhat
under the administration of thyroid extract. After remaining
there for 2 or 3 months his parents insisted on his removal. This
case is of interest on account of its severity, its long duration and
the seriousness of the sequellae.
^ Case 2. E. M., a girl of 14 years. Seen January 16, 1920.
•Her parents stated that 4 or 5 years before she had suddenly
developed a paralysis of the left arm and leg, which had practical-
ly cleared up. So far as could be ascertained this occurred dur-
330 Neai-: lethargic Encephalitis in Children
ing the epidemic of poliomyelitis in 1916 and was probably an at-
tack of poliomyelitis. Her present illness began rather slowly on
January 12, apathy, tremors, and a subnormal temperature 96° F.,
being the chief symptoms. She had grown progressively worse
and when examined, January 16, had the appearance of being in
a very serious condition. Her temperature was still 96" F., she
was sweating profusely, catatonia had developed, and there were
marked tremors. She was extremely apathetic and apparently in
a semi-stuporous condition, but she answered questions correctly,
though very slowly and in a monotonous voice. Her neck was
moderately stiff, and there was a question as to the Kernig, since
there was a general hypertonicity of the muscles. The knee jerks
were equal and exaggerated. The pupils were equal and respond-
ed to light. There was no paralysis or disturbance of vision. A
lumbar puncture revealed clear fluid, under increased pressure.
For about a week following the temperature was elevated.
She had a rigid neck and suffered from insomnia. She then slept
for about 17 hours and after that began to improve rapidly. She
was seen about 2 months later, at which time she was perfectly
recovered, with no sequellae.
Case 3. A boy of 12 years. Past history negative. Ex-
amined December 19. Present illness began December 14 sud-
denly with headache. Diplopia and impaired vision soon devel-
oped. When examined the pupils were equal and reacted to
light — the reflexes were sluggish but equal, there was stiffness of
the neck and a moderate Kernig. The pulse was regular and
ground 100, and the range of temperature was from 103° to 100"
F. There was a slight facial paralysis and a double ptosis, more
marked on the right side. There were muscular twitchings,
especially of the extremities. The diplopia and impaired vision
persisted. A provisional diagnosis of tuberculous meningitis had
been made by the doctor in attendance. The case gradually
cleared up but the diplopia returned at times for 3 to 4 months
and it was reported in April that his mentality was slower than
Jjefore the illness.
It will be interesting to follow up these cases several months
or a year after the illness to determine whether any permanent
defects result from the disease. From a limited number of ob-
servations it seems that the return to a normal condition is very
Neal: Lethargic Encephalitis in Children 331
slow in certain instances. One man who sufifered from a very
severe form of the disease was reported after more than a year
as being quite changed in disposition, being very irritable. He
had previously been even-tempered.
Many cases run a much milder course than these first de-
scribed. In about 25 per cent, of cases death occurs, usually
from 1 to 3 weeks from the time of onset.
Laboratory Findings: The blood picture is not characteris-
tic. It may be normal or may show slight leucocytosis, perhaps
up to 15,000. The blood cultures are sterile. The urine is nega-
tive or shows the mild degree of nephritis that is common in
acute infectious conditions. The examination of the spinal fluid
throws more light on the diagnosis than does any other laboratory
procedure.
The spinal fluid shows practically the same picture as in poli-
omyelitis. It is clear and is usually increased in amount. The
cells are usually slightly or moderately increased, seldom greatly,
perhaps up to 150 or 200. The cell counts may run higher in
poliomyelitis ; the great majority do not. As in poliomyelitis,
there is usually an excess of mononuclears, but an excess of poly-
morphonuclears may occur. The albumin and globulin are in-
creased in varying degrees, the reduction of Fehling's is normal.
The increase in cells and protein content is not always in the same
ratio. No organisms are reported by smear or culture by most
workers. The gold chlorid curve depends apparently on the
amount of albumin and globulin present and duplicate curves may
be selected from those in poliomyelitis fluids. In some instances,
more often in convalescent or mild cases, the findings may depart
little from the normal. This is true also in poliomyelitis. Many
reports of encephalitis show that the cell count (which, unfortu-
nately, is often the only information given) falls oflf very quickly.
This has been our experience in most instances. In 2 of our cases
of long duration, the character of the fluid did not change materi-
ally over a period of several weeks, but the condition of the
patients also showed little change. As in poliomyelitis the fluid may
^n rare instances be slightly blood-tinged, probably indicating a
,more than usually severe hemorrhagic process. This comparison
with poliomyelitis is made not because I believe the 2 diseases are
<^t all identical, but to emphasize the fact that in each instance
332 Neal: Lethargic Encephalitis in Children
the spinal fluid is not specific, but shows the reaction of the
meninges to an inflammation of the brain substance. A some-
what similar condition exists in the various syphilitic involve-
ments of the central nervous system, but in these conditions the
gold chlorid curve and the Wassermann test are helpful in making
the diagnosis.
The most difficult and the most needed diagnosis is that made
from the fluid of tuberculous meningitis. While generally the
number of cells and the increase in albumin and globulin is greater
in the latter disease, it is by no means always so, and it is some-
times necessary to examine more than one fluid before one can be
certain of the diagnosis, as it is often difficult to find the tubercle
bacillus in early tuberculous meningitis and the reduction of
Fehling's may be normal, at that time. The reduction of Fehling's
is usually diminished or lost in late cases of tuberculous meningi-
tis. Table II shows the findings in the spinal fluids in our cases
of lethargic encephalitis under 15 years of age.
Inoculation of monkeys, with the emulsified brain and cord of
fatal cases, has not given conclusive results. Most observers re-
port that they are unsuccessful in reproducing the disease in
monkeys.
Strauss, Hirshfield and Loewe, however, report the successful
reproduction of a disease which they consider encephalitis both
in monkeys and rabbits by using the emulsified brain substance of
a fatal case of encephalitis.
Pathology : Lethargic encephalitis belongs to the class of in-
flammatory diseases, in which also are included poliomyelitis,
syphilitic lesions of the central nervous system and trypanosomi-
asis. While these different diseases have, broadly speaking, cer-
tain characteristics, the cases in a given class differ so widely
that it is difficult, if not impossible to accurately diagnose, by a
study of the pathology alone, the less typical cases.
The meninges are usually described as showing only slight
changes — an increase in the cellular content, particularly in the
neighborhood of the blood vessels of the pia-arachnoid. The
cerebral cortex is generally normal, except for congestion of the
vessel of the leptomeninges. In the brain substance, the changes
are most marked in the basal nuclei of the brain, the upper part of
the pons and peduncles, the gray matter of the floor of the fourth
Neal: Lethargic Encephalitis in Children 33i
ventricle, and the aqueduct of Sylvius. The changes in the
medulla and cord are often reported as less pronounced, though
observers have noted the same changes occurring in the upper
section of the cord. This was certainly observed in the case of
an adult which came to necropsy (reported in the International
Clinics).
The lesions are generally described as consisting of 4 kinds;
1. Infiltration of the walls of the small vessels with lympho-
cytes and plasrna cells. i
2. Foci of interstitial and parenchymatous infiltration with
round cells. In this reaction neuroglia cells may take part.
3. Lesions of the nerve cells — usually not so extensive as in
poliomyelitis, and with less neuronophagia. These lesions of the
cells usually occur when the inflammatory process takes place in
the gray matter, but they may develop in the absence of an in-
flammatory reaction. Such is the case with regard to the cells
of Purkinje in the cerebellum where inflammatory changes are
almost entirely absent.
4. Foci of perivascular hemorrhage. The vessel walls are
usually not necrosed.
In connection with the statement that lesions of the cells may
occur in regions where there is no evidence of inflammatory re-
action, it is interesting to recall that Abramson, in a very excel-
lent study of the pathology of poliomyelitis made at the Research
Laboratory during the epidemic of 1916, brought out the same
fact in regard to the lesions of poliomyelitis.
Theories : Three theories have been advanced to explain the
occurrence of lethargic encephalitis. When it first appeared in
England, it was suggested that it was caused by food — botulism
or some poison derived from substitutes or solanin accumulating
in sprouts of potatoes or other vegetables. This theory has been
definitely disproved and discarded. According to a second theory,
it is a form of poliomyelitis; and, according to a third, it is con-
nected with the epidemic of influenza.
The theory that it is a form of poliomyelitis has not been
.definitely proved or disproved. Epidemic poliomyelitis usually
^occurs in hot weather, the majgrity of the victims are children,
,and the lower motor neuron type of paralysis constitutes the
igreat majority of the cases with paralysis. The onset is usually
sudden and the greater number of deaths occurs in the first
334
Neal: Lethargic Encephalitis in Children
TABLE II.
Laboratory Findings in Cases of Lethargic Encephalitis.
2
a
a
n
2"
Onset
o
u
go
Cytology
a
'C
o
u
I""
11
4"
E-3
1^
to
Puncture
14
30
36
30
262
388
15
25
368
88
IS si.,
cloudy
r60
35
32
i30
30
S
9
371
10
30
10
323
102
94
49
45
IS
12
93
40
54
5
16
280
87
30
20
351
137
198
281 1
20
10
30
40 1
240
295
304
25
30
25
391
25
39S
15
19
41
15 1
20 1
80
254
15
Greatly increased....
Mononuclears 80%
Greatly increased . . . .
Mononuclears
No increase in cells
Greatly increased....
Mononuclears 907o
Greatly increased....
Mononuclears 90%
No increase
Greatly increased. . . .
Mononuclears 80%
Greatly increased....
Mononuclears 80%
Slight to moderate in-
crease. Monos. 90%
Greatly increased....
Mononuclears 80%
No increase in cells. .
No increase
Greatly increased....
Mononuclears 80%
No increase
No increase
No puncture
Slight increase
Mononuclears
Slight increase
Mononuclears
Slight increase
Mononuclears
No increase
No puncture
Very great increase..
Mononuclears 70%
No increase
No increase
Great increase
Moderately increased.
Mononuclears 90%
•Slipht increase
Slight increase
Slight to moderate
increase. Monos.
Slight to moderate in-
crease. Monos. 90%
Very slight increase.
Mononvjclears
Slight increase
Greatly increased . . .
Mononuclears 95%
No nuncture
Slight to moderate in-
crease. Monos
+++
++
+ 1
++++
++
+ 1
++ 1
+++
+++
++++
+
+ 1
++
+ 1
+
+ 1
+
+ 1
+
+
++ 1
+ 1
+++
++ 1
+ 1
+ 1
++
+ 1
±
++
++ 1
+ 1
+++
+++
+++
+++
+++
+++
+++
++
++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
++ 1
+++
+++
+++
+++
+++
+++
?
1 day
7 days
3 days
3 days
5 days
14 days
15 days
16 days
18 days
3 days
5 days
18 days
4-5 wks.
10 days
4 days
14 days
5 days
4 days
4 days
3 days
12 days
14 days
9 days
14 days
4 days
7 days
4 days
4 days
30 days
15 days
Neal : Lethargic Encephalitis in Children
335
TABLE II.— Continued.
Laboratory Findings in Cases of Lethargic Encephalitis.
r
Cytology
a
a
"apt;
S <*
3
<
U
Onset
to
Puncture
55
12
16
40
30
35
60
30
10
65
30
357
35
1
15
46
25
30
J 20
20
15
35
.20
10
100
20
42
20
70
15
38
15
332 1
30
78
327
245
187
317
22
69
81
331
83
77
30
6
25
50 si.
tinged I
18
35 I
30
25
30
30
30
Slight increase
Mononuclears
Slight increase
Mononuclears
Moderately increased.
Mononuclears
Greatly increased . . .
Mononuclears
Moderately increased.
Mononuclears
Greatly increased . . .
Mononuclears
No increase
Moderate increase . .
Polymorphonuclears
60%
Bloody fluid
Bloody fluid
Moderate increase...
Mononuclears 80%
Moderate increase...
Mononuclears 80%
Moderate increase...
Mononuclears 95%
Slight to mod. increase
Moderate increase...
Mononuclears
Very great increase. .
Mononuclears
Slightly increased . . .
Mononuclears
Greatly increased . . .
Mononuclears
Slightly increased...
Mononuclears
Moderately increased.
Mononuclears 80%
Greatly increased . .
No increase
Greatly increased . . .
Mononuclears 90%
No increase
Slightly increased..
Mononuclears
Moderately increased
Mononuclears 90%
Greatly increased..
Mononuclears
Moderately increased
Mononuclears
Slight increase . • • •
Slight to mod. in-
crease
Slight increase ....
+
+
+ 1
+ 1
+
++
++
++
+ 1
+++
++
++
+++
+++
++++
++
+
+
++
++++
++ 1
++
++
+
+
++ 1
+++ 1
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
+++
—
7 days
7 days
11 days
9 days
9 days
12 days
14 days
3 days
4 days
5 days
6 days
8 days
32 days
50 days
2 days
2 days
14 days
3 days
4 days
2 days
14 days
5 days
14 days
13 days
12 days
4 days
5 days
6 days
21 days
7 days
10 days
336 Neal: Letlmrgic Encephalitis in Children
week. Lethargic encephalitis has occurred in its present appear-
ance during the cool weather, the majority of cases having been
adults (my own list of cases shows a large number of children,
but this is undoubtedly because I am so often called to see the
milder type of case where tuberculous meningitis is suspected).
yery few cases of the lower motor neuron type of poliomyelitis
are occurring, and among the cases diagnosed as lethargic ence-
phalitis there are evidences of involvment of the higher centers
in the way of cranial nerve palsies and prolonged lethargy which
are rare even in epidemics of poliomyelitis. Certainly among the
hundreds of cases of the latter disease that came under my obser-
vation during the epidemic of 1916 there were no cases at all
^approaching the characteristic picture of lethargic encephalitis,
and only a few of the encephalitic type of poliomyelitis, with
which some of these milder cases might easily be confused. More-
over, in lethargic encephalitis the onset is usually slow, and death
occurs oftenest in the third week. The similarity of the spinal
fluid findings is of little significance, since in neither case are they
specific. The same may be said in regard to the pathology,
though here there are, as a rule, more points of diflference. As
regards animal inoculation, it is certainly much more difficult to
reproduce the disease in monkeys than is the case in poliomyelitis.
For all these reasons it seems to me most improbable that lethargic
encephalitis is a form of poliomyelitis, though the causative agents
in the 2 diseases may perhaps be closely allied. Certainly the
organisms described by Strauss, Hirshfield and Loewe in cases of
encephalitis closely resemble morphologically the organisms de-
scribed by Noguchi and Flexner in poliomyelitis. Of course both
organisms are so small that it is difficult to satisfactorily study
them.
In regard to the possible relation between influenza and leth-
argic encephalitis, the evidence is as yet entirely circumstantial.
In the first place, attention may be called to the fact brought out
by historical study that on several occasions epidemics of a disease
resembling lethargic encephalitis and influenza have occurred to-
gether. The impression is gained from these studies that ence-
phalitis has not appeared in anything like an epidemic form ex-
cept with influenza. It is certain that in their last appearance,
1889-1890, they occurred simultaneously, and it would seem that
enough time has elapsed since for either to appear by itself if
there were no direct connection between them. Then again, in a
Neal: Lethargic Encephalitis in Children 337
large proportion of cases, occurring in this country at least, the
onset has been preceded by an attack clinically influenza. More-
over, that influenza has a marked effect on the central nervous
system is shown in 2 ways: First, in nearly every instance, the
convalescence from influenza is characterized by a profound
mental depression and nervous exhaustion out of all proportion
to the severity of the disease; secondly, as indicated by the re-
ports of Jeliffe, Menninger, Burr and others, influenza is far
more likely than any other acute infection to be followed by dis-
turbances of the nervous system either psychic or organic. There-
fore, it seems to me probable that there is a definite connection
between influenza and lethargic encephalitis. Just what the rela-
tion is, I am not prepared to state. Since we do not know the
etiological agent of influenza and since the specific cause of ence-
phalitis has not been determined with absolute certainty, though
the work done by Strauss, Hirshfield and Loewe must be given
great \reight, one cannot say that the 2 diseases have the same
origin. The virus causing influenza may make the individual
more susceptible to the causative agent of encephalitis or it may
enhance its virulence, either directly or indirectly by its effect on
organisms associated with influenza.
Treatment: Lumbar puncture seems to afford so much re-
lief in most cases that its repetition is sometimes desirable. I
liave felt that it should be repeated not oftener than every week
or 10 days in most cases and in many cases only a single lumbar
puncture may be indicated. Every effort should be made to keep
the patient comfortable and general eliminative and supportive
measures should be carried out. Symptomatic treatment should
be instituted as the indications arise.
REFERENCES
Barker, Cross and Irwin: Amer. Jour. Med. Sci., CLIX No. 2 & 3. 1920.
Batten & Still: Lancet, May 4, 1918. p. 636.
Netter: Societe med. des Hopitaux, March 22, 1918.
Netter: Bull, de I'Academie de Medecine, May 7, 1918.
Netter: Bull, et mein. Soc. Med. d. hop. de Paris, 43:300 April 4, 1919, July
5, 1919.
Comby: Arch de med. d'enf. 22:259, May, 1919.
Heiman: Amer. Jour. Dis. of Children, August, 1919.
Tilney and Riley: Ncurd. Bull II. no. 3, March, 1919.
McNalty: Report of an Inquiry into an Obscure Disease, Encephalitis Lcthargica,
Local Government Board on Public Health and Medical Subjeects, N. S. 121.
England.
Netter: Bulletin de I'Academie de Medecine. Jan. 6, 1920, 83. No. 1, p. 45.
Neal: Archives of Pediatrics, August, 1916, p. 595.
Strauss, Hirshfield & Loewe: New York Med. Jour., May 3, 1919; Jour. Inf. Div.,
Nov. 1919.
Neal, Abramson, et al.: Archives of Int. Med. Sept.. 1917 and Sept., 1918.
Neal: Int. Clinics, Vol. II, Series 29; Arch. Neur. and Psy., Sept. 1919.
Loewe and Strauss: Jour. A. M. A., May 15, 1920.
Loewe and Strauss: Jour. A. M. A., Oct. 4, 1919.
THE PREDOMINANCE OF SEBORRHEIC ECZEMA IN
EARLY LIFE.*
By Thomas S. Southworth, M.D.,
New York
At the present moment, our views concerning the large group
of cases, formerly classed as eczemas, are undergoing revision.
The similarity of early forms has led to a wider application of
the term dermatitis, especially in the acuter types. There is also
a further tendency to separate those cases in which there is a
demonstrable sensitization of the body to proteins, and to make
a distinction between eczemas of external and internal origin.
The recent trend of pediatric literature appears to be that of
considering the majority of infantile eczemas to be due to dietetic
or other internal causes, and the value of the excellent work done
in this direction, both from an etiological and a therapeutic
standpoint, is fully acknowledged by the writer. Nevertheless
it would appear that the part played by seborrhea has been over-
looked and has failed to receive the recognition which it deserves.
In our pediatric literature and text-books, eczema is described
without any reference to seborrhea or else the latter is dismissed
with brief mention as an entity apart. Kerley mentions certain
intertrigoes which responded to treatment on this basis, but no-
where is there any suggestion that any considerable part of
eczemas in early life have this foundation.
My own observation, on the contrary, has been that predomin-
ance of the cases of eczema presenting themselves in the ordinary
routine of pediatric practice are associated with seborrhea, many
of which are mild and would rarely reach the dermatological
specialist. The prevalence of milder types led me to examine the
severer eczemas with a view to determining the presence of
seborrheic manifestations, and I have not been surprised to find
them frequently present.
The clue to such basic causation is found about the ears as
well as upon the scalp. To trace the seborrheic factor it is neces-
sary to begin with the milder forms upon the face and body whose
identity may be established by finding seborrhea upon the scalp
and in the characteristic location in the folds above and below
the ear. In such cases, if the present condition of the scalp does
* Read before the 31st annual meeting of the American Pediatric Society, held
at Atlantic City, New Jersey, June 16, 17 and 18, 1919.
338 :^
South WORTH : Seborrheic Eczema in Early Life 339
not permit of an exact diagnosis, inquiry will usually elicit the
information that the ''milk crust or cradle cap" persisted un-
usually long and was eliminated with some difficulty.
It is unnecessary to describe seborrhea of the scalp, but the
ear signs may vary from a mere adherent dry exfoliation to a
moist and exuding surface where 2 surfaces are in contact, either
above, where the pinna joins the hairy scalp, or below at the
juncture of the lobe of the ear with the upper part of the neck.
When marked, and with some severe eczemas, the moist surface
may invade considerable portions of the sulcus behind the ear.
There is something significant also in the predilection of such
eczemas for fat babies fed on breast milks rich in fat, and for
bottle babies suffering from disordered digestion caused by a rela-
tively excessive intake of fat. In both groups of infants, we
might expect the fat glands of the skin to be more readily sub-
jected to seborrheic disturbance. Towle and Talbot, in their de-
scription of cases of eczema associated with faulty digestion of fat,
noted "the tendency of the exudative eruption to remain limited to
the regions of the head for an appreciable length of time, even for
months. Many cases, in fact, showed no tendency to spread to
other parts,"
Many must have been struck by this proneness to localization,
for which no explanation has been forthcoming other than that
the eruption tends to appear upon the blushing areas where pre-
sumably there is greater vasomotor activity. Such an explana-
tion is not of much etiological value.
Neither does any internal cause serve to explain this limited
and peculiar localization, since any sensitization to proteins or
toxins, which have gained entrance to the body, should give rise
to generalized manifestations, unless, indeed, there be some local
predisposition to determine its localization.
That such a predisposition exists, when there is visible sebor-
rhea in the neighborhood, would not appear to be a presumptuous
assumption. In nearly every case of marked facial eczema, some
characteristic lesion will be found, if sought for, above or below
the ear. No attention has heretofore been called to this associa-
tion, and it has been generally overlooked. When the auricles are
massively involved in the eczematous process, the characteristic
lesion is, of course, overshadowed.
340 SouTHWORTH : Seborrheic Eczema in Early Life
Some explanation also is due us for the fact that such facial
eczemas tend to involve the hairy scalp rather than the neck and
chest. Here the acceptance of a seborrheic predisposition appears
particularly reasonable.
While McKee has wisely said that the diagnosis of an internal
cause for eczema should not be made until all external causes have
been eliminated, there is no real conflict between the two, since in-
ternal causes undoubtedly predispose the skin to succumb to ex-
ternal factors. Indeed it is, or should be, recognized that the
seborrhea sicca of adults suffers exacerbations with a lowered tone
of the body or faulty assimilation due to excessive intake of cer-
tain types of food.
Although Pussey states that seborrheic dermatitis of itself does
not become of sufficient intensity to produce a weeping dermatitis,
we need not limit its possibilities to the dry scaly type, to which
our understanding of seborrhea is so commonly restricted. He
himself admits the possibility of infantile eczemas of the face and
scalp being manifestations of a seborrheic dermatitis, and says
that seborrhea of the axilla may become macerated, just as I have
above pointed out that in infants it may become moist behind the
ear.
To grasp the possibilities of seborrhea in furnishing a starting
point for eczema, we must realize the ease with which other in-
flammations and infections are engrafted upon a seborrheic neigh-
borhood. I have seen an intense dermatitis produced about the
seborrheic ear of an adult by the application of a solution of car-
bolic acid purchased at a drug store. Here the pre-existing sebor-
rhea undoubtedly constituted the predisposing cause for so violent
a dermatitis.
The recognition of a seborrheic basis for a lesion by no means
excludes the possibility of other micrococcic invasion. On the con-
trary, it is probable that a majority of the more typical facial
eczemas of infancy are associated with a mixed infection.
If further criteria be necessary, such may be found in the re-
calcitrancy of this group of eczemas to bland ointments. Oxide of
zinc ointment, so helpful in other types, is, as a rule, useless by
itself in seborrheic cases of even the simplest form. Something
else is necessary.
In this connection, we note the prevailing use of the term
SouTHWORTH : Seborrheic Eczema in Early Life 341
"stimulating" to denote such remedies as mercury, tar, and resor-
cin, commonly employed in various forms of eczema, including the
seborrheic. This term undoubtedly arose from their efficacy in
some of the chronic, dry and thickened types, where stimulation is
necessary.
Such stimulation would not only be unnecessary but possibly
harmful in the more acute and moist types. Yet, since we find
them distinctly helpful in the moist intertrigoes of seborrheic
origin as well as in the dry forms, it is probable that their efficacy
is due to their germicidal properties. Indeed, it has been my ex-
perience that the bland and soothing ointments of the zinc oxide
sort are unavailing until to them are added ammoniated mercury
or tar, or resorcin to destroy the microorganisms present.
Beyond pointing out this fact, I shall not go further into the
treatment. We all recognize the part played by diet, both in the
causation and the cure of the severe facial eczemas of infancy,,
and that this dietetic factor must be differentiated and corrected
before the larger number will yield to our efforts.
My object is attained if I have called attention to the number of
minor cases of dry seborrheic eczema, and to the frequency with
which scalp and ear manifestations of this condition accompany
the aggravated types of facial eczema in infancy.
807 Madison Avenue.
Calcium by the Vein in Spasmophilia (Pediatria, Naples,
March, 1919). Maggiore injected calcium intravenously in 8
children with tetany, mostly with rachitis. The youngest was 20
months, the oldest 10 years old, and electric tests were applied
just before and at 1,2, 3, 4, 12, 48 and 72 hours thereafter. The
dose was 1, 2, 3 or 5 eg. of calcium chlorid with enough of the
vehicle to make 5 c.c. Each child was treated twice. No incon-
veniences were observed from the intravenous administration,
while the drug promptly reduced the galvanic excitability of the
nerves. This eflfect was most pronounced by the third hour and
began to decline by the twelfth. The responses to the electric
tests became approximately normal, and this effect was equally
apparent with the second application of the drug. — Journal
A. M. A.
SOCIETY REPORT
SECTION ON DISEASES OF CHILDREN
AMERICAN MEDICAL ASSOCIATION*
Fritz B. Talbot, M. D., in the Chair.
Dr. Fritz B. Talbot, of Boston, delivered the chairman's ad-
dress, in which he brought out the fact that many people, both in-
side and outside the medical profession, were giving more and
more thought to the subject of child hygiene. He expressed the
belief that in the future this subject would attract more attention,
and would draw to the solution of its problems greater minds than
it had done in the past. It was pointed out that research into the
cause and nature of disease had assumed an importance which was
not recognized a decade or more ago, and, as a result of the work
. done in the past 10 years, the general practitioner was able to treat
successfully today many diseases that he was formerly unsuccess-
ful in treating. We also had gained a knowledge of normal
physiological processes of the child's body with which v/e could
compare pathological processes, and that had been very important
because we had not had any normal standards with which to com-
pare the pathological. The speaker also emphasized the great im-
petus which preventive pediatrics had received during the war
owing to the campaign and propaganda of Children's Year. At
the International Conference called at Cannes by the Red Cross it
was stated that next to the then present typhus fever epidemic,
child welfare had assumed the place of greatest importance of all
the specialties represented there. The establishment of normal
health in childhood laid the foundation for normal healthy adult
life. This foundation might be laid either by attending the individ-
ual child or by classes in clinics. Dr. Talbot discussed somewhat
in detail the deficiency of pediatric teaching in our medical schools
and particularly the failure to teach infant feeding. The medical
student in order to get his degree had to care for 12 obstetrical
cases. Why should he not care for 20 normal infants, both on
the breast and on the bottle, before he received his degree? In this
* Seventy-first Annual Session held in New Orleans, April 28, 29 and 30, 1920.
Detailed report specially made for Archives of Pediatrics.
342
Section on Diseases of Children 343
way he would obtain actual first hand, knowledge which he never
got from books, and when he went into private practice he would
be familiar with what he would have to do. Many diseases were
becoming extinct. Could not the time used in learning their recog-
nition and treatment be used to better advantage in learning their
prevention ? Every so often it was important that the relative
value of subjects should be balanced anew so that teaching could
be readjusted to the times. At the present time there was the
necessity of understanding social questions that had an influence
on health, home life, etc. The social element of medicine could
well be taught along with the scientific aspect at the bedside at the
same time that clinical medicine was taught. That would bring
the pediatrician back to the place that the general practitioner
formerly held with so much pride. The teacher of pediatrics
should cooperate with those specializing in other subjects and
particularly with the obstetrician with the object of enabling the
student to acquire a knowledge of the theory and practice of an-
tenatal care. It would be ideal if the student could observe the
prenatal care, be present at the delivery and then follow the child
for 5 months after birth in a certain number of cases before receiv-
ing his degree.
THE TREATMENT OF INDIGESTION IN CHILDREN.
Dr. John Lovett Morse, of Boston, presented this paper, in
which he stated that digestion might be disturbed by decreased
powers of digestion or increased work in digestion. Decreased
powers of digestion might be due to diseases other than digestive,
physical or mental overfatigue or digestive diseases. Increased
work might be due to too much digestible food or to indigestible
food. The treatment consisted primarily in relieving diseases
other than digestive and removing causes of overfatigue. The
regulation of intervals between feedings and methods of taking
food was often enough to eflfect a cure. In the more severe
cases there was intolerance for individual food elements, often
with intestinal fermentation from abnormal bacterial activity.
Examination of the stools would reveal which food was badly
borne and caused fermentation. A microscopic inspection was
often sufikient to determine this but should never be depended
upon alone. A microscopic examination should therefore always
344 Section on Diseases of Children
be made. In fat indigestion, the stools were large and semi-
solid, with the odor of butyric acid, and contained a considerable
amount of mucus. Microscopically fat was present, more often as
fatty acids and soap. The stools of sugar indigestion were usual-
ly loose, greenish, containing acetic or lactic acid and often mucus.
In starch indigestion, the stools were usually loose, brownish in
color, contained acetic or lactic acid, sometimes butyric acid and
occasionally mucus. Almost invariably the starch was changed
partially into dextrin. In general the bacteriological examination
was not of great importance in diagnosis for usually no additional
information was obtained. Usually the character of the intestinal
flora could be ascertained from the reaction of the stools. There
was no place for the so-called digestants in the indigestion of in-
fancy for there was probably never an insufficiency of hydro-
chloric acid or pepsin. The treatment consisted in the regulation
of habits and the regulation of the quantity of food to the capacity
of the individual child. If it was necessary to cut down one food
element, this should be made up by substituting another food ele-
ment in a quantity sufficient to make up the required number of
calories. Then the food element that caused the trouble must be
given in a small quantity and increased as fast as would be al-
lowed. The diet list must be written out explicitly and the num-
ber of calories indicated. A list of foods and their caloric values
should also be given to the parents. Dr. Morse said he had
found that almost all parents were sufficiently intelligent to use
these tables. In cases in which there was marked clinical evi-
dence of fermentation, it was difficult to say what proportion of
the disturbance was due to bacteria and what proportion to
chemical processes. It was probable, however, that the original
difficulty was not due to bacteria. The bacteria could not be
changed by giving bacteria by the mouth bufc only by changing
the intestinal contents and this must be done by diet. The only
exception to this was the gas bacillus, the growth of which might
be inhibited by butyric or lactic acid. There was no place for the
use of drugs in the treatment of the indigestion of childhood ex-
cept for the temporary relief of symptoms. Cure could only be
brought about by the regulation of life and diet. Recovery was
a matter of years sometimes, but was usually certain provided
treatment was kept up for a sufficiently long time.
Discussion. — Dr. L. W. Hill, of Boston, said he wished to
Section on Diseases of Children 345
bring out 2 points, as he had been seeing a great many of this
group of cases. First, Dr. Morse got results which were equalled
by very few men in this country not only because he had seen a
great many cases, but primarily because he took infinite pains.
That was the one thing of importance; one must be willing to
work, and to follow the cases closely and to see them often. One
must take as much trouble with these cases as with a difficult
surgical or obstetrical case. Second, with reference to the rela-
tion of bacteria to the food supply, Escherich had brought out the
fact in 1886 that the intestinal bacteria depended upon the food
supply, and by changing the food supply one could change the
bacteria. Two types of bacteria were distinguished, the putrefac-
tive and the fermentative. If the intestine was infected with the
fermentative bacteria, one should withdraw the carbohydrates and
substitute protein food. If the putrefactive bacteria were present,
one should withdraw protein food and substitute carbohydrates.
That was one of the most important things in infant feeding. Dr.
Hill said that if he had to choose one particular principle in infant
feeding that was the one he would adhere to. The intestines
were swarming with bacteria and if the infant was overfed the
bacteria seized the food and decomposed it, so if the baby was
overfed an indigestion with fermentation resulted.
Dr. Clifford G. Grulee, of Chicago, called into question the
statement Dr. Morse had made to the effect that you could not
change the intestinal flora by administering another type of bacilli
by mouth. He said he did not see how they were going to account
for certain phenomena unless one admitted that bacteria intro-
duced by mouth did show growth in the intestines. Typhoid
bacilli were introduced into the mouth and developed and multi-
plied in the intestines. It was also true that some types of dysen-
tery were produced by bacilli introduced by way of the mouth.
His experience was contrary to that of Dr. Morse. It seemed to
him there was no scientific reason why lactic acid bacilli, intro-
duced by the mouth, could not be taken up by the intestines. The
latest results obtained by the use of the duodenal tube showed that
there was a definite relation between the bacteria in the stomach
and duodenum in various types of nutritional disturbances.
Dr. L. T. Le Wald, of New York, said he wished to endorse
what Dr. Morse had said but he wished to supplement it by a
346 Section on Diseases of Children
few remarks on what to do when treatment failed. His work in
the study of children had been along the lines of roentgenological
diagnosis in cases that did not yield to ordinary methods of treat-
ment. He had a little more distinct view of the subject than the
man who saw it only from the standpoint of the pediatrician.
Their observations in obscure conditions in adults 10 years ago
were about what they were in pediatrics today. A more careful
study with the x-ray of cases of indigestion that did not yield to
ordinary methods of treatment frequently showed anatomical
anomalies, or definite mechanical obstructive lesions that could be
dealt with effectively only by knowing the exact nature of the
lesion.
Dr. Isaac A. Abt, of Chicago, agreed with Dr. Morse, and
said he was particularly impressed by the fact that Dr. Morse had
recognized that gastrointestinal disturbances might be produced
by constitutional disturbances. He doubted whether there was
such a thing as indigestion, pure and simple. Indigestion was but
one step in the general metabolic disturbance. The problem was
not as difficult as some had thought. It was a question of finding
what the difficulty was and of diminishing the amount of the food
element that was causing the trouble. So far as placing great
reliance on the examination of the stools, he doubted whether this
was the most important element in the diagnosis. Some times one
found fat when the food was perfectly correct. Personally he had
found little help from the examination of the excreta.
Dr. Morse, in closing, said he did not think Dr. Grulee's
argument was very good when he spoke of typhoid bacilli in the
intestine. Typhoid fever was a systematic infection, and infec-
tious dysentery was a disease of the intestinal walls. By giving
bacteria by the mouth they could not be implanted permanently in
the intestines, unless the food was also changed so that they had
a favorable medium in which to grow. There was a great deal to
be learned from the examination of the stools but if one thought
because he saw a few fat globules or a little starch that the child
had fat or starch indigestion he had better not examine stools
microscopically. One must first take what he saw in the normal
child as a basis for forming a judgment as to what was abnormal.
One thing that furnished more information than any other single
thing was the reaction of the stools.
Section on Diseases of Children 347
THE TREATMENT OF INDIGESTION IN CHILDREN
FROM 6 TO 12 YEARS OF AGE
Dr. Harry M. McClanahan, of Omaha, read this paper
which was based upon the study of 96 school children between
the ages of 6 and 12 years. This was the age at which children
were subjected to the stress of school life, the age at which the
permanent teeth erupted, and the age at which they began to get
a little away from close parental supervision. In 24 of these
cases there was a history of nervousness and 3 of these children
had to be sent away from home before anything could be done for
them. In 27 cases there were distinctly diseased tonsils, and 10
of these were associated with adenoids, sufficiently large to cause
mouth breathing. These were operated on and all received bene-
fit. Ten of the tonsillectomy cases, however, were operated on
without benefit to their general condition. Twenty-five children
in this series had distinctly bad teeth, and one point that had im-
pressed him was that these children would not chew their food
properly because of pain. Three children, who had malocclusion,
were sent to the orthodontist and distinctly improved after treat-
ment. Indigestion in the largest number of these children appeared
to be due to high protein feeding and neglect of fruits, cereals and
leafy vegetables. Those showing obstinate constipation were fluoro-
scoped for the purpose of ascertaining if there were anatomical
defects present. All had the urine examined several times. Dr.
McClanahan recalled that some years ago he had read a paper on
the significance of indican in the urine. All of these children
complaining of indigestion had an excess of indican in the urine.
There were 5 alimentary glycosurias which disappeared under
proper diet. Practically all of these children had some nervous
symptoms, such as increased irritability, restlessness, grinding of
the teeth, etc. Fourteen had enuresis, and 10 of these recovered
under rational treatment. Of the series, 52 were constipated and
5 only suffered from emesis. Seven of the children had intestinal
parasites. In 25 cases, the abdomen was distinctly enlarged. In
those children having epigastric tenderness and pain on pressure,
these symptoms were associated with a distinctly red tongue. In
the treatment qf indigestion in children of this age the most im-
portant factor was the cooperation of the mother. It was his rule
in all cases to write a simple diet, giving what the child could
348 Section on Diseases of Children
have rather than what he could not have. A psychological factor
of importance was the gaining of the good will of the child. If
there was one factor in the treatment that was important it was
that rest and regularity in sleep were of the greatest value in the
physiological restoration of the nervous system. Eleven of the
nervous children were kept out of school. The importance of
regular bathing was also stressed. The essayist said he wished
to confess that he used drugs in the treatment of these cases.
He found that before these children came under his observation
most of them had been drugged to the extreme and he felt that it
was better for the children to have some drug under the direction
of the average physician than to take drugs of the mother's
choosing. The main object of the drug was to get the bowels
regular. He had given paraffin at bed-time and had found nux
vomica valuable given after meals.
Discussion. — Dr. Laurence R. DeBuys, of New Orleans,
said they should all feel greatly indebted to Dr. McClanahan for
bringing up this subject inasmuch as this was a period in the
child's life which frequently did not receive suffilcient attention.
The foundation of the future individual was laid, it was true,
during the first 2 years of life and influences were more important
the nearer they approached his birth time. However, one could
not build a good foundation in infancy and then let the structure
go uncared for later on. At the period Dr. McClanahan had
chosen for discussion one could not watch the child as closely as
in infancy. Indigestion at this period of the child's life had to be
considered from 2 view points — ^that of the child and that of the
child in relation to his surroundings. It had been well said that
some children were bom nervous, some acquired nervousness and
some had nervousness thrust upon them. It was sometimes neces-
sary to take these nervous children away from their homes in
order to get results. The teeth should receive attention and reg-
ularity of habits should be insisted upon. It was important to
ascertain the amount of food that the child could take care of and
then see that he received this food at regular intervals and nothing
between meals. The food should be plain and wholesome, rather
than palatable. Unfortunately, too often the parents allowed a
child to have what he liked rather than what was best for him.
Dr. DeBuys condemned the practice of drugging children and said
Section on Diseases of Children 349
that too often the child at this period of Hfe had already become
dependent upon drugs, especially as regarded bowel movements.
He also condemned the use of glycerine suppositories and soap
in infancy; if it was necessary to use something, water should be
used.
Dr. Henry Dwight Chapin, of New York, observed that
there were many factors that entered into indigestion in childhood,
but that he wished to mention one only and that was to emphasize
the deleterious eflfect of the lack of proper rest. An interesting
experiment had been performed in the case of a few children in
the public schools of New York, They took the undernourished
children in the Public School across the street from the Post
Graduate Hospital and gave them a mid-day meal and then
weighed the children to observe the effect. They all gained in
weight except about a half a dozen. They found that the reason
these children did not gain was because they did not get enough
rest. By having these children sleep an hour every day they
were made to gain in weight. Some children played too hard and
over-exerted themselves and this was an important factor in their
malnutrition and indigestion. A little more rest would cure some
of these cases.
Dr. John Lovett Morse, of Boston, said he wished to cor-
roborate what Dr. McClanahan had said. He did not think they
stood so differently on the question of drugs as Dr. McClanahan
had intimated. In his paper he had said that he had no use for
drugs except for the treatment of symptoms, but they were not
used with the idea of curing the condition. He was glad to hear
that Dr. McClanahan used nux vomica because that was the one
drug he used in cases of this kind. He had found it wise to get
the cooperation of the child rather than of the parents. There was
one form of treatment that might be called psychotherapeutics
which he had taken advantage of. Before examining the child
he saw the mother first and had her tell him what the child had
eaten for the past 2 meals. He then examined the child's abdo-
men and told the child what he had been eating; after that the
child was afraid to disobey orders in regard to his diet for fear
when thp doctor examined him again he would find it out.
Dr. Lydia a. DeVilbiss, of the U. S. P. H. S., said it was
important to make the child understand that this was his own
problem. In their work they had had to make the best of condi-
350 Section on Diseases of Children
tions as they found them and to work with such material as was
at hand. They told the mother about the child and what should
be done ; perhaps she would act and perhaps not. They put the
child on the scales and showed him that he was underweight and
that was a mark against him. The child then immediately be-
came interested and wanted to know why he was underweight
and what he should do to come up to the standard. He was
willing to do almost anything in order to "go over the top" with
the other children. They first corrected physical defects — teeth,
tonsils, adenoids, etc. — and then by gaining the cooperation of the
child they were able to get results.
Dr. George Dow Scott, of New York, emphasized 3 points
with reference to the successful treatment of these children :
1. The neglect of feeding stewed and raw fruits which acted as
a laxative, diuretic and tonic to the stomach and intestines ; 2. The
advantages of semi-solid foods, cereal with enough milk to put
on the cereal, with toast and cooked food ; 3. Bathing was a better
tonic than any drug. A bath 15 minutes before meals was a
tonic to the nervous system and helped digestion.
THE RELATION OF ACQUIRED FOOD DISLIKES OF
CHILDHOOD TO THE ILLS OF MIDDLE LIFE
Dr. C. Hilton Rice, Jr., of Montgomery, Ala., contributed
this paper. He first discussed the phenomena of life and nutri-
tion from the view point of biologic chemistry, showing that a
defect in nutrition might not be immediately perceptible but was
nevertheless often cumulative in its effect. Against this back-
ground the following facts of general observation v.^ere set up :
I. All healthy adults and children, with few exceptions, ate a
variety of foods. 2. Many children, particularly in the second
and third years, left to eat what *hey liked, turned to the carbo-
hydrates and formed dislikes for essential foods, especially inilk,
eggs, fresh meats and green vegetables. 3. Many middle-aged
sufferers from disturbances of metabolism had food dislikes that
dated back to childhood. These individuals had often been
anemic and constipated from childhood. After a careful exclu-
sion of other etiological factors the conclusion seemed war-
ranted that the total or partial absence of essential foods over a
long period of time might account for much disease of middle
Section on Diseases of Children 351
life. This disease was only the maskeid and remote effect of the
gradual, cumulative action of malnutrition on tissues and organs
over long periods of time. Some of the conditions that might be
related to defective nutrition dating from childhood were hyper-
tension, gastric and duodenal ulcer, visceroptosis, etc.
Discussion. — Dr. W. W. Butter worth, of New Orleans, ex-
pressed the opinion that Dr. Rice had presented a new viewpoint
in reference to disturbances of nutrition. Instead of looking
backward as the internist did, he was looking forward, and
while it might be difficult to prove his assertions there was much
in them to commend itself to one's attention. For instance, the
effects of rickets, which were brought about by deficiency in
certain food elements in infancy, were seen later in bone de-
formities, stunted growth, etc. Pellagra might also be cited as a
condition that showed the far-reaching effects of a deficiency in
certain food elements. Many of these conditions, due to food de-
ficiencies, were slow in onset and might have disturbances in
digestion over years and years before finally definite disease
resulted.
Dr. Fritz B. Talbot, of Boston, said he thought we were all
searching back to the cause with the idea of prevention in the
background. It was going to be difficult to prove many things
but it was obvious that many of the diseases of adult life had
their origin in childhood. In regard to digestive disturbances
and food likes and dislikes. Dr. Talbot said he had very little ex-
perience with patients who were on an extremely unbalanced diet.
Education in his community was such that most people came to
know what a good diet was. There was, however, a certain
group of children who had food dislikes and did not get a well
balanced diet. Most of these food dislikes came in certain types
of families in which the history showed asthma, hay fever or
urticaria and they had food idiosyncrasies due to anaphylaxis.
One must bear in mind that food dislikes might be due to anaphy-
laxis.
Dr. May G. Wilson, of Newi York, stated that in 1916 they
had made a study of diet in a larjge group of children and found
that outside of potatoes, tomatoes and lettuce there was a lack of
green vegetables in the diet. In many children, who were in the
lower grades in school, milk was omitted from the diet and tea
352 Section on Diseases of Children
substituted. By the time the children were 10 or 11 years of age,
they began to use condiments, and acquired a dislike for the
essential foods. In a group of 2,000 children, only 5 per cent,
used green vegetables.
Dr. O. M. Gilbert, of Boulder, Colo., said it fell to him to
treat a great deal of tuberculosis and he had observed that a
great many of these patients did not like milk or eggs and never
could take meat. He felt that this defective diet or lack of
dietetic training was an important factor in relation to tubercu-
losis. There were a few cases with anaphylaxis but they were
very rare. With the average individual it was only a matter of
taking time and of gradually adjusting the patient to the proper
diet. Irving Fisher should be credited with having called atten-
tion to the injurious effects of an excess of protein diet after
middle life. But a proper protein diet was essential during the
formative period of life, and lack of a proper protein diet was a
factor in developing not only conditions like pellagra but of
tuberculosis as well.
Dr. Rice, in closing, said the conclusion he had reached on
this subject had come to his mind too recently for him to give
statistics, but that he had observed that in Alabama one of the
commonest diets of children was bread and cane syrup with too
much candy and too many ice cream cones between meals, and
that most of these children did not like green vegetables. From
the point of view of the pediatrist, they were in a position to look
forward and see the effects of the food dislikes of childhood on
the metabolic disturbances of middle life better than the internist
who got only a fragmentary history.
THREE PERTINENT QUESTIONS ON MATERNAL
FEEDING
Dr. William A. Mulherin, of Augusta, Ga., read this paper
in which he considered the following questions: 1. Should our
text books unqualifiedly state that intercurrent pregnancy was an
indication for immediate weaning? 2. Might we not question
the advisability of immediate weaning in'mild typhoid fever? 3.
Should not more positiveness exist in our text books regarding
the advantages of complemental feeding over the method of alter-
nating the breast and the bottle ? In discussing the first question,
Section on Diseases of Children 353
he emphasized the advantage of slow weaning when the baby
reached a certain age and the breast milk was no longer sufficient
to properly nourish it. The evidence seemed to show that un-
complicated pregnancy did no more than weaken the milk and
perhaps diminish the quantity so that there was no need for imme-
diate and abrupt weaning. It seemed advisable that in uncompli-
cated pregnancy weaning should be brought about slowly. With
reference to the question of immediate weaning in typhoid fever,
the writer stated that in severe typhoid fever there could be no
question that immediate weaning was advisable. In mild typhoid
fever, however, with the diagnosis made from the tenth to the
twelfth day of illness, the breast secreting freely, a positive Widal
with the baby's blood, the mother feeling equal to and desirous of
nursing her baby, he felt that it might be permissible to continue
the baby at the breast and to piece out, if necessary, with comple-
mental feeding. He cited 3 cases in which this course was fol-
lowed with no ill effects and with possible advantage to both
mother and child. It was evident that if the child had been nurs-
ing for 10 or 12 days, during which time the mother had typhoid
fever without it being known, the danger of the child contracting
the disease was greater than after the condition had been diag-
nosed and care taken to avoid infection. Again the wear and tear
on the mother of sudden weaning was perhaps greater than any
ill effects of continuing to nurse the infant. There was not much
danger of the mother transmitting typhoid fever to the baby
through the milk and the child could be protected from infection
from other sources. In reference to the third question, he felt
that greater stress should be laid on the advantages of comple-
mental feeding over the method of alternating the. breast and *he
bottle. It was well known that stimulation was an important
factor in increasing and preserving the milk supply and when the
bottle was alternated with the breast the latter received less stimu-
lation and the milk supply decreased. This was an important
matter and should be stressed much more than it had been.
Discussion.-^T)R. John Lovett Morse, of Boston, said that in
regard to weaning in cases of uncomplicated pregnancy, 5t
seemed to him that it was impossible for a woman to properly
nourish 3 people — the infant at the breast, the child in utero and
herself. With regard to complemental feedings. Dr. Morse em-
phasized the fact that he thoroughly believed in breast feeding
354 Section on Diseases of Children
and that he believed a great many more mothers could nurse
their children than did do so, and that such women should be
made to nurse their children. Of course, there was a limit to the
amount of milk the civilized woman of today could produce.
Personally, he had had no luck in re-establishing breast feeding
when it had once been abandoned. There was no question but
that it was better to give a complemental feeding than to alter-
nate the breast and bottle, but one had to take into consideration
the state of society in which the mother lived. If she was at
home it was best to nurse the baby at every feeding time, but if
she was a woman with other cares and duties it might be well
to substitute the bottle at 1 or 2 feedings a day. There was a
certain class of mothers who produced more milk if this plan was
followed than if she attempted to nurse her baby every time.
Dr. James D. Love, of Jacksonville, Fla., stated that in his
experience he had seen uniformly bad results from the sudden
withdrawal of the baby from the breast where the mother had
mild typhoid fever. The danger to the baby was practically nil,
much less than from sudden weaning, and the mother was saved
the discomfort and nervous wear and tear of having the milk
withdrawn artificially; then, too, she had the satisfaction to be
derived from being able to nurse her baby. He believed Dr.
Morse expressed the sentiments of the section in reference to the
advisability of withdrawing the baby from the breast in uncom-
plicated pregnancy and febrile disturbance.
Dr. William Westok, Jr., of Columbia, S. C, pointed out
that in animals and primitive man the fact of pregnancy was not
a reason for the cessation of nursing the offspring. If that was
true, why should one insist upon immediate weaning in more
civilized peoples. He thought the answer must depend upon
how the mother was getting on and how the baby was doing. Per-
sonally he believed that if both were getting along well one
should leave things as they were.
Dr. Mulherin, in closing, said that he would find no fault
with the textbooks if everyone interpreted them as Dr. Morse had
done, but the statement was made that one of the indications for
immediate weaning was the occurrence of pregnancy. Personally
he did not advocate nursing after pregnancy had taken place, but
slow weaning. With regard to the complementary and supple-
Section on Diseases of Children 355
mentary feeding, the point to be made was that the way to in-
crease the milk supply was not to relieve the breast of work but
to make it do more work, as in that way the capacity for work
was increased.
HOW PEDIATRIC TEACHING OF NUTRITION MAY
AFFECT THE NATION'S WELFARE
Dr. Henry Dwight Chapin, of New York, read this paper
in which he dwelt upon the important part that nutrition played
in the development of the child and hence in the future of the
nation. The pediatrician was the one most frequently consulted
with reference to diet and nutrition in childhood, and hence was
in a position to perform an important function in national af-
fairs. That we had not given sufficient attention to the subject of
child welfare in all its aspects had been shown by the results of
the draft examination which revealed the fact that 1 in every 4
of our young men of draft age was physically defective. An
investigation as to the extent of malnutrition among children in
certain New York public schools was made and 20 per cent, of the
school children were found undernourished. This condition was
not limited to the poor but was found among all classes of society.
The question that suggested itself was to what extent these
physical defects and this malnutrition were the result of the teach-
ing of faulty theories of nutrition. The literature of infant feed-
ing had been based upon the theories of pediatric authorities. It
was time to test these theories and see if they were borne out by
experience and facts. Animal experiments had shown that poor
growth and a satisfactory gain in weight might go on together.
Real growth was not simply the storing of water and fat in the
tissues. After emphasizing the importance of breast feeding, Dr.
Chapin pointed out certain errors in their teachings. We had
been taught that the suitability of a food depended upon the
quantity of pr^tein, carbohydrate, fat, etc., that it contained. But
it must be remembered that there were many forms of proteins,
fats, carbohydrates, and mineral substances. Some proteins
would produce growth and some would not, so it was easy to see
how one might go wrong by basing his estimate of food values
simply upon chemical composition. It was quite customary to
add bicarbonate of soda to cows' milk to neutralize the acidity,
but frequently cognizance was not taken of the fact that heat
356 Section on Diseases of Children
rapidly changed the bicarbonate of soda to carbonate. Again the
fat soluble and water soluble vitamines played an important part
in nutrition. Here it had beien shown that the water soluble B.
was rapidly destroyed when bicarbonate of soda was added to the
food, so that this procedure must be eradicated if milk was to
have its full nutritive value. The popular teaching had been that
food values were valuable in proportion to the amount of heat they
produced on combustion, this being expressed in calories, but it
had been shown that much nutrition did not depend upon com-
bustion. There were those who advocated cereals and milk as
the best form of food for infants and children. The cereal was
used not only for its nutritional value but to adapt the cows' milk
to the infant's digestive tract. Milk mixed with cereal formed an
efficient food provided a sufficient amount of antiscorbutic was
added. The practical advantage of such a dietary was demon-
strated on a large scale in Denmark during the war, where the
people were given a ration of bread made of bran wheat and
other cereals, potatoes, cabbage and some milk. This proved a
very satisfactory diet, and practically all our experience in mat-
ters of nutrition showed the efficiency of a diet of cereals and
fresh vegeables. The real value of protein depended upon its
containing the correct kind of amino-acids and not upon whether
it was an animal or a vegetable protein. One of the future
sources of protein food would be the soy bean, which contained
much protein and fat.
Discussion. — Dr. John A. Foote, of Washington, D. C, con-
gratulated Dr. Chapin on having emphasized the need of active
interest on the part of this section in public education, not only
of the physicians, but of the lay public, in the matter of food
values. The United States Public Health Service went a little
further than Dr. Chapin had done in interpreting the statistics of
the draft — Dr. Chapin said that 1 man in 4 was found to have
some defect ; the United States Public Health Service said 1 out
of 3 men had some physical defect. When we remembered the
large number of men who were examined this meant that there
were at least 1,000,000 men of draft age with physical defects
which prevented them from doing the work that they might
otherwise do, one could appreciate what this meant economically.
Possibly the relation of these defects to the diseases of childhood
was not apparent at first. Sir Arthur Newsholme, a short time
Section on Diseases of Children 357
ago, in an address stated that the same condition was found in
England and he beUeved that they had not understood the im-
portance of having the functions of child welfare work vested
in local and national health departments.
Dr. L. W. Hill, of Boston, said it was the impression among
physicians, as well as among the laity, that children needed a
great deal of protein food in order to thrive and grow. He did
not think the standard of 2 grams per kilo was correct. There
were no accurate figures as to the requirements ; what little we
knew had been handed down from book to book and from mouth
to mouth. He cited an instance of 3 husky boys in one family,
ranging in age from 6 to 12 years, all perfectly healthy and
athletic, who had always eaten vegetables and never any animal
food. These boys weighed from 10 to 15 per cent, above the
average of boys of their age and were taller and larger in every
way. He had had the chemist at the hospital work out the nitro-
gen metabolism of these boys and he found that they were receiv-
ing an adequate supply of that element.
THE CLINICAL VALUE OF VEGETABLE OILS IN CER-
TAIN ABNORMAL CONDITIONS OF INFANCY
AND CHILDHOOD
Dr. George Dow Scott, of New York, read this paper in
which 3 classes of cases were studied: 1. Inanition. 2. A sub-
normal period following gastroenteric conditions, such as malnu-
trition, marasmus, etc. 3. Conditions such as secondary broncho-
pneumonias, in lysis or crisis, following acute gastrointestinal
intoxications. The fats were poor in oxygen, rich in carbon and
hydrogen. After describing the physiology of fat digestion. Dr.
Scott pointed out that the primary function of the fats was to fur-
nish heat and that the higher the proportion of carbon and the
lower the amount of oxygen the greater would be the heat pro-
ducing power of foods. The amount of fat needed by an infant
could not be stated in terms of calories but depended upon the
fat tolerance of that individual patient. The fat tolerance varied
greatly in both physiological and pathological conditions. In
health, fat absorption varied between 90 and 98 per cent. The
excessive ingestion of fats retarded the emptying time of the
stomach and delayed normal secretion so that vomiting or regur-
358 Section on Diseases of Children
gitation of the food might occur. Healthy children assimilated
solidified fats, but the sick or delicate child might reject them.
Such patients thrived best on a fluid fat or oil, one whose melting
point was at about the body temperature. Such a fat was easily
emulsified and digested. It was practically immaterial whether
cod liver oil, cotton seed oil, peanut oil, sunflower, soy bean or
other oil was employed so long as the little patient enjoyed it.
His observations, however, inclined him to prefer olive oil, which
was easily digested and absorbed and could be pushed except
during the torrid heat of summer. Rosenberg had pointed out
that olive oil was a strong cholagogue. The percentage of fat in
olive oil was much more constant than that of cream. Olive oil
consisted of stearin, olein and palmatin. A number of cases were
cited to show that, given with malt extract, it served to bridge
over the time when the amount of carbohydrate or protein had to
be limited in various conditions of malnutrition or following acute
illness.
ACRODYNIA
Dr. William Weston, Jr., of Columbia, S. C, said that the
general impression seemed to have been that this was a Southern
disease, or one confined to particular sections of the country. On
the contrary, this disease was found universally and was probably
more frequent in the West than in any other section of the coun-
try. The Surgeon General's Library reported a great paucity of
literature on the subject. There were records of previous out-
breaks in this country. Acrodynia had been confused with ma-
laria, pellagra, and beri-beri. The purpose of this paper was to
ask physicians to be on the lookout for this disease in order that
it might be studied and further information regarding it ob-
tained. Though the etiology of acrodynia was unknown, the fact
that it generally occurred as an epidemic suggested that it was
probably due to some organism. The children attacked by this
disease lost appetite, became listless; some manifested gastro-
intestinal symptoms ; in some there was diminished weight, and
diminished reflexes had been noted. There was often profuse
perspiration and the hands and feet became cold, swollen and
tender, and about one half the cases were painful to the touch.
Photophobia, conjunctivitis, and gingivitis had been observed.
Of his 8 cases, all but 2 had gotten well.
Section on Diseases of Children 359
A point that had impressed him was that he did not feel that
anything he had done for them had been of any benefit except in
1 case in which a balanced diet of vegetables, eggs and milk had
seemed to be beneficial. There were descriptions of an epidemic
of this or a similar disease in Paris, in 1828. Several German
writers had also described the condition under various names.
It had been described, under the name of podalgia, as occurring
in India. It had been observed in barracks among soldiers
where the conditions were the same, yet in one barracks one set
of symptoms would predominate and in another barracks a dif-
ferent set of symptoms would be noted. The first symptom was
pain in the hands and feet with tingling and burning. These
sensations and the pain were aggravated at night and in wet
weather. Many skin manifestations had been described; edema
sometimes occurred, confined to the extremities. The skin der-
matitis was different from that of pellagra and it did not seem to
be due to any specific dietetic error. The prognosis under favor-
able circumstances was fairly good. There was no specific treat-
ment known for the disease at the present time, though diet and
hygiene were important factors in the treatment.
Discussion. — Dr. A. H. Byfield, of Iowa City, la., reported
that during the past few years he had had 14 cases of this disease
and that it was so definite, so clear-cut and so unmistakable that
the nurse had in several instances made the diagnosis before the
doctor saw the child. Even when the characteristic eruption on
the hands was absent, the internes had been able to make the
diagnosis upon the extraordinary picture of wretchedness which
the child presented. One characteristic thing was that the child
preferred to bury his head in the pillow and suffered from
paresthesia of the extremities. There were very few diseases
that aroused one's sympathy to the extent that acrodynia did.
The skin dermatitis was sharply differentiated from that of typical
pellagra. Cases were reported in which the teeth came out. The
speaker had observed no very striking change in the gums. He
had observed a double keratitis and a pulling out and falling out
of the hair. There seemed to be an extensive involvement of the
fifth nerve. Anorexia was sometimes very striking; in some
cases this became so severe that it became necessary to resort to
stomach feeding. The nature of the disease was that of a sensory
360 Section on Diseases of Children
polyneuritis. In the first case he saw he made a diagnosis of
trophoneurosis. In his cases the question of diet had been gone
into as carefully as possible, and a number of the cases were in
breast fed babies. In only 1 or 2 cases did the diet present any-
thing that was open to reproach. All the cases had a leucocytosis ;
some as high as 27,000. Reflexes were sometimes present, some-
times absent. The spinal fluid findings were negative. Pellagra
usually had a history of gastrointestinal disturbances at the on-
set. In practically none of the cases of acrodynia was this
stressed, but rather emphasis was laid upon a respiratory factor.
Jacobi gave a brief description of acrodynia as a complication of
diphtheria and he had been impressed by finding a diphtheroid
organism in the nose, and the diphtheroid organisms might be
distinctly toxic though he knew that they were in disrepute as
etiological agents at the present time. He had been impressed by
the fact that though a scientific diet, containing antiscorbutic
vitamines, was given the paresthesia continued for weeks and
months. He was inclined to think that respiratory infection, if
it was primarily responsible, at least played an important role;
if the diet played some role it must have been a slight one. They
were inclined to think they were dealing with a polyneuritis be-
cause at autopsy it was found that the anterior horns in the
mesial aspect had lost their power to take stain.
Dr. Joseph Goldberger, of Washington, D. C, said he had
been interested in acrodynia because of its possible relation to pel-
lagra, though he had not seen anything that he was prepared to
say was acrodynia. The loss of weight, the edema and the erup-
tion were part of the picture of pellagra. The older descriptions
of acrodynia emphasized certain definite things in respect to the
eruption. In the older descriptions, the eruption was spoken of
as favoring the palmar surfaces of the hands and feet; it was
known that the palmar surfaces of the hands and feet might be
affected in pellagra. Dr. Goldberger said his suspicion would be
that they were dealing with a nutritional condition in some way
allied or related to pellagra. As he believed was the case in pel-
lagra, there was not a distinct specific condition but a combination
of symptoms due to corresponding defects in diet. There was a
range in dietetic defects and therefore a range in the manifesta-
tions of those defects. At a certain point, the defect in the diet
Section on Diseases of Children 361
caused a certain clinical manifestation which might be considered
as coming under acrodynia. Further along one would have pel-
lagra and then edema. If one went still further up the scale he
would find the manifestations of the gastrointestinal tract and
still further along the nervous manifestations. One could not
regard this as settled but he regarded it as a very useful hypo-
thesis and a suggestive line of research. In studying these cases,
it would be extremely valuable if the clinician would record not
only the clinical manifestations but would make careful note of
the diet of the individual for a considerable period of time prior
to the first manifestation of the disease, possibly a quantitative
statement of the ingredients of the diet for a considerable period
of time.
OBSERVATIONS ON THE SALT CONTENT OF BREAST
MILK
Dr. Warren R. Sisson and Dr. W. Dennis, of Boston, pre-
sented this paper which was read by Dr. Dennis. He stated that
the fact was recognized that the standard amounts for fat, carbo-
hydrate, and protein used in the diets of infants had been estab-
lished in large measure. It was also recognized that a large class
of infants fed on so-called rational mixtures might develop in-
testinal disorders. Attention had been attracted to the relative
and absolute proportions of fat, carbohydrate and protein with
absolute disregard to the mineral content of the diet. It was
assumed that the salts being in excess in breast milk had no effect
on nutrition. During the last 5 years relatively simple methods
had been devised for the determination of the mineral constituents
of the blood and it had been a simple matter to adopt these for
the estimation of the salts in milk with a quantity of milk as small
as 10 c.c. About 1 year ago, they started a study of the mineral
constituents of breast milk and of the ordinarily used modifica-
tions of cows' milk with the idea that by a study of this kind it
might be possible to trace the connection between obscure in-
testinal disorders and the mineral content of the milk. About 400
samples of breast milk were taken from the first day to the
eleventh month. They found that during this time the chloride
content was not changed and that the average was about 50 mgs.
to 100 c.c. or 0.5 of a grain to the liter. This was about the aver-
age figure given in the text-books. They felt, however, that
362 Section on Diseases of Children
these averages were of little value because of the very great
variation in the chloride content in different mothers. Samples
of milk were taken at different hours of the day from 6 A. M.
on. These showed the chlorides excreted in a perfectly uniform
way and with little change from day to day. In some mothers,
particularly those of the nervous type, however, tremendous vari-
ations occurred from hour to hour. They might start with 20
mgs., go up to 50 mgs. and then fall back again. In looking up
the histories of the infants in these cases, it was found that
though nursing at their mothers, they were not gaining as they
should. They had also examined a large number of formulas
for bottle fed infants in Boston and found that the ordinary salt
content was about 75 per cent. But this was not the case with
the whey mixtures used in the younger infants. In these whey
mixtures, values up to 200 were frequently found. This sug-
gested the possibility that the high chloride content might be a
factor in the gastrointestinal disturbances so frequent in infants
on whey mixtures.
Discussion. — Dr. Fritz B. Talbot, of Boston, said that when
they were feeding babies on whole milk mixtures and for various
reasons put them on whey, cream and sugar, it was sometimes
noticed that the babies had diarrhea, and they often noticed in
private practice that babies on breast milk had more movements
than they thought these babies should have. This work suggested
that the chlorides were the background of the diarrhea, but it did
not tell why one baby could take chlorides and another could not.
Another point was the clinical observation of Dr. Sisson that
the character of the nervous system of the mother, who had
high chlorides in her milk, was apt to be less stable than that of
the mother whose milk went along the level supposed to be
normal.
CHRONIC NEPHRITIS IN CHILDREN
Dr. Lewis Webb Hill, of Boston, stated that acute nephritis
in children was usually a long drawn out affair and the nephritis
could not be called chronic until the albuminuria had existed for
a year. The chronic nephritis of children differed from that of
adults because in adults we were dealing with a kidney that had
gradually become damaged while in children the kidneys had been
suddenly damaged. In adults there were usually concomitant
Section on Diseases of Children 363
cardiac conditions which were as a rule absent in children. The
paper dealt only with the mild type of chronic nephritis. Ton-
silitis seemed to be the most important etiological factor. They
had never seen a case due to dental trouble though they thought
it might occur. In these mild cases there was usually a small
amount of albumin, casts, and red blood cells. The blood pres-
sure was usually normal or below normal. This form of nephritis
was differentiated from orthostatic albuminuria, where the albu-
minuria was temporary and due to posture, and the urine did not
contain red blood cells and casts. The 2 hour functional test of
Mosenthal was studied and found to Jbe a most practical test in
children. It was found that the normal phthalein for children
was higher than for adults. An excretion below 50 per cent,
meant severe damage to the kidneys. Blood urea examinations
were made and led to the belief that damage to the kidney, in the
mild cases, was not sufficient to cause marked urea retention. In
the treatment of these cases general hygiene was most important.
The lives of these children should be carefully supervised. Plenty
of rest, physical and mental, and plenty of good nourishing food
were essential. The nephritic child might bathe in water 70 de-
grees or over but the surface of the body should not become
chilled. The tonsils and teeth should receive attention. The
tonsils which were the cause in many cases should be removed, if
there was the slightest suspicion that they might be the source of
infection. It was of the utmost importance to guard against acute
infections, since the kidneys were hypersensitive and should not
be called upon to eliminate toxins of any kind. It was a mis-
take to restrict diet too closely. The diet of those children might
include meat and eggs in moderation, a moderate salt intake and
plenty of water. There were 3 prognostic possibilities : First,
the kidney might recover entirely after several years; second, a
severe and fatal chronic nephritis might follow; third, a con-
tracted kidney might result, giving rise to the picture of chronic
interstitial nephritis. We had not seen the third occur. It was
quite possible to recover from this type of chronic nephritis. A
normal phthalein output was not of much value as regarded prog-
nosis, but an abnormal 2 hour test meant a damaged kidney,
though not necessarily a severely damaged one.
Discussion. — Dr. C. W. Wahrer, of Fort Madison, la., said
364 Section on Diseases of Children
that these cases of nephritis in children were usually secondary
infection, following tonsilitis, rheumatism, etc. They were more
frequent in boys than in girls, because boys subjected themselves
to greater exposure. They had been told that diet had a great
deal to do with it, but he would suggest warm clothing. One
should be cautious in the use of drugs in these cases, because an
irritating drug might cause an acute exacerbation of the nephritis
in chronic cases. In regard to the prognosis, his experience was
that it was favorable rather than unfavorable. The majority of
these mild cases usually made a recovery, but they should remain
under the care of a physician and be watched closely for a long
time.
Dr. John Lovett Morse, of Boston, expressed the opinion
that one of the most difficult things in connection with these
cases was to determine where the subacute nephritis ended and
the chronic began. Almost all the cases that started as acute ran
into subacute and chronic, and one did not know what length of
time made the diagnosis. Speaking of the preventative treat-
ment, the vast majority of physicians were satisfied if they suc-
ceeded in getting the urine free from albumin once, but one could
not call a patient well on 1 negative examination. The patient
was not well until the urine was microscopically clear after cen-
trifuging.
Dr. George Dow Scott, of New York, said that at the Wil-
lard Parker Hospital in New York they saw a great many of
these cases following the acute infectious diseases and it had been
observed that the younger the patient the more quickly recovery
took place, so that the prognosis depended to a considerable ex-
tent upon the youth and the early nutrition of the patient. Bath-
ing and fresh air were important.
Dr. Harry M. McClanahan, of Omaha, spoke of the results
of nephritis in childhood upon the adult, and cited cases showing
that some cases apparently made perfect recoveries, while in
others serious conditions developed and proved fatal. He had
never seen acidosis in these cases. He believed it was more likely
to occur in adults with contracted kidneys. He did not believe
that chronic nephritis was always a mild thing in childhood ; they
saw children with severe chronic nephritis just as they saw it in
adults. So long as there was sediment, and red blood cells in the
Section on Diseases of Children 365
urine, one should be very careful in allowing the child to be up
and about.
INFANTILE SPINAL PROGRESSIVE MUSCULAR
ATROPHY— (Werdnig-Hoffm an)
Dr. Edgar J. Huenekens, of Minneapolis, presented this
paper. After reviewing the literature of the Werdnig-Hoflman
and Oppenheim syndromes, he discussed the evidence for and
against their identity. He presented for comparison the differ-
ential diagnosis of Marburg showing that Oppenheim had
termed the condition indicated by his syndrome as amyotonia
congenita and had described it as (1) congenital; (2) usually
single; (3) showing generaHzed hypertonia ; (4) atrophy masked
and not grossly apparent; (5) tendon reflexes absent; (6) stim-
ulated by electricity ; (7) course usually marked by improvement.
The Werdnig-Hoffman description was as follows : ( 1 ) Acquired
in early infancy; (2) usually familial; (3) locaHzed atrophies,
usually beginning in the pelvic region and spreading; (4) atrophy
easily recognized and apparent; (5) tendon reflexes proportional
to atrophies; (6) reaction of degeneration; (7) course of the
disease progressive, the child becoming a mere skeleton at 4 or 5
years of age. The essayist analyzed these syndromes and ex-
pressed the opinion that they were extreme types of the same
disease. He described the anatomico-pathological basis as being
the same in both conditions. He then reported a case of typical
Werdnig-Hoffman type with necropsy findings which supported
the conclusion that, amyatonia congenita and Werdnig-Hoffman
disease were extreme types of one and the same disease. He
called attention to the fact that this was the first necropsy on a
typical case of Werdnig-Hoffman disease in this country.
Discussion. — Dr. Frank C. Neff, of Kansas City, regretted
that Dr. Heuenekens did not read his autopsy findings, but felt
that there was such a variation in the symptomatology that he
could scarcely accept them as the same condition. He thought
the diagnosis had to be based on the autopsy findings.
Dr. John Zahorsky, of St. Louis, thought that between mya-
tonia and Werdnig-Hoffman there was a wide distinction and it
would take a great deal of study on the part of the pathologist to
convince him that they were the same disease. The course of the
diseases was entirely different. The Oppenheim disease was a
366 Section on Diseases of Children
congenital disease in which the baby did not commence to use its
muscles early but gradually developed; he had such a case now
which was gradually approaching normal. Another case had died
not of the disease but of an intercurrent infection, while the
Werdnig-Hoffman cases went from bad to worse and died of
paralytic symptoms and complications.
Dr. Huenekens, in closing, said that his case was a typical
amyotonia congenita in the beginning. The point to be emphasiz-
ed was there was no difference in the pathology between these
diseases. The improvement that seemed to be noted in Oppen-
heim's disease was only temporary ; these patients all died later
just as they did with Werdnig-Hoffman disease.
NEWER IDEAS OF HEART DISEASE APPLIED TO
PEDIATRICS
Dr. Richard S. Eustis, of Boston, reviewed the work of
Lewis, Barringer and Rapporte with reference to the differentia-
tion of functional and organic heart disease as it had been applied
in the army and made a plea for its adoption by the pediatrician in
dealing with cardiac conditions in children. He pointed out that
the systolic murmur should be considered merely as a signal for
a more careful examination of the heart. Systolic murmurs were
of importance in children only where they were due to congenital
heart disease. Many children with poor exercise tolerance fell
into the effort syndrome group. The significance of a low pitched
diastolic rumble, reduplicated second sound, and pre-systolic cres-
cendo were discussed. In certain respects the findings in children
were somewhat different from those found in adults. In adults
the transverse diameter of the heart was one-third to one-half the
internal diameter of the chest. In children this measurement was
not so certain. For this reason slight or doubtful enlargement of
the heart was of little value in diagnosis. Definite enlargement
meant cardiac disease. It was safe to regard as potential cardiacs
those children who had rheumatism or chorea. The determina-
tion of the functional capacity of the heart was of great value. It
should be remembered, however, that exercises carried out under
observation often introduced a nervous element which gave a
wrong impression. Dr. Hill presented an analysis of a series of
52 children to whom the principles employed in cardiac examina-
Section on Diseases of Children 367
tions in the army were applied. In this series were 28 normal
children, while the remainder exhibited various kinds of murmurs
and there were a few suspicious cases. In the series were 19 chil-
dren with systolic murmurs in whom there was no etiological fac-
tor and 15 of these were considered to be normal hearts. The
series was considered too small to warrant conclusions, as definite
information could only be obtained by following these children into
adult life.
Discussion. — Dr. Julius H. Hess, of Chicago, said he believed
it would be a good plan to adopt Dr. Eustis' method by which he
used the exercise tests employed in the army in the study of
cardiac conditions in children. Many children in whom organic
cardiac disease was diagnosed on the basis of a loud systolic mur-
mur were restricted in their lives so that they did not develop
properly and their education was interfered with. It was certainly
desirable to differentiate these children from those having organic
heart disease.
Dr. J. M. DoDSON, of Chicago, suggested that a better term
than normal was range of the normal. There was no such thing
as a normal heart. The student was apt to take as his criterion of
a normal heart the first heart he examined. There were no 2
hearts exactly alike, but slight shades of difference within a nor-
mal range.
Dr. Isaac A. Abt, of Chicago, recalled that 20 to 25 years ago
the German authorities made the statement that there was no such
a thing as a functional murmur in a child under 2 years of age.
Organic murmurs might be both congenital and acquired and
might occur at any age. With reference to diagnosing disease of
the heart, it was well to remember that the heart might be diseased
in any layer — the pericardium, the endocardium or the myocar-
dium. The myocardium was frequently affected after acute in-
fections and there was scarcely an acute infection that did not
leave its mark on the heart muscle.
Dr. Eustis, in closing, said he was glad to hear that there had
been difficulty in distinguishing between functional and organic
cardiac conditions. That was the reason he was so enthusiastic
over this method of determining the condition of the heart by
functional tests. Such tests must be interpreted with caution,
however.
368 Section on Diseases of Children
CIRCULATORY REACTIONS IN NORMAL CHILDREN
AFTER EXERCISE
Dr. May G. Wilson, of New York, stated that exercise was
necessary for the development of the normal child and that it
was important in the child with chronic valvulvar disease, to
decide how much exercise might be allowed in a given case.
The determination of this matter on the basis of clinical symptoms
or subjective statements was open to error, hence an accurate
method of determining exercise tolerance was desirable. It was
well known that the heart reached the limit of its powers
before the skeletal muscles. According to Mackenzie the
functional efficiency of the heart depended upon its reserve
powers. The test applied was based upon the circulatory
reaction to muscular exertion. Heretofore, the reports of the cir-
culatory reaction to exercise in children had been limited to
changes in the pulse rate. Estimation of the blood pressure in
children had not been considered to be of value. The present
study undertook to ascertain whether the circulatory reactions
were similar to those found in adults and whether anything could
be found to act as a guide or check to determine the exercise toler-
ance. Observations were made on 20 normal children between the
ages of 6 and 12 years. Repeated observations were made follow-
ing the termination of the graduated exercise on pulse rate, sys-
tolic blood pressure and clinical symptoms. Over 500 tests were
made representing 150 complete experiments, which consisted in
3 or 4 graded test exercises with 1 or 2 iron dumb-bells varying
from 3 to 10 pounds in weight, swung from the floor to a position
over the head from 10 to 60 times. The blood pressure readings
were made immediately upon the termination of the exercise and
at 2 minute intervals. The effect on pulse rate of increasing
amounts of exercise was noted and the time required to reach
normal. The normal curve of systolic blood pressure immediately
after the termination of moderate exercise was plotted, and varia-
tions in the systolic curve after increasing amounts of exercise
noted. The conclusions reached were that the circulatory reac-
tions to graduated exercises obtained in normal children were
similar to those reported in adults. It was found that there was
a constancy of circulatory reactions immediately following similar
graduated exercises at 2 day intervals over periods of weeks in a
Section on Diseases of Children 369
given individual. It was shown conclusively that exercise toler-
ance could not be determined by the pulse rate. The systolic
blood pressure curve, however, was significant and of great value
in determining exercise tolerance. In over-fatigue, this curve
showed an increased period of rising, a delayed rise or delayed
summit, and a prolonged period of falling. In general the in-
crease in breathlessness, dyspnea and fatigue were directly pro-
portional to the delayed rise and prolonged fall of the systolic
curve. These experiments had also demonstrated that by means
of graduated exercises the exercise tolerance of a child could be
increased.
Discussion. — Dr. Alexander Lambert, of New York, pointed
out that the value of Dr. Wilson's work was that it showed that
the human organism worked as a whole from the beginning of
life to the end, and that which was true of the adult cardiac muscle
was true of that of the child. The test described did not depend
upon reaching any particular number of mm. of mercury, but
upon a definite blood pressure curve, and it taught what was hap-
pening in the myocardium. It taught that it was the energy con-
tent of the heart muscle and not what you heard that was of im-
portance. Many a useful young man had been thrown out of
the army because he had a murmur in the second left pulmonary
space. Such a murmur was found in many children and chiefly in
vigorous young adults. This murmur was caused by the conus
arteriosus rubbing against the chest wall, because the lung was
not big enough to cover the heart and the murmur frequently dis-
appeared when the lung was expanded. By this method, after a
child had had an attack of sepsis or endocarditis, one could judge
whether that individual child could take a certain amount of exer-
cise. Mitral stenosis was more common in girls than in boys be-
cause when the mitral valve was involved a boy was not so easily
controlled and broke open the slight adhesions that formed at the
base of the valve while a girl was afraid of overexerting herself
and the mitral valve closed at its base.
Dr. Maud Loeber, of New Orleans, emphasized that Dr. Wil-
son had given them a definite guide so that they oould know just
what to do in regard to giving children permission to take exer-
cise. This would be of particular value in schools or gymnasiums.
The test used most frequently had been to go by the pulse rate, but
370 Section on Diseases of Children
this work had introduced an entirely new idea and would make
them review the methods they had been using in permitting chil-
dren to enter competitive tests and games.
Dr. William P. St. Lawrence, of New York, stated that Dr.
Wilson had confirmed the work of Barringer, Rapporte and
Lewis. These curves which she had demonstrated were sufficient-
ly accurate for clinical purposes ; however, their interpretation was
still a matter of judgment. Dr. Wilson had studied these curves
in cardiac children and had treated children by graduated exercise
with the methods of Lewis. These she had found of considerable
use within rough limitations. Her precise methods, however,
would be a great addition to the subject.
Dr. Fritz B. Talbot, of Boston, congratulated Dr. Wilson on
her paper, more particularly because it was a study of the normal,
and it was by the study of the normal that pediatrics would be
advanced. Although he had made no actual measurements, he
thought what she said of the child applied also to the infant judg-
ing from certain observations that he had made during metabolic
experiments in infants.
Dr. E. C. Fleischner, of San Francisco, said that the im-
portant feature in all this work was that it was one more point in-
dicating that the main thing in the observation of cardiac cases
was the appearance of the child. He hoped in closing the discus-
sion she would mention the color of these children. As one
watched the cardiac child, he was struck by the fact that frequent-
ly "the effect of exercise was indicated by the color of the child.
Another point was how they would be able to make mothers grad-
uate properly the exercises in normal children. Many mothers
showed no judgment in regulating the amount of exercise of their
children and many young children were unduly fatigued because
the inclination of the nurse rather than the exercise tolerance of
the child was the guide as to the amount of exercise the child
took.
Dr. Wilson, in closing, stated that she was now interested in
exercises for cardiac children and had been impressed by how
much many of these children could do and how little we had ap-
preciated this fact. The curve demonstrated was not exact but
was a check on personal observation. One should observe the
symptoms of overexertion in normal children and then check up on
Section on Diseases of Children 371
his own judgment; then this method would be found to be of
practical value. She had found it a good plan to do this work
with the mothers present, for when they saw the work they were
convinced and were willing to follow directions.
INTUBATION OF THE LARYNX
Dr. Henry J. Cartin, of Johnstown, Pa., reviewed a former
communication reporting 317 cases of intubation in laryngeal diph-
theria. He had now collected additional cases, bringing the num-
ber up to 440 cases. The mortality was 14.5 per cent. He made
a plea for a more careful diagnosis, as he believed that many cases
of so-called croup were cases of laryngeal diphtheria, and urged
the early administration of antitoxin in large doses. He gave
20,000 units as the initial dose. Most of these intubations were
performed in the home, and in homes of the poorer classes where
all facilities were lacking. He formerly had operated only when
stenosis threatened life, but after several losses he had concluded
that it was better to operate early ; he then began to operate when
there was beginning dyspnea. Some of the cases at that time
might have recovered without operation, but he thought it safer
not to take the chance where these children were in homes, and
not under the constant supervision of the doctor or nurse. On
the other hand, no case was too far gone to be deprived of the
chance for life that intubation might offer. He used the O'Dwyer
hard rubber tubes with the child in the dorsal position. After the
operation the string was removed. He used rather large sized
tubes and had not found that they caused paralysis. The tube was
usually removed on the fifth day. In this series of cases there
were no chronic cases and no tracheotomies. Where reintubation
was necessary it was usually within the first 2 hours following the
introduction of the tube. After a detailed analysis of these cases,
Dr. Cartin concluded that the low mortality, 14.5 per cent., was
due to early intubation and large doses of antitoxin.
Discussion. — Dr. Lsaac A. Abt, of Chicago, said he had had
the privilege of hearing Dr. Cartin's former paper in 1917, and at
that time was very much impressed with the work he was doing
and with the success that attended it. This operation was not
being performed as frequently as it formerly was because chil-
dren were receiving antitoxin earlier and there was not so fre-
quent need for it. Dr. Abt called attention to retraction of the in-
372 Section on Diseases of Children
tercostal muscles and retraction at the end of the sternum and up-
per portion of the manubrium as evidence of laryngeal stenosis.
There were of course minor degrees of stenosis in which this pic-
ture might not be so marked. If the patient was in a hospital,
where he could be watched by an interne, one could wait a reason-
able length of time before operating, but where the patients were
distributed over a wide area and more or less inaccessible one
could stretch the indications for intubation. Everybody was not
master of the technic as Dr. Cartin was, and as Dr. Cartin had
suggested intubation was becoming a lost art. The younger men
knew very little about the operation or the technic. He had rarely
intubated with the patient in the recumbent position, having pre-
ferred the vertical position advocated by Dr. Northrup. In using
tubes of large size, it must be remembered that the trauma inflicted
was greater in proportion.
Dr. L. T. Royster, of Norfolk, Va., stated that he had had an
average of about 13 cases requiring intubation every year for the
past 20 years. In every community there should be 1 expert in-
tubator. With proper assistance, an expert should be able to per-
form the operation in 10 seconds and very rarely should he have
to make a second attempt. He also felt that it was better to in-
tubate early, even -unnecessarily, rather than wait until too late.
Many of these children did not die of diphtheria septicemia but of
candiac failure because of the additional work thrown upon the
heart which was compelled to work against a stenosed larynx.
It was well never to take chances with a case of croup unless one
was certain that it was a catarrhal and not a membranous croup.
It was better to do a tracheotomy than to intubate the same patient
8 or 10 times. One should never allow the child to become cyano-
tic before intubating.
Dr. a. J. Scott, of Los Angeles, stated that in their county
hospital service they had 2 or 3 cases of laryngeal diphtheria every
month. The point he wished to bring out was that laryngeal
diphtheria started out like croup and the parents did not pay any
attention to it and neither did the physician. In giving antitoxin
he never gave an initial does of less than 20,000 units when there
was a beginning laryngeal stenosis and he preferred to make the
injection in the vastus externus, high up.
Dr. Solon G. Wilson, of New Orleans, said he had changed
Section on Diseases of Children 373
his opinion many times during 22 years, and one point on which
he had changed his mind was as to the length of time the tube
should remain in place. There were different opinions on this
point in different countries. In France, they left the tube in only
24 to 48 hours. He agreed with Dr. Cartin that 5 days was about
the correct time. Dr. Wilson said he never intubated with the
child in the recumbent position.
OBSERVATIONS ON TUMORS OF THE KIDNEY IN
CHILDREN
Dr. William E. Carter and Dr. Langley Porter, of San
Francisco, classified tumors of the kidney in children as follows :
1. Malignant tumors — sarcoma, adenosarcoma, teratoma, sarco-
carcinoma. 2. Benign solid tumors — lipoma, chondroma, osteo-
ma, fibroma, adenoma. 3. Cysts — congenital cystic kidney, hydro-
nephrosis, pyonephrosis, hydatid cysts. They found the greatest
number of cases of tumor of the kidney in children between the
sixth month and the sixth year of age. In going over the records
of 3 hospitals and their private cases, they had collected 12 cases
of tumor of the kidney in the past 5 years. These all occurred in
children under 7 years of age. There seemed to be nothing in the
histories of the pregnancies and labors to explain them. The most
distinctive physical signs of tumor of the kidney in children were
fullness at the costal vertebral space and at times intermittent
hematuria. Tumor of the kidney might be confused with tuber-
culous peritonitis, but usually fullness at the costal vertebral angle
served to make the differentiation. Other symptoms and signs
were asthenia, pain presence of varicocele, Lucas-Campionnere's
sign, secondary blood changes, and digestive disturbances. Kid-
ney tumors were differentiated from adrenal cystoma by the eye
symptoms. J^requently metastases occurred early and were some-
times observed before the original growth made itself manifest.
The treatment was surgical. The 12 cases were reported in de-
tail.
Discussion. — Dr. L. T. Le Wald, of New York, reported 1
case of kidney tumor in a baby 6 months old in which there was
a hydronephrosis and referred to 2 other cases of cystic kidney in
babies, all 3 of which were operated upon successfully, though the
374 Section on Diseases of Children
impression was given by a urologist and other physicians who ex-
amined them that they were inoperable.
Sir Humphrey Davy Rolleston, of London, expressed his
admiration for this paper which he said showed not only a very
extensive acquaintance with the literature of this subject but a
great deal of personal observation. He then discussed the difficul-
ties surrounding the study of the pathology of tumor kidneys in
children and their classification, referring particularly to the diffi-
culty of determining in some instances whether the tumor was of
embryonal origin, and of drawing the dividing line between sar-
coma and leucemia before the blood changes became marked. He
also spoke of rabdomyosarcoma, which he said had impressed him
as being very rare in children. He had never come across a kid-
ney tumor in a child containing striated tissue. In discussing the
clinical aspects of kidney tumors in children he said that the posi-
tion of the colon, in front or below the kidney, might be of aid in
differentiating between renal and adrenal tumors. In malignant
tumors, producing secondary growths, often the first symptoms
appeared in the eyelids, and eye symptoms pointed to a tumor
arising from the medulla. There was also an interesting group of
tumors arising from the cortex which gave rise to 1 or 2 changes.
There might be a precocious growth of hair or a change in the
muscle tissue with a deposit of fat infarcts, producing the infant
Hercules type. In connection with tumors of the cortex, another
interesting point was that the question had came up whether they
might not arise from bits of adrenal tissue in the kidney cortex,
and if such was the case whether they were not comparable to
tumors arising from the renals.
THE TEMPORARY TEETH: DISORDERS DUE TO
THEIR NEGLECT
Dr. J. RoscoE Snyder, of Birmingham, Ala., declared that
pediodontia was still in its infancy but merited culture and devel-
opment. The care of the child's teeth was a subject that until re-
cently was ignored by the pediatrist and neglected by the dentist.
The dentist was not altogether to blame if he gave more attention
to the apparently more urgent and more lucrative demands for his
services from adults. The majority of dentists had neither the
time nor the inclination to treat temporary teeth. The early care
Section on Diseases of Children 375
of the child's teeth was a matter in which the pediatrist should as-
sume greater responsibility. It had been estimated in New York
that 98 per cent, of all teeth were perfect when they emerged from
the gums but that by the time the children reached the first grade
in school 98 per cent, of them had bad teeth, and one-third had
abscess conditions. Equally bad conditions had been revealed by
the inspection of the mouths of school children elsewhere. Much
time was spent in the preparation of the food supply so that it
should be free from contamination and properly prepared, yet when
it passed through a neglected mouth it might become contaminated
and give rise to gastrointestinal disturbances. In the presence of
an unclean mouth, infection occurred more easily. The premature
loss of the deciduous teeth was the most frequent cause of maloc-
clusion and deformities of the face and jaws. There was great
need in every community of education as to the need of early den-
tal hygiene and prophylaxis. The education of parents in this
matter should not be left to the dentist but was a responsibility
which the physician, and particularly the pediatrician, should as-
sume.
Discussion — Dr. Julius P. Sedgwick^ of Minneapolis, said he
was very glad to hear this paper, for frequently they had cases
which were obscure in diagnosis which were cleared up by
examining the teeth carefully. He cited an instance of 1 child
sent from Oklahoma to Minneapolis to recover from malaria.
This child's teeth were properly cared for and the malaria dis-
appeared. They had in their children's clinic, attached to the
University, dentists who cared for the children's teeth. In their
private clinic they also had a dentist, and they found that many
times he helped to make the diagnosis in obscure cases. As to
the prophylaxis, Dr. Snyder was quite right; children should be
sent to the dentist regularly.
Dr. Isaac A. Abt, of Chicago, called attention to the fact that
most dentists now hesitated to extract the temporary teeth because
if they were removed there was no room left for the eruption of
the permanent teeth, and malocclusions and deformities resulted.
In addition to what had been said of the influence of proper feed-
ing on the teeth, there were other diseases of infancy that had an
effect on the teeth later on. Tetany in infancy might be responsi-
ble for poorly developed teeth, enamel erosions, and lamellar catar-
376 Section on Diseases of Children
act. The question was one which deserved further consideration.
He suggested that some of the men who had the opportunity to
see a number of children should study the relation of malocclu-
sion and other dental conditions in relation to their effect upon
constitutional states, growth, nutrition, development, blood condi-
tions, etc.
Dr. Laurence R. DeBuys, of New Orleans, brought out the
point that the care of the teeth should begin when the first tooth
erupted. Too frequently parents waited for the appearance of
several teeth before they began to use the tooth brush. Another
point that had impressed him was the slightly elevated tempera-
ture found in the mouths of those who had dental caries over a
long period. In such cases the mouth temperature should be dis-
regarded and the rectal temperature employed.
Dr. Fritz B. Talbot, of Boston, said Dr. Abt had spoken of a
case of tetany having poorly developed teeth. The recent work of
Rowland on the blood calcium showed that the blood contained a
diminished amount of calcium during the acute stages of certain
diseases. There was a direct relation between the teeth and diges-
tion, and there was scientific proof that the digestion had a great
deal to do with the teeth.
Dr. E. C. Fleischner, of San Francisco, suggested the axiom,
"Every tooth is either good enough to fill or poor enough to pull."
A carious tooth corresponded to a sequestrum of bone in another
part of the body and should be treated on the same principles as
such a sequestrum would be treated.
THE COAGULATION TIME OF THE BLOOD IN THE
NEW BORN WITH SPECIAL REFERENCE TO
CEREBRAL HEMORRHAGE
Dr. Frederick C. Rodda, of Minneapolis, stated that his in-
terest in this subject had been aroused by autopsy findings. In the
post mortem examination of infants dying of cerebral hemorrhage
over 50 per cent, had been found to follow non-instrumental de-
liveries and many followed normal and easy births. In these cases,
the blood was found slightly or not at all coagulated. He had
also been struck by the fact that cerebral hemorrhage was by far
the most frequent cause of death in the new born. In many cases
at post mortem, no torn veins were found in the cerebrum or
Section on Diseases of Children 377
cerebellum to account for the hemorrhage, and multiple hem-
orrhages were found in portions of the body where it was incon-
ceivable that they could be explained by trauma. Over 25 per
cent, of all infants dying of cerebral hemorrhage showed this pic-
ture of multiple hemorrhages. An analysis of cases reported in
the literature deepened the conclusion that these hemorrhages
were due to factors other than trauma. Further study led to the
conclusion that there was a disturbance in the coagulation time of
the blood in the new born. It was found that the average coagu-
lation time in the new-born was 7 minutes. In icterus, melena,
jaundice, syphilis, and nontraumatic cerebral hemorrhage, the co-
agulation time of the blood was prolbnged. In melena it might be
delayed to 90 minutes. The subcutaneous injection of normal
blood was eflfective in cases in which there was delayed or slow
bleeding. A careful study of the blood and spinal fluid was
made in cerebral hemorrhage. In one case cited it was found
that the average clotting time was 13 minutes; on the first day it
arose to 90 minutes and after transfusion dropped to 1 1 minutes.
Where the blood clot could be localized in the brain, as was some-
times possible, operation was justifiable.
Discussion. — Dr. Isaac A. Abt, of Chicago, said they were ac-
customed to think of cerebral hemorrhage as the result of trauma
and frequently the obstetrician was blamed for damage for which
he was not responsible. Dr. Rodda had brought out the most
frequent cause, and the reasons for it. This contribution to their
knowledge should be helpful in the clinical management of these
cases. It showed the importance of ascertaining the coagulation
time of the blood in babies that showed a tendency to bleed. If
one could detect oozing by estimating the coagulation time of the
blood, extensive hemorrhage into the meninges might be prevent-
ed in many instances. If one recognized that there was slow ooz-
ing into the subdural or subarachnoid space, an injection of blood
might be made into the muscles or a transfusion into the longitud-
inal sinus. Another point of importance was that surgery in some
cases was successful, and when one considered the severity of these
cases, if the seat of the hemorrhage was localized, it was quite
possible that surgical interference was justifiable, if not indicated.
If nothing else was done a decompression to relieve the pressure
on the cortex might be advisable.
Dr. John A. Foote, of Washington, D. C, considered this
378 Section on Diseases of Children
work of Dr. Rodda's of great importance and particularly so when
one took into consideration the influence of infant mortality at
the time of birth on the general infant mortality rate, and the fact
that 50 per cent, of the infant deaths during the first month of life
occurred during the first 2 days of life. The condition described
by Dr. Rodda was found in a large number of cases in routine
autopsies where no symptoms had been present so that a standard
and rapid method for obtaining the coagulation time of the blood
would be very useful. He had found it necessary in some cases
to use thromboplastin and he had used blood transfusion with good
results.
Dr. H. B. Hamilton, of Omaha, Neb., said it had been his
good fortune to see some of Dr. Rodda's work and he felt that it
would be a great aid not only in reducing infant mortality but in
lessening the morbidity, the physical deformities and perhaps the
deformities of mental and moral character that followed a failure
to recognize and treat these cases of cerebral hemorrhage. In
cases associated with intracranial pressure it might be necessary
to resort to extreme measures. If the hemorrhage was localized
he thought it was sometimes justifiable to operate. Some one had
suggested repeated lumbar punctures where the hemorrhage was
localized and the question of opening the cisterna magna had been
discussed. This he felt was rather a formidable procedure, but
possibly even an unsuccessful operation was preferable to the
condition in which some of these children had to live.
Dr. Rodda, in closing, again emphasized the frequency with
which cerebral hemorrhage occurred and the difficulty of explain-
ing it where labor had been normal. Lumbar puncture might give
good results if the bleeding occurred below the infratentorium. In
discussing the possible causes of delayed bleeding, he said it had
been noticed in taking blood for the purpose of estimating the
coagulation time, that if the little clot that formed after the with-
drawal of blood was brushed off fresh bleeding occurred ; it was
possible that after such a small clot had formed in the brain of an
infant crying or vomiting might dislodge the small clot and start
fresh bleeding. Surgery to be effective should be done early and
before it was undertaken a transfusion should be done. If, how-
ever, operation had been delayed for 14 days it was not necessary
to give a transfusion.
Section on Diseases of Children 379
THE ANTISCORBUTIC VALUE OF PROPRIETARY
BABY FOODS.
Dr. Josiah J. Moore, of Chicago, described feeding experi-
ments with white mice and guinea pigs in which various propri-
etary infant foods were employed. The proprietary foods were
divided into 2 groups, namely, those that were supposed to be
complete foods without the admixture of milk, and those to which
cows' milk was added. Certain of these foods were found suffi-
cient for the maintenance of white mice, but were inadequate in
antiscorbutic properties when fed to guinea pigs. Frequently the
animals gained rapidly for a short time but they all developed
scurvy later. The only difference noted between the foods that
were modified with milk and those to which no milk was added
was that scurvy appeared earlier when the latter class of foods
were used but they all eventually succumbed. It was observed
that the foods modified with milk induced more rapid growth
than those not thus modified. It was also found that normal
adult guinea pigs did not develop scurvy on these diets as soon as
did young, growing animals. It might be argued that the findings
in guinea pigs did not form a criterion as to what would happen
in the human infant, for it was known that the guinea pig re-
quired more antiscorbutic food than the infant, but the experi-
ments were suggestive and confirmed the findings of other in-
vestigators as to the need of antiscorbutic food for infants. All
infants receiving proprietary foods, whether or not modified by
the addition of cows' milk, should receive an antiscorbutic.
Discussion. — Dr. Julius H. Hess, of Chicago, said he had had
occasion to follow some of Dr. Moore's work and he regretted
that one part of the work was not sufficiently near completion to
be reported. He had been verifying some of the work done by
Dr. Hess of New York. The work was done on guinea pigs,
though this animal was far from ideal and the results could not
be definitely compared with the results in the human. Unless the
guinea pig was fed considerable roughage it had intestinal stasis
and this had a profound influence on scurvy ; then, too, the guinea
pig was very susceptible to infection. In the foods not contain-
ing milk the shortage was not in one only but in several elements
and unless milk was added they were by no means complete
380 Section on Diseases of Children
foods. Manufacturers knew this and these foods were not put
on the market as complete foods, but most of them while calling
for the addition of milk did not advise the addition of sufficient
milk and did not make provision for an adequate amount of anti-
scorbutic food to guard against the milder forms of scurvy.
Antiscorbutics should be given to infants earlier than most
writers advised, and if a proprietary food was used the child was
susceptible to scurvy much earlier than if cows' milk were fed.
STUDIES OF THE EFFECT OF DIPHTHERIA TOXIN
ON THE HEART
Dr. Hugh McCullough, of St. Louis, said it was a well
recognized fact that during the course of infectious disease in
childhood certain changes in the heart muscles occurred, due to
the action of toxins. Diphtheria toxin acted on highly specialized
tissue in the body, producing parenchymatous degeneration with
secondary interstitial changes. A very important effect was on
the heart muscle. This action was not a local infection, but an
action of toxins on the muscle cells. Occasionally at autopsy
they found a case in which these changes in the heart muscle
could not be demonstrated and yet these children during life had
shown the signs of myocarditis. They felt that in such cases
functional changes must be responsible for the acute cardiac
failure, breathlessness, and cyanosis which was observed. A study
of this question led to the conclusion that the effect of the toxin
might be on the whole heart muscle or on the structures con-
trolling the rate and propagation of the impulse from auricle to
ventricle and through the walls of the ventricles. Experiments
had been carried out on animals to show the effect on the heart
under such conditions and electrocardiographic tracings had been
made. The conductivity might be interferred with at any point
along the path of the impulse, giving rise to auricular flutter,
paroxysmal tachycardia, or ventral fibrillation. The electrocardio-
graphs frequently showed a change in the ventricular complex.
The essayist presented an analysis of a series of 80 cases. Those
cases, in which the muscle alone showed changes, might recover
provided the cardiac reserve was preserved. It seemed that func-
tional changes rather than organic were responsible for some of
Section on Diseases of Children 381
the cardiac conditions seen in diphtheria, and it seemed altogether
probable that these conditions led to chronic cardiac disease sub-
sequently in life.
Discussion. — Dr. Frederick C. Rodda, of Minneapolis, em-
phasized the point that it was the diminution of the cardiac re-
serve that was responsible for the fatal ending in so many of these
cases. He felt that the application of the electrocardiograph to
the study of cardiac disease in children would show a great deal
in the future with relation to heart disease due to other causes
than diphtheria.
INTRAMUSCULAR BLOOD INJECTIONS AS NUTRI-
TIONAL AIDS
Dr. Thomas D. Parke, of Birmingham, Ala., reported 4 cases
of ileocolitis in which nourishment and even water could not be
retained when given by mouth. These cases were treated by
hypodermoclysis and intramuscular injections of citrated blood
administered daily, the average injection being 10 c.c. of blood.
Although these cases were too few to warrant definite statements
he felt that the blood injections had been responsible for tiding
these children over a critical period until feeding by mouth could
be resumed. Where many injections had to be given it was some-
times difficult to find a muscle. He had made injections into the
pectorals, the hamstring muscles and the gastrocnemius. Fifty
c.c. was the largest amount given at 1 injection.
Discussion. — Dr. Fritz B. Talbot, of Boston, said it was well
to bear in mind that there were a great many things that played
a part in the recovery of a child. Among these was the fluid
intake and output of the body. The fluid output in cases of diar-
rhea was extraordinarily great. It was surprising how much
could be lost in 24 hours and if nothing was going into the body
a great deal of tissue was being lost. Great emphasis should be
placed upon giving enough liquid in these cases to maintain the
body.
LOCAL ANESTHESIA IN INFANCY AND CHILDHOOD
Dr. Robert E. Farr, of Minneapolis, presented this contribu-
tion which was illustrated with lantern slides. He said he thought
382 Section on Diseases of Children
it was quite generally known and appreciated that novocaine was
the safest anesthetic known, therefore if one could use novocaine
he would not use a more dangerous drug. It was also known
that many children were in a bad condition following the use of a
general anesthetic and that the anesthetic often decided the issue.
The psychological effect did not play as important a part in local
aesthesia in children as it did in adults. The illustrations showed
how the child could be restrained on an arm table set at right
angles to the operating table.
The child's feet were attached by bandages to the operating
table and the nurse held the arms above the elbow. In this way
children even several years old could be held quite well.
As a rule the child needed restraint only while the
anesthetic was being given. They had been doing many dif-
ferent kinds of operations under anesthesia. Recently they had
been using local anesthesia in operating for harelip and for ab-
dominal operations. The apparatus for giving the local
anesthesia was very simple. They were always prepared to rein-
force the local anesthesia with general anesthesia but it was rarely
necessary to do this. The infiltration was made beneath the skin
and when the reflexes were abolished abdominal operations could
be performed without extrusion of the viscera, and was particu-
larly applicable to operations for hypertrophic pyloric stenosus.
If there was pain, the procedure could not be called anesthesia.
Dr. Farr reported a series of 129 cases of children, operated un-
der local anesthesia, and in only 9 was there any pain, and when
this occurred it was due to an error in technic. The operation for
hypertrophic pyloric stenosis could be done under local anesthesia
in 12, 15 or 18 minutes, and with the danger of a general anes-
thetic eliminated it was possible that borderline cases might come
earlier to operation. The solution used was a 0.6 per cent, to 1
per cent, novocaine in Ringer's solution.
Discussion. — Dr. Martin B. Tinker, of Ithaca, N. Y., ex-
pressed the opinion that local anesthesia in children was a life-
saving procedure. The point to be emphasized was that any
local anesthesia, that was not satisfactory to the patient, was not
local anesthesia. If the child struggled and cried that was not
anesthesia at all It was understood that a general anesthesia
should be given at any time if the local anesthesia was not satis-
Sectibn on Diseases of Children 383
factory. Another advantage in the use of a local anesthesia was
that the surgeon was more likely to handle the tissues gently and
that was even more important in children than in adults. In
hypertrophic pyloric stenosis, Dr. Bevan and other surgeons in
the surgical section had favored the use of local anesthesia, and
thought that a general anesthetic should not be used in these cases.
Still another point in favor of local anesthesia was the loss of
blood was less than with general anesthesia. Local anesthesia
was unquestionably the anesthesia of choice, if the child was not
of the nervous type, but in children from 2 to 7 years of age, who
were nervous, there might be some question whether the shock
from the local anesthesia was not greater than from a general
anesthetic. However, as a rule, the nervous shock was greater
from general than from local anesthesia.
GoNococcus Vulvitis in Little Girls (Pediatria, Naples,
May, 1919, p. 257). S. Maggiore reports seven cases to illustrate
the advantages of treatment of infantile gonococcus vulvovaginitis
with tannic acid in powder form. The secretions in the vulva
and at the opening of the vagina are washed off under a stream
of 1 per twenty thousand solution of potassium permanganate,
without pressure, and the parts are dried with cotton. Then they
are dusted with a thick layer of tannic acid and a small pad of
cotton is applied and held with a bandage. Each time the child
urinates the powder is applied anew. It sticks long to the tissues
and exerts a mild antiseptic action. The results have been very
encouraging in his experience, the most rebellious forms of the
vulvitis soon healing under this treatment. The children were
from 5 to 10 years old and the disease was of one or two weeks'
standing, and recovery was complete in from one to three weeks
at most. This technic requires less manipulations than with fluids.
— Journal A. M. A.
BOOK REVIEW
The Problem of the Nervous Child. By Elida Evans.
Introduction by C. G. Jung, M.D., L.L.D., New York.
Dodd, Mead & Company, 1920.
This interesting little bool< by a lay woman should be read by
all pediatrists and by most physicians. It is written in such an
entertaining style that one learns without being conscious of so
doing, so much so that one puts it down with regret. We, as
physicians, and those of us who are interested in the mental
hygiene of the child and in neuroses in adults, realize that a great
many of the abnormal mental conditions which we encounter owe
their origin to early impressions in childhood. It is equally im-
portant for us as physicians, to realize the vast importance of the
parent's mental attitude toward, and its result on the psychology
of the child. Too little attention has been paid, in the past and
at the present time, to the mental hygiene of the child and
adolescent. Parents have not been enlightened. Too little time
has been spent on teaching the importance of the sexual instinct,
and indeed the physician is usually to blame for this state of
afifairs. In addition, the proper psychological environment and
attitude of many children has not been determined. This wrong
psychological position, which is at the bottom of almost every
neurosis, has, as a rule, been built up during adolescence, and
begun in early childhood as a consequence of incompatible familial
influences. Mrs. Evans in this book more than fully covers the
field. Of particular interest to the reviewer were the chapters
on "The Parent Complex" ; "Child Training" ; "Teaching of
Right and Wrong" ; and "Self and Character." It is a well
printed and well bound book of 300 pages with a very complete
index. Illustrative cases are given for most of the conditions.
It is well worth while.
384
Archives of Pediatrics
JULY, 1920
HAROLD RUCKMAN MIXSELL. A.B.. M.D., Editor
CHARLES ALBERT LANG, M.B.. M.R.CS., Associate Editor
COLLABORATORS :
L. Emmett Holt, M.D New York Fritz B. Talbot, M.D Boston
W. P. NoRTHRUP, M.D New York Maynard Ladd, M.D Boston
Augustus Caill^, M.D New York Charles Hunter Dunn, M.D. .. .Boston
Henry D. Chapin, M.D New York Henry I. Bowditch, M.D Boston
Francis Huber, M.D New York Richard M. Smith, M.D Boston
Henry Koplik, M.D. New York L. R. De Buys, M.D New Orleans
Rowland G. Freeman, M.D. ...New York Robert A. Strong, M.D. ...New Orleans
Walter Lester Carr, M.D... New York S. S. Adams, M.D Washington
C. G. Kerley, M.D New York B. K. Rachford, M.D Cincinnati
L. E. La FfiTRA, M.D New York Henry J. Gerstenberger, M.D. .Cleveland
Royal Storrs Haynes, M.D... New York Borden S. Veeder, M.D St. Louis
Oscar M. Schloss, M.D New York William P. Lucas, M.D... San Francisco
Herbert B. Wilcox, M.D New York R. Langley Porter, M.D..San Francisco
Charles Herrman, M.D New York E. C. Fleischner, M.D....San Francisco
Edwin E. Graham, M.D Philadelphia Frederick W. Schlutz, M.D.Minneapolis
}. P. Crozer Griffith, M.D.Philadelphia Julius P. Sedgwick, M.D. . .Minneapolis
. C. GiTTiNGS, M.D Philadelphia Edmund Cautley, M.D London
A. Graeme Mitchell, M.D. .Philadelphia G. A. Sutherland, M.D London
Charles A. Fife, M.D Philadelphia J. D. Rolleston, M.D London
H. C. Carpenter, M.D Philadelphia J. W. Ballantyne, M.D Edinburgh
Henry F. Helmholz, M.D Chicago Tames Carmichael, M.D Edinburgh
L A. Abt, M.D Chicago John Thomson, M.D Edinburgh
A. D. Blackader, M.D Montreal G. A. Wright, M.D Manchester
PUBLISHED MONTHLY BY E. B. TBEAT & CO., 45 EAST 17tH STBEErT, NEW YOBK.
SOCIETY REPORT
THE AMERICAN PEDIATRIC SOCIETY
THIRTY-SECOND ANNUAL MEETING, HELD AT
HIGHLAND PARK, ILL., MAY 31, JUNE 1 AND 2, 1920.*
The President, Dr. Thomas S. Southworth of New York,
IN the Chair.
SEGREGATION OF PNEUMONIA
Dr. Thomas S. Southworth, of New York, after express-
ing his appreciation of the honor conferred upon him in his
election to the presidency of the American Pediatric Society,
paid a tribute to the memory of Dr. Abraham Jacobi, who had
been twice president of the Society. He said it would have been
Dr. Jacobi's dearest wish, as indeed of every great teacher, that
the torch which he relinquished should be caught up and carried
to still greater heights by younger men. He also recalled the
•Detailed report especially made for Archives of Pediatrics.
385
386 American Pediatric Society
work of Dr. Floyd M. Crandall, who was at one time a member
of the council of the Society, and recommended the appointment
of a committee to frame a fitting memorial to these men.
In speaking of the segregation of pnemnonia, Dr. South-
worth said that more and more attention was being paid to the
prevention of infectious diseases, especially such as bore particu-
larly on the child. Here adequate separation of the sick from
the well was indispensable, and the principle was capable not
only of stricter enforcement, as in rural communities, but of
intelligent extension everywhere into new fields. One of these
was pneumonia, which today was one of the great endemic
plagues of the world, for which less had been accomplished in
the way of limiting its ravages than for any other malady of
like import save pandemic influenza. This was not due to lack
of interest in the problem but rather to its complications, since
the processes as we called pneumonia were several pathologic
entities of diverse etiology, and with somewhat loosely correlated
clinical manifestations. Untiring zeal had been expended to
find a remedy for the pneumonias, but they had not considered
so clearly the possibility of guarding against their inception.
Here the field was a wide one worthy of further patient study.
There was one avenue not properly guarded and that was the
exposure of susceptible individuals in dangerous propinquity to
active cases of the disease.
We had in the pneumonias processes caused by the presence
of microorganisms of recognized pathogenic virulence, yet it had
long been their custom to treat pneumonias in the general wards
of hospitals, and to place about them in the home only the ordi-
nary precautions of the sick room. Segregation of such cases
might have been practiced by thoughtful individuals, but the
idea had not found its way into the general medical conscience
nor been advocated widely in our literature. Evidence of the
infectiousness of pneumonia was not wanting. Whenever it
appeared among children, quarantined for measles, it spread
rapidly with an appaling mortality. He had therefore for years
insisted, when possible, upon the prompt isolation of the first
cases of pneumonia among children having measles with a result-
ing limitation of the number of cases, and had extended segrega-
tion to all the pneumonias.
The real question was not whether the case for the individual
American Pediatric Society 387
infectiousness of the pneumonias was fully proven to the satis-
faction of the most skeptical, but whether we were individually
to assume responsibility for permitting exposure of cases of pneu-
monia which we would not permit to many types of much less
serious illness, the latter having- been declared quarantinable
while the pnemonias thus far had not been. The obligation was
imperative to anticipate the day, not far distant, when the move-
ment to control the scourge of pneumonia might make the re-
tention of such cases in a general ward as repugnant to our
medical sense of propriety as the retention of a case of open
pulmonary tuberculosis.
STUDIES ON BLOOD SUGAR : THE EFFECT OF BLOOD
ON PICRATE SOLUTIONS. A CONSIDERATION
OF THE LIMITATIONS OF THE LEWIS-
BENEDICT TEST.
Dr. David Murray Cowie, and Dr. John Purl Parsons, of
Ann Arbor, reported a series of experiments which tended to
show that blood contained substances other than sugar which
induced a color change in the picrate solution employed in the
modified Lewis-Benedict blood sugar method. Under normal
conditions these substances did not interfere with the established
normal range for this method. Under pathological conditions
several of these substances which showed the most marked in-
fluence were epinephrin, acetone and diacetic acid. Creatinin
might interfere but did so in a less marked degree if we con-
sidered the comparative sensitiveness of the picrate solution to
these substances.
As picrate solution reacted to smaller quantities of acetone
than were normally found in the blood, the question might well
be raised: "Do not the acetone bodies of the blood contribute
to the established normal blood sugar range for the Lewis-
Benedict test?" Still another question might be asked: "As
epinephrin in infinitesimally small quantities induces a color
change in picrate solution, is it not possible that this substance,
when thrown into the general circulation, as is supposed to hap-
pen in emotional states, may induce a so-called hyperglycemia
without mobilizing the glycogen stores of the liver?"
Discussion. — Dr. Oscar M. Schloss, of New York, said it
388 American Pediatric Society
seemed probable that under normal conditions the Lewis-Ben-
edict method was an essentially accurate clinical method, though
it had a moderate error such as was present in any colorimetric
method. He had run a series of observations using the Lewis-
Benedict method and a control series in which the method of
Bertrand was used. It was quite true the Lewis-Benedict method
gave results that were constantly higher, but the difference was
consistent and did not influence the results of observations made
in normal cases. It was quite true, however, that a marked in-
crease in creatinin would influence the results. The relationship
of acetone and adrenalin were quite interesting and should require
careful tests of the accuracy of this method.
EPIDEMIC ENCEPHALITIS LETHARGICA.
Dr. Linnaeus E. LaFetra, of New York, stated that cases
of a disease accompanied by profound somnolence and lethargy
had occurred at various times in sufficient number to have been
regarded as epidemics. It was evident both from the difference
in the lesions and also from the results of animal experimentation
that poliomyelitis and epidemic encephalitis were distinct dis-
eases. He had not found that it followed influenza with suf-
ficient regularity to warrant one in stating that it was caused
by influenza, though influenza might possibly predispose the
patient to infection or increase the virulence of the prevalent
virus.
Loewe stated that he had obtained organisms from the brain,
the spinal fluid, the nasal washings and twice from the blood
of encephalitic patients which he believed were the cause of the
disease. Dr. Loewe and Dr. Strauss had made an exceedingly
careful study and their conclusions were: 1, That the virus of
epidemic encephalitis could be maintained by regular rabbit pas-
sages. That it became a fixed virus, killing the animal on the
fourth, fifth or sixth day, with symptoms of torpor, myoclonia,
meningeal irritation, fleeting epileptiform convulsions, rigidity
and typical lesions. After many passages (7) through this species
of animal it became pathogenic for catarrhine monkeys. 2. The
virus was not cultivatable by the usual methods. 3. It could be
preserved in glycerol. 4. It was a filterable virus. It passed
with facility through Chamberland filters 1 and 3. 5. It could
be inoculated into the rabbit either by the intracerebellar route
American Pediatric Society 389
or by way of the peripheral nerves. . Subcutaneous inoculation
had no effect.
Dr LeFetra said his own cases, 11 in number, had all been
seen at Bellevue Hospital since January 1st. Of the 11 cases,
4 had died. Two of the children were 5 years old, one 7, four
8, three 10, and one 12 years. There was no relationship between
any 2 of the patients and they did not live in close proximity
to each other. In only 2 was there any history of influenza.
The symptoms were varied, but in most instances there was
marked headache accompanied occasionally by dizziness. Vomit-
ing occurred in about one-half of the cases. Pain in the eyes
and cheeks compelling drowsiness was present in most of the
cases. Two children were very wakeful and talkative for a day
or two and then became lethargic. In 1 case, there was sleepless-
ness for 56 hours. When the disease was well under way the
outstanding features were lethargy, general weakness and ptosis
or paralysis of the ocular or facial muscles, with double vision
in several instances. Fever was usually very slight, from 101° to
102°F., and that for only a few days. Weakness of the muscles
of the face gave the mask-like appearance. The muscles of the
extremites had a peculiar wax-like tone and the limbs remained
in the position in which they were placed. Three cases were so
lethargic and weak that they had to be fed by tube; the other 8
could be aroused and answered questions. The response would
come, however, after very long latent periods, so it might be
thought the question was not heard. It was noted that the fatal
cases had higher white cell counts than those that recovered.
The spinal fluid was under little or no increased pressure, and
in some instances was perfectly normal, there being no increase
in the number of cells. In most cases, however, globulin was
present and there was an increase in the number of cells. The
highest number of cells found *was 275 in a fatal case. The
average number ranged from 50 to 100, all of which were mononu-
clears. The fluid was sterile on culture. The chloride of gold test
was negative.
Recovery took place gradually, there being first a return to
consciousness, then a diminution of catatonia and paralysis, and
last of all the asthenia and ptosis disappeared. Two patients
showed serious sequelae, one imbecility and the other spastic
paralysis and mental impairment. Undoubtedly, as with poliom-
390 American Pediatric Society
yelitis, abortive, mild atypical cases of the disease occurred, many
of these probably being unrecognized. The disease had to be
differentiated from tuberculous meningitis, poliomyelitis, cere-
brospinal syphilis, brain tumor and meningism. From tuberculous
meningitis it was differentiated by the high cell count in the latter
and by finding the tubercle bacilli. The course in tuberculous
meningitis was 2 or 3 weeks while in encephalitis lethargica it
was longer. In encephalitis, ptosis and facial palsy appeared
early and did not progress. In differentiating the disease from
poliomyelitis, one must be guided by epidemiology. Poliomyelitis
was more apt to occur late in the summer and in the fall and the
cell counts in the spinal fluid were higher, and there was a larger
percentage of polymorphonuclears. In encephalitis, the cells were
practically all mononuclears. However, that point was not abso-
lutely diagnostic. From cerebrospinal syphilis the disease could
be differentiated by the negative Wassermann and negative gold
chloride tests; from brain tumor, by the absence of choked disc
and changes in the spinal fluid; from meningism, by the absence
of other disease that would cause meningism. Meningism was
likely to give an increased spinal fluid with normal findings. The
mortality of the disease was about the same as that of poliomye-
litis. How great a proportion might later show damage to the
brain it was too soon to state. The treatment, until a specific
serum was produced, was symptomatic.
ACUTE CEREBRO-CEREBELLAR ATAXIA, WITH
REPORTS OF CASES.
Dr. J. P. Crozer Griffith,, of Philadelphia, presented 3 new
cases of encephalitis and a resume of a case previously reported,
all of them pointing to an involvement of the cerebellum as well
as the other parts of the brain. ^ The first case exhibited inco-
ordination, nystagmus, affection of speech, confusion of mind,
increased knee jerks, but no paralysis. This patient made a rapid
and complete recovery. The second case exhibited a staggering
gait, dizziness, incoordination, no nystagmus or affection of
speech. This child showed some incoordination 3^ years later.
The third case had a staggering gait, strabismus, nystagmus,
vertigo, mental backwardness, affection of speech; normal eye-
grounds. A year later the symptoms were still present but im-
American Pediatric Society 391
proved. The fourth case exhibited early symptoms suggesting
encephalitis lethargica. During improvement marked incoordi-
nation and affection of the speech became manifest. Recovery
was very slow. At last report the slow speech still persisted.
The conclusion to be derived from these cases, and from 17
cases previously collected from the literature was that this was
a condition not common but still certainly more frequent than
ordinarily supposed, in which acute hemorrhagic encephalitis
involved the cerebellum, and which might be designated "acute
cerebellar encephalitis." With this disease there were always
combined symptoms indicating an involvement of the large brain
as well, and for these the title cerebro-cerebellar encephalitis or
cerebro — or cerebro-cerebello bulbar encephalitis was to be pre-
ferred. The degree to which the process involved one or another
part of the brain varied with the cases, but in all there was a
combination of the symptoms affecting both regions. The cause
of cerebro-cerebellar encephalitis varied decidedly. In the ma-
jority of cases previously reported, some infectious disease had
preceded the attack. This was true in 2 of the cases reported
in the paper; in the other 2, no such connection could be discov-
ered. The syniptoms were those mentioned in the cases cited.
The prognosis so far as life was concerned seemed good. That
clinical evidence of the disease would not persist was uncertain,
but so far as statistics went it would appear that the disease
would leave no traces in the majority of instances. Lumbar punc-
ture was done in all the cases reported by the writer and was
always negative.
THE SIGNIFICANCE OF XANTHOCHROMIA OF THE
CEREBROSPINAL FLUID, WITH REPORT OF
A CASE IN A PREMATURE INFANT.
Dr. Isaac A. Abt^ of Chicago, said this case was reported
because of the yellow coloration of the spinal and ventricular
fluid. The infant was 37 days old at the time of death and was
of 8 months gestation. Interest also attached to this case because
of the occurrence of bronchopneunionia and pyelitis.
Xanthochromia was found in the complete syndrome of Froin
and in the incomplete syndrome of Nonne. Froin's syndrome
included massive coagulation, while Nonne's syndrome included
392 American Pediatric Society
increased globulins, but not massive coagulation. The importance
of cell increase was mentioned by some and ignored by others.
Considering xanthochromia or yellow color by itself is the
simplest way of elucidating the subject. It was most frequently
found in cases of tumor, inflammation or trauma cutting off part
of the spinal canal. The cul-de-sac so formed usually contained
a yellow fluid which coagulated en masse. The pigment comes
from the blood ultimately. In addition to the process of transu-
dation, which occurred in a cord compression, it was readily seen
that any condition which permitted red blood cells to escape
into the spinal fluid might produce a yellow color when the red
cells had been dissolved and the hemoglobin freed.
The globulins were always increased in a yellow fluid, whether
massive coagulation occurred or not. It might be due to transu-
date in the case of a tumor pressing on the cord; exudate in the
case of a meningeal inflammation, and hemorrhage in cases due
to trauma, inflammations and tumors.
Increased cell count occurred in cases of meningitis and was
also found in cases of tumor and hemorrhage. In the last case,
the presence of red cells usually excluded other conditions, al-
though blood might be present as a concomitant finding in tu-
mors and meningitis.
Pellicle formation was of little importance, was usually found
in meningitis, and had been reported in a case of tumor without
meningitis.
Where the process had been of short duration and where
the compressions have not been sufficient, massive coagulation
might not occur. In fact, many writers stated that Nonne's com-
plete syndrome was merely a precursor of Froin's complete syn-
drome. Some cases of Nonne's syndrome probably never reached
Froin's stage. Similarly, conditions causing hemorrhage might
never give sufficient plasma and fibrin to cause coagulation.
Another class of cases causing a yellow spinal fluid was
that type associated with red cells in the fluid. Many considered
this a separate syndrome, and applied the name erythrochromia
to this condition. It was shown by quotations from the literature
that no hard and fast line could be drawn between yellow fluid
on the basis of the presence of red cells. The other dififerences
which were stated as distinguishing erythrochromia from xantho-
chromia were proved to be not differences at all, because such
American Pediatric Society 393
properties of variability of a single fluid as regards color and
globulin content applied just as much to one as to the other.
The case reported was that of a child brought to the hospital
as a feeding case. About the fourteenth day the temperature rose
to 106°F. and the child was seized with severe convulsions. The
urine showed pyelitis, and, upon examining the lungs, patches
of bronchopneumonia were found. The convulsions, urinary and
pulmonary findings persisted until the end. The anterior fontanel
was tense and bulging. On the thirtieth day, spinal puncture
yielded 4 c.c. of distinctly yellow fluid. The fluid was clear but
the first 2 c.c. yielded a filmy pellicle. The second tube, contain-
ing 2 c.c, did not change. Three days later, the right ventricle
was punctured and 20 c.c. of yellow fluid was removed. In both
specimens of fluid there were red cells, increased globulin, and
increased cell count, most of which were polymorphonuclears.
The child died on the thirty-seventh day and autopsy showed a
fibrinous, hemorrhagic meningitis and encephalitis. There were
sub-pial hemorrhages, marked internal hydrocephalus, sub-acute
pyelitis, and bronchopneumonia.
Two other cases were quoted from the literature in which
ventricular punctures were performed. In one of these, the fluid
was yellow and the condition was due to a tumor of the pineal
gland. In the other, the fluid was colorless, and the yellow color
of the spinal fluid was due to a tuberculosis mass at the foramen
magnum. Previous to this case, the youngest case on record
of xanthochromia of the cerebrospinal fluid occurred in an infant
of 9 months. This case was one illustrating the second type of
xanthochromia. Both the spinal and the ventricular fluids were
yellow and both contained red blood cells. It should be noted
also that the infant was an infant of 8 months gestation, who
lived 37 days, and who also had bronchopneumonia and pyelitis.
NATURE OF THE REDUCING SUBSTANCE IN THE
URINE OF CHILDREN SUFFERING FROM
NUTRITIONAL DISORDERS.
Dr. Oscar M. Schloss, of New York, said that the work of
Langstein and Steinmetz had led them to believe that this reduc-
ing substance was lactose or galactose. Experiments which he
had carried out did not confirm this finding. The only reducing
substance which he had found constantly present in perceptible
394 American Pediatric Society
amounts was glucose. There was usually a non-fermentable
reducing substance similar to that found in normal urine. This
might be lactose, but its amount was too small to identify it with
certainty.
Discussion. — Dr. David Murray Cowie, of Ann Arbor, asked
whether in these cases in which Dr. Schloss did not find a ferment-
ing substance like glucose or lactose, he ran an acetone test?
Dr. Henry Heiman, of New York, asked whether any at-
tempt had been made to exclude glucose and then to test for
pentose and galactose.
Dr. Schloss, replying to Dr. Cowie, said the acetone and
the creatinin would of course be present in the non-fermentable
fraction. Both substances were excluded, the acetone by boiling
the urine and the creatinin by first precipitating with mercuric
nitrate solution. If pentose was present, it could only be present
in the non-fermentable fraction. The proportion was so small
it was difficult to determine its presence with any degree of cer-
tainty,
BODILY MECHANICS: ITS RELATION TO CYCLIC
VOMITING AND OTHER OBSCURE
INTESTINAL CONDITIONS.
Dr. Fritz B. Talbot and Dr. Lloyd T. Brown, of Boston,
stated that faulty bodily mechanics was responsible for a great
loss of efficiency among adults during the war. Many men broke
down in France under the strain of training and war. The large
numbers could not be sent home and were therefore given special
physical training. This brought back 80 per cent, to full physi-
cal efficiency. There was a great shortage of man power in
England and it was found that about one-sixth of the men were
physically unfit. The lack of proper education during the grow-
ing and formative periods of these men's lives not only cost
the British Government a great deal of money but also much
anxiety as to how to obtain the necessary amount of man power.
Poor bodily mechanics were more easily prevented and cor-
rected in childhood than adult life and time spent on training
at this age brought more far reaching results than the same time
spent on adults. There were 3 abnormal conditions which came
in childhood with poor bodily mechanics that were so frequently
relieved by correcting the posture that posture must be the prin-
ALUMNI ASSOCIAXrON,
COLLEGE OF PHYSICIANS A,^0i;UKGE0N8
COLUMBIA UNIVE?<srrv
American Pediatric <^g^^ YORK ^^^
cipal cause, or the principal contributing cause of these condi-
tions, granting- that all other causes were ruled out. Correcting
improper posture often corrected chronic constipation, hastened
the cure of recurrent vomiting, and the cure of certain types of
attacks of acute abdominal pain in children.
Discussion. — Dr. Charles Gilmore Kerley, of New York,
asked Dr. Talbot if he had made an x-ray study of the intestinal
tract of any of these children. He had been studying along the
same line and had found practically the same things true except
that he had always attributed the faulty posture and distension of
the abdomen primarily to a defect in the intestinal tract. In these
cases one almost invariably found an elongated sigmoid. As-
sociated with the elongated sigmoid and faulty posture one found
all sorts of intestinal disturbances. It was remarkable what an
abdominal support would do for these cases. It seemed to him
that it was the faulty structural conditions rather than faulty
mechanics that was the primary cause of the trouble.
Dr. Talbot, in closing the discussion, said they had had
x-rays of the intestinal tract taken in most cases and had found
a number with elongated colons. It had been shown that in
some cases, if the child was lying down, the x-ray showed almost
nothing, but if the child stood up there would be a great deal
of ptosis. The same individual might assume both a good posture
and a poor one, and it might happen that the transverse colon
was 5 inches higher during good posture than when the poor
posture was assumed. There was no question but that there
was a great variability in the intestinal tract in different indi-
viduals. The most important thing in these cases was to keep
the child in one's own hands and guide the treatment. The next
most important thing was to prevent fatigue. Fatigue caused a
poor posture and poor posture caused fatigue. The belt alone
did not do everything. With the best there must be proper
curative exercises, and these latter were a very essential part
of the treatment.
A BRIEF CASE REPORT ON AN EPIDEMIC OF
HEMORRHAGIC DIARRHEA DUE TO THE
STREPTOCOCCUS MUCOSUS.
Dr. a. D. Blackader, of Montreal, said he was summoned
to Waterloo, 60 miles southeast of Montreal, because of an epi-
396 American Pediatric Society
demic of diarrhea. The first case occurred on March 22, 5 on
the following day, and since then the number had increased to
65 in the town itself and there were other- cases within a short
radius. Adults composed about one-fourth of the entire num-
ber. The larger proportion, however, were children under the
age of 6 years. The attack began abruptly with high fever,
nervous symptoms, vomiting, and diarrhea set in early. Mucus
and blood appeared in the stools and the amount increased rapid-
ly as the stools became more frequent, and in the severe cases
seemed to form almost all of the stool. Blood was a prominent
feature in the stools in 60 per cent, of the cases. The attack
lasted from a few days to 12 to 14 or even to 21 days. The tem-
perature in the severe cases went as high as 106° F., while in the
milder cases it was comparatively low, 100° or 102° F. In a
few cases, there was no rise above normal. Notwithstanding
the severity of the cases no deaths occurred. Examination of the
stools in one case showed large numbers of chains of strepto-
coccus encapsulatus, and about an equal number of colon bacilli.
There were very few other bacteria. There were no organisms
of any of the types of bacillus dysenteriae. In a second case
examined, there were large numbers of streptococcus mucosus. It
was unfortunate that bacteriological examination of the stools
was not carried out in a larger number of these cases as he had
hoped it would be.
In searching for the origin of this epidemic an inspection
was made of the milk supply, but a careful study of the situation
seemed to eliminate the milk as a source of infection. The water
supply came from springs and several of these were thought to be
insufficiently protected against contamination. The epidemic
occurred after a few days of pronounced warm weather when
the snows melted rapidly on a still frozen soil. The presence
of such large numbers of streptococcus mucosus, associated with
other streptococci and of equal numbers of colon bacilli, and the
absence of any bacillus dysenteriae indicated that the streptococcus
must be regarded as the chief organism in the production of the
epidemic.
PHLYCTENULAR OPHTHALMIA AND ITS RELATION
TO TUBERCULOSIS.
Dr. Border S. Veeder and Dr. T. C. Hempelmann, of St.
American Pediatric Society 397
Louis, presented this study which was read by Dr. Hempelmann.
He stated that there was a widespread impression among ped-
iatricians that phlyctenular ophthalmia was closely associated
in some way with tuberculosis, but many ophthalmologists were
as yet unwilling to concede this relationship. In an effort to
gather additional clinical evidence on this point, 196 children
with phlyctenular disease were subjected to a careful study to
determine the possible presence or absence of tuberculous infec-
tion. The study revealed an intimate association between the 2
diseases. Skin tuberculin tests were positive in over 92 per cent,
of the cases. The results of the complement fixation test for
tuberculosis were strikingly similar to those obtained in cases
of proved tuberculosis. Tuberculous lesions involving other or-
gans than the eye were definitely demonstrable in over half, and
seemed probable in almost two-thirds of the cases. Children
observed over periods of 1 year or more showed an even greater
proportion of tuberculous lesions, more than four-fifths of this
series giving such evidence. Cough, malnutrition and history of
exposure to other cases of tuberculosis were frequent. No other
points were brought up in the study nvhich would seem to have
a bearing on the etiology.
A STUDY OF PNEUMONIA IN INFANTS AND
CHILDREN DURING THE RECENT EPIDEMICS.
Dr. Henry Heiman, of New York, presented an analysis of
336 cases of pneumonia admitted to the pediatric service of Mt.
Sinai Hospital during the pandemic of influenza. Not all of these
cases were influenza pneumonias. There were 288 bronchial pneu-
monias and 48 lobar. The mortality was 16.6 per cent. With
the exception of the 2 to 5 year period the mortality varied in-
versely as to age. A variety of organisms were found in the
sputum, including the influenza bacilli, pneumococci, strepto-
cocci, staphylococci, but none in sufficient predominance to justify
conclusions.
The x-ray was found to be of valuable assistance in the diag-
nosis of both types of pneumonia. The most frequent complication
was otitis media, which occurred in 75 of the 336 cases. Empyema
developed in 17 cases". When this complication occurred, he ad-
398 American Pediatric Society
vised against early operation before the acute stage of the pneu-
monia process had subsided.
Of prime importance in the treatment of pneumonia in chil-
dren were hygienic care, and efficient nursing, a bright sunny
room and an abundance of fresh air, quiet surroundings and
close supervision. Vigilance should be exercised to protect
against infection of the eyes, skin and mouth.' A cleansing bath
should be given each morning as a routine measure. While
fresh air was very necessary, the author did not favor the cold
air treatment. It was important that the digestive tract should
receive the closest attention. Milk of magnesia might be given
at night. Aromatic spirits of ammonia might be given. For the
moderately severe cases, with high temperature, hydrotherapy
might be employed in the form of warm packs. In toxic cases,
atropin and adrenalin might be given. The promiscuous use of
dry cupping was to be condemned. It might be regarded as a
demonstration of spectacular therapeutics of no real value. Dr.
Heiman did not recommend the general use of digitalis in chil-
dren since as a rule the pulse was not lowered or the blood
pressure raised by this agent. It was to be hoped that there
would be a further differentiation of types of pneumonia of in-
fants and children with the hope of securing specific therapy.
Discussion. — Dr. J. P. Crozer Griffith, of Philadelphia,
spoke of the difference in different epidemics in different years
and in different localities. During 1918 and 1919, in the in-
fluenza epidemic which struck them with unusual severity, there
was a great deal of pneumonia; but everybody was struck by
the fact that the number of children suffering from it was small
as compared with the number of adults, and that the disease
in them was not nearly as severe. In the last epidemic of in-
fluenza in 1919 and 1920, which was much less severe, he had
been impressed with the large number of cases of pneumonia
occurring in children as well as by the large percentage which
died. This was true both in the wards of the Children's Hos-
pital and in cases seen in consultation in private practice. There
was a marked absence of leucocytosis in all of the cases of
pneumonia, and the germ most often found was a hemolytic strep-
tococcus. They had noted, too, that it was extremely common
to have empyema develop and that it came, on very insidiously.
Empyema was, indeed, so often present that in cases which ordi-
American Pediatric Society 399
narily would have been diagnosed as free from this, puncture
was done as a precautionary measure, and repeatedly such cases
would show fluid.
As to when operation should be done, this was perhaps a
surgical matter, yet the question as to whether the child was
over its pneumonia was one often put to them, and which re-
peatedly they had been unable to answer. The cases in the past
winter had not shown the usual drop of temperature with sub-
sequent rise, but had developed empyema while the pneumonia
was still present.
Dr. Heiman^ in closing the discussion, said it had not been
his purpose to give a formula for the treatment of pneumonia.
He had simply attempted to generalize, and had suggested rem-
edies that while they might do no good would do no harm. With
reference to the high mortality in hospital cases, it must be
remembered that there were different strains of organisms, and
with some the mortality was higher than with others, and again
many of the children that were brought to the hospitals were
of low resistance, and consequently the mortality was high. An-
other reason results were better in private practice was that the
cases were treated earlier. Dr. Heiman said he was in favor of
fresh air but not cold air and fresh air contained just as much
oxygen as cold air. In the application of hydrotherapeutics he
never used a cold sponge, and if cold water was not used the
child's fear could soon be overcome. He agreed with Dr. Smith
as to the advantage of using codein.
FURTHER PROGRESS IN THE STUDY OF THE
RELATIVE EFFICIENCY OF THE DIFFERENT
MERCURIAL PREPARATIONS IN THE TREAT-
MENT OF CONGENITAL SYPHILIS IN
INFANTS AND CHILDREN, AS DE-
TERMINED BY A QUANTITATIVE
ANALYSIS OF THE MERCURY
ELIMINATION IN THE
URINE.
Dr. Walter R. Ramsey and Dr. O. A. Groebner, of Min-
neapolis, presented this study which was read by Dr. Ramsey.
He declared that the treatment of syphilis with the different
400 American Pediatric Society
mercurial preparations was still a haphazard affair, the rule be-
ing to give as much mercury as the patient would tolerate with-
out salivation or diarrhea. Assuming that the amount of mercury '
eliminated in the urine during a given time would give a fair
index of the amount in the circulation. Dr. Ramsey and Dr.
Ziegler made some experiments, a report of which was read
before this society in 1918. In these experiments it was demon-
strated that mercury whether given by inunction, by mouth or
by hypodermic injection was eliminated in the urine in ap-
preciable amounts. Where only one dose was given by any
of these methods mercury continued to be eliminated in the
urine for a variable time and in one case as long as 10 days.
In this new series of experiments, they had sought to deter-
mine with some degree of accuracy the amount and rapidity
of absorption and elimination of the common mercurial prepara-
tions in common use as determined by quantitative estimates of
the amounts eliminated in the urine. The method was the same
as that employed in the previous experiments. It was observed
that where 50 per cent, mercurial ointments were used the elimi-
nation began soon after administration, the maximum elimina-
tion occurring during the following 3 days, the elimination being
fairly complete within 5 days. With 33yi per cent, mercurial
ointment, even when double the quantity was used, the elimination
did not begin in appreciable amounts until the second day after
inunction and then in much less quatities than when the 50 per
cent, ointment was given. When the mercurial ointment was
simply used by smearing on the skin, without rubbing, the
amount eliminated was much less than when used as an inunc-
tion. In the case of calomel ointment, it would be seeh that the
elimination was delayed and the total quantity eliminated was
much less than with the mercurial ointment although two grams
were used for each inunction. With the mercurial salicylate in oil
used hypodermically, it would be seen that the maximum elimina-
tion was within the first 24 hours, smaller quantities continuing
to be eliminated for 6 or 7 days. The mercuric chloride solutions
used hypodermically continued to be eliminated in amounts not
sufficient to be measured for 6 or 7 days. In 1 case there was
an appreciable amount of protein in the urine following its use,
a point which was observed in the last publication. Calomel and
gray powder by mouth were apparently not absorbed to any
American Pediatric Society 401
great extent, the calomel being absorbed to a much greater
degree than the gray powder. It did not seem to make any
difference whether the calomel v/as given in one or divided doses,
the elimination was the same.
The practical deductions which might be drawn from this
series of experiments were therefore as follows: 1. Mercurial
ointment 50 per cent, was to be preferred to the less concentrated
preparations and should be repeated not more often than twice
weekly instead of daily. 2. Calomel ointment was absorbed but
less rapidly and to a less extent than mercurial ointment and
should therefore be given in greater concentration twice weekly.
3. The salicylate of mercury in oil should be given hypodermically
twice weekly instead of once. 4. The mercury chloride by
hypodermic injection, although the dose was very small, con-
tinued to be eliminated for several days, but owing to the fact
that its use was frequently followed by the appearance of protein
in the urine should exclude it from the treatment of syphilis. 5.
Calomel by the mouth was absorbed in small amounts and con-
tinued to be eliminated for a considerable time so that it was
probable that it would be sufficient to give it at intervals of several
days without producing diarrheas. 6. Gray powder was ab-
sorbed to a small degree and eliminated rapidly so that fairly
large doses repeated daily would probably be necessary to main-
tain mercury in the circulation. Experiments were being con-
tinued to determine, if possible, whether the clinical results would
bear out the observations made in this paper. In one case of
congenital syphilis treated by inunctions, and not repeated oftener
than once weekly, the clinical progress was apparently not less
satisfactory than in cases in which daily inunctions were given.
A STUDY OF THE INCIDENCE OF HEREDITARY
SYPHILIS.
Dr. p. G. Jeans and Dr. J. V. Cooke, of St. Louis, made this
study aided by a grant from the U. S. Interdepartmental Social
Hygiene Board. The method used was the histological examina-
tion of a series of placentas, together with a Wassermann reac-
tion on the fetal blood collected from the umbilical cord at birth.
In order to determine the reliability of such a method it was
necessary to secure additional Wasserman reactions on the mother.
402 American Pediatric Society
and on the infant, after 2 months, in as many cases as possible.
It had been shown that there was a high percentage of agree-
ment between the resuhs of the Wassermann reaction on the
maternal blood and histological evidence of syphilis in the pla-
centa. The necropsy findings in still-born infants likewise corre-
sponded closely with the placental histology in so far as syphilis
was concerned. The writers had hoped therefore that a similar
close agreement could be demonstrated between the placental his-
tology and fetal blood Wassermann on the one hand, and the liv-
ing infant on the other, in which case the incidence of hereditary
syphilis in the middle and upper classes could be estimated by
examination of the placenta and cord blood. Their material col-
lected from several sources included about one-fifth of the chil-
dren born in St. Louis over a period of months, almost equally
divided between charity and private patients. The results pre-
sented were based on data thus far collected from the first thou-
sand cases. Up to the present time they had examined 129 infants
at 2 or more months of age. Of these, 10 per cent, presented
undoubted evidence of syphilis, and the remainder were just as
evidently non-syphilitic. Classification of this group, according
to race, showed an incidence of 15.8 per cent, among negroes
and 5.5 per cent, among whites. The histological examination
of the placenta as to the presence or absence of syphilitic changes
corresponded to the established diagnosis in 95.5 per cent, of
the cases. The lack of correspondence consisted entirely in
finding no syphilitic changes in the placenta in cases in which
the infant had syphilis. In every instance in which the placenta
was noted as showing syphilitic changes, the infant was found
later to have syphilis. In this group of cases, in which the diag-
nosis was established, the Wassermann reaction on the placental
cord blood corresponded to the diagnosis in the infant in 96.5
per cent. Here also the discrepancies were entirely due to finding
of a negative Wassermann reaction in the fetal blood in instances
in which the infant was syphilitic. In every instance in which
the fetal blood gave a positive Wassermann reaction, the in-
fant was later found to have syphilis. Of the 1000 cases,
574 were of the dispensary or poorer class, and in this group
there was an estimated incidence of syphilis in 9.6 per cent.
Classified according to race the incidence among negroes was
14.4 per cent, and among the whites 5.8 per cent. The observa-
American Pediatric Society 403
tions tend to confirm the reliability of the method of estima-
tion and establish the justification of applying either or both
methods of estimation. Among privatie patients, able to pay a
physician's fee, and private room rates in a hospital, the esti-
mated incidence, based on examination of placentas, was 1.4
per cent. Including the doubtful cases, the incidence was 1.8
per cent. Estimating the incidence from the Wassermann reac-
tion on the cord blood, the incidence was found to be 1.6 per cent.,
again showing the close agreement between the two methods.
In some instances, in which the infant had syphilis, the maternal
Wassermann reaction alone was positive, in others the placenta
alone. Therefore, in order to give a clean bill of health to an
infant at birth, it was necessary to have all 3 examinations nega-
tive that was, maternal Wassermann reaction, placenta, and cord
blood and, even then there might be some uncertainty. The fact
that the treatment of the mother during pregnancy will result
in a non-syphilitic child had been proved by other observations.
In this series this observation had been confirmed.
There was an incidence of hereditary syphilis of 5.5 per cent,
among the poor of the white race, 16 per cent, among the ne-
groes and 10 per cent, among the whole group of dispensary
cases. The incidence among the combined middle and upper
social classes was in the neighborhood of 1.5 per cent. The total
incidence in the whole series was 6 per cent. It was their feeling
that the whole group fairly represented a cross section of the
population of St. Louis, and, if such was the case, the incidence
of hereditary syphilis at the time of birth was 6 per cent. When
syphilitic changes were present in the placenta, the infant was
syphilitic even though the Wassermann reaction was negative
on the fetal blood, and vice versa, the infant had syphilis if the
cord blood showed a positive Wassermann even though the
placenta appeared normal. The infant might be syphilitic if both
placenta and cord blood were negative. A syphilitic child might
be bom to a woman with a negative Wassermann, and a mother
with untreated syphilis and a strongly positive Wassermann
reaction might have a healthy child.
Discussion. — Dr. H. J. Gerstenberger^ of Cleveland, said
that in going over their records of 20,000 patients, treated since
1906, they had found an incidence of syphilis of 14 per cent. ;
the highest percentage of syphilitics was found among poor
404 American Pediatric Society
whites of American ancestry, the next highest among negroes,
the Italians, and the fewest among the Jews. During the last 6
years, they had checked up their clinical diagnosis with the Was-
sermann test and found very little difference in the incidence as
determined clinically alone and since the Wassermann test had
been employed. Dr. Gerstenberger recalled one instance in which
a woman came with twins 8 weeks old, one of which showed skin
symptoms of syphilis while the other was perfectly normal. The
Wassermanns corresponded with the clinical picture. Both chil-
dren were alive and the one that had a negative reaction at that
time still had a negative reaction, while the other with the posi-
tive reaction was still positive.
Dr. Henry Heiman, of New York, asked Dr. Jeans whether
he had had any experience with cases of congenital lues sub-
jected to treatment and then a second Wassermann test made.
Some had reported that once a Wassermann positive always
a Wassermann positive.
Dr. Langley Porter, of San Francisco, said that in a small
series of cases tested at the Sloane Maternity they found that
unless the blood was heated there was a great deal of difficulty
with the anti-complementary properties of the cord blood. They
had been able to get data on 118 mothers and babies. They found
that 63^ per cent, were luetic taken routinely from the Sloane
Maternity without any knowledge of the Wassermann reactions.
With one exception, in the luetic cases, the placenta showed
changes both grossly and microscopically.
Dr. Jeans said any statistics based on clinical examination
alone gave a lower incidence of lues than those based on the
Wassermann reaction. Dr. Heiman asked whether there could be
a serological cure of hereditary syphilis, and whether that would
be true of infants and not of older children. They had been
getting a negative serological result in every instance in which
the child came for treatment for the required time, so that he
could say that it was not only possible to get a negative serological
result in congenital lues, but that it was the rule under proper
treatment. With regard to twins, sometimes one would be posi-
tive and sometimes both would be positive. Statistics gave a slight
preponderance in favor of both infants being infected. As to
the placental blood becoming anti-complementary, they had found
American Pediatric Society 405
this in so few instances that they had not thought it worth while
to report their findings.
PRELIMINARY OBSERVATIONS ON THE PATHOGEN-
ICITY FOR MONKEYS OF THE BACILLUS
ABORTUS BOVINUS.
Dr. E. C. Fleischner and Dr. K. F. Meyers, of San Fran-
cisco, stated that intravenous injections of known strains of
bacillus abortus bovinus produced in a monkey a definite symptom
complex characterized by irregular temperature, loss of weight
and positive agglutination reactions. It was possible to recover
the organisms post mortem from the spleen, lymph nodes and
kidney of the infected animals. Whereas this type of infection
was interesting from the scientific standpoint, it was only by
feeding the organisms that deductions could be drawn as to
the possible danger entailed when large numbers of these bacteria
entered into the intestinal tract. Macacus monkeys were fed
daily cultures of known virulent strains over varying periods of
time. Agglutination reactions became positive using bacillus
abortus as an antigen, and on sacrificing the animal the infecting
bacilli were found in the spleen, lymph nodes and kidneys. A
goat was infected by injecting into the udder a very virulent
strain of B. abortus that had been recently recovered from a hog
suffering from abortion disease. The muscles of this goat, which
contained about 200,000 bacteria per c.c, were fed to a Macacus
monkey for 52 days. Positive agglutination reaction developed
and at post mortem the spleen and lymph nodes were enlarged.
Enormous numbers of B. abortus were recovered from the vis-
cera. It seemed reasonable to assume that the B. abortus bo-
vinus was pathogenic for monkeys that had been fed virulent
strains of the organisms in large numbers.
Dr. Fleischner spoke of the economic side of this question.
Abortion disease, he said, was much more prevalent than bovine
tuberculosis. For many years there had been a tremendous eco-
nomic loss because we thought we must eradicate bovine tuber-
culosis from cattle. He did not want to leave the impression that
we must eradicate abortion disease from cattle at the present time.
406 American Pediatric Society
LESIONS IN THE MID-BRAIN : REPORT OF A CASE.
Dr. J. H. M. Knox, Jr., of Baltimore, reviewed the anatomy of
the mid-brain, referred to the difficulty of distinguishing between
symptoms that might be due to the destruction of nerve tissue by
disease and those which were produced by alteration in function
m the same area because of the involvement of neighboring struc-
tures, and described the syndromes of Weber, Benedict and Noth-
nagel.
In view of the confusing symptomatology often noted in
patients suffering from mid-brain lesion, the case reported in
which the symptoms were comparatively definite and the path-
ological findings fairly circumscribed was of interest. The pa-
tient was a colored boy, 3 years of age, brought to the Harriet
Lane Home, Johns Hopkins Hospital, February 3, 1915, because
of general weakness, trembling, and drooping of the eye-lids.
The family and personal history of the patient were negative,
the boy appeared perfectly normal until 6 months before admis-
sion, when he stopped crying almost completely. About 4 months
later, the tremor was' noted and a little later the drooping of the
eyelids. The outstanding abnormalities revealed by physical
examination were some enlargement of the epitrochlear glands
and the eye symptoms. The pupils reacted to light but the left bet-
ter than the right. There was occasional lateral nystagmus of the
right eye, marked bilateral ptosis of the eyelids, apparently equal
on both sides, and a definite deviation of the eyeball to the right.
Two weeks later, the patient returned with the history of having
had 2 attacks of paraplegia, having become very weak and limp
iafter the second one. The symptoms before noted were increased.
There was great uncertainty of movement, and examination of
the fundi showed a very slight degree of secondary atrophy.
The spinal fluid was under marked pressure, gave a reaction
for globulin, and contained an increased number of cells, mostly
mononuclears. The x-ray examination of the head showed a
moderate hydrocephalus and a probable tumor above the sella
turcica. About 10 days after his admission, a slight rigidity of
the neck was noted and from that time on the child grew con-
stantly weaker, there were slight daily fluctuations of tem-
perature of about 2^ degrees. He died after being under ob-
servation for 42 days. The acquired ptosis and the curious tremor
of long standing noted in the extremities and the gradually de-
American Pediatric Society 407
veloping paralysis of the movements of the eyeballs excepting
those produced by the external recti with resulting external
strabismus in a child previously well, led one to venture the
diagnosis of a tumor of the mid-brain, interfering with the nuclei
of the third and fourth cranial nerves. The ataxia might also
be accounted for by lesions in this region, involving the red
nucleus or cerebellar tracts. Towards the end there was certainly
meningitis, probably of tuberculous origin, associated with hydro-
cephalus, although the tubercle bacillus was not demonstrated.
The positive von Pirquet reaction and the subsequent develop-
ment of meningitis suggested that the tumor was probably tuber-
culous in origin.
The post mortem findings were given, leading to the anato-
mical diagnosis of solitary tubercle of the mid-brain and right
parietal lobe together with tuberculous meningitis. The anato-
mical findings confirmed in the main the clinical symptoms de-
scribed. The writer further discussed the affections produced by
mid-brain injury and also the symptomatology of pineal tumor,
which was identical with that of primary lesions of the mid-brain.
The order in which the symptoms developed was of the ut-
most importance in reaching an accurate diagnosis. When the
early symptoms were general and attributable to increased cere-
bral pressure, such as headache, vomiting, optic atrophy, hydro-
cephalus, etc., followed, it might be, with ptosis and oculo-motor
palsies, one would be inclined to place the initial lesion outside of
the mid-brain — such symptoms might result from meningitis or
tumor elsewhere, possibly originating in the pineal gland where-
as, as in the boy here reported, the limitation of the symptoms
for months to ptosis and paralysis of the oculo-motor nerves and
tremor without evidence of intracranial pressure supported the
diagnosis of an injury beginning in the mid-brain and, as far as
it went, the absence in his case of an increase of growth or of
sexual development suggested that neither the pineal nor pituitary
glands were involved.
THE ULCERATED MEATUS IN THE CIRCUMCISED
CHILD.
Dr. Joseph Brennemann, of Chicago, stated that ulcera-
tion of the meatus was very common in circumcised children.
408 American Pediatric Society
There was usually ulceration, scab formation, narrowing of the
meatus, painful urination, often partial obstruction, and occasion-
ally hemorrhage at the end of urination. The condition seemed
always associated with what was known as the "ammoniacal
diaper," and apparently resulted from direct contact of the
meatus with the wet diaper. The treatment consisted in apply-
ing -vaseline or wet boric acid dressings to the meatus, if in-
flamed, and in the prophylaxis of the ammoniacal diaper. The
latter was probably due to a metabolic disturbance that was not
yet fully understood but probably commonly due to overfeeding
with cow's milk fat as a result of which there was an excessive
excretion of ammonium salts in the urine. Inasmuch as the
ammonium salts must be broken down to liberate ammonia and
this was commonly effected by an alkali, it was well in addition,
to reducing the ammonium content of the urine to rinse the
diapers to remove all excess of soap and also to boil them for
a long time to eliminate the possible influence of bacterial action.
Discussion. — Dr. W. McKim Marriott, of St. Louis, thought
the ammonia which was present did not occur in the urine, when
passed, as the kidney did not secrete a urine containing any ap-
preciable amount of free ammonia. The ammonia was produced
after the passage of the urine and must be the result of the
breaking down of either ammonium salts or urea. Ammonium
salts were increased in certain types of feeding and these salts
might be broken up by the action of alkali, either of soap left
in the diaper or as the result of standing with alkaline soap stools.
A more important factor in the production of ammonia in the
diaper was bacterial decomposition of the urine either of the
urea or of the ammonium salts. Quite a number of bacteria
were capable of doing this. It could be prevented if the diapers
were thoroughly boiled and the child's buttocks and perineal
region kept thoroughly clean.
DYSPITUITARISM SO-CALLED: ABSORPTION OF
MEMBRANOUS BONES, EXOPHTHALMOS AND
POLYURIA.
Dr. Alfred Hand, Jr., of Philadelphia, recalled a case which
he had reported in the Transactions of the Pathological Society
of Philadelphia, Vol. XVI, 1891-1893, under the heading "General
American Pediatric Society 409
Tuberculosis" and also in the Archives of Pediatrics, Vol. X,
1893, under the title of "Polyuria and Tuberculosis." The patient
was a boy 3 years old, seen December 1, 1892, with a history of
great thirst and polyuria of sudden onset 8 weeks earlier. He
had had enterocolitis at the age of 8 months and croup and
measles at the age of 2 years. The family history was negative.
The boy was undersized, with a dry bronzed skin, exophthalmos,
corneal opacities in each eye and anterior synechiae in the right.
The thyroid was not enlarged. There had been rachitis. The
urine had a specific gravity of 1,000 and the maximum quantity
in 24 hours was 150 ounces, containing neither sugar nor albumin.
After 2 months, the boy died of bronchopneumonia, the main
feature of the autopsy being a yellow area of softening in the
right parietal bone involving both tables of the skull, with other
areas affecting only the outer table. The kidneys were enlarged
and the left had 3 small cysts, and in the pelvis of each was a
hard, tuberculous mass ; the lungs showed bronchopneumonia
and there was small round-celled infiltration of the liver, spleen
and kidneys with degeneration of the epithelium of the uriniferous
tubules.
Dr. Hand quoted the notes of a case shown before the Medical
Society of the State of Pennsylvania, 1906, by Dr. T. W. Kay
and reported by him as a case of acquired hydrocephalus, with
atrophic bone changes, exophthalmos and polyuria. In the Osier
Memorial Volume, there was an article "Defects of Membranous
Bones, Exophthalmos and Polyuria, an Unusual Syndrome of
Dyspituitarism" by Dr. Henry A. Christian, who reported such a
case and had found 2 similar ones described by a German writer,
Schueller. The latter said "We can therefore make a presump-
tive diagnosis of anomaly of the skeleton as a result of disease of
the hypophysis." Dr. Christian treated his case with pituitrin
which, when given under the skin and into a vein, caused great
dimunition in the amount of fluid ingested and excreted, but,
given by mouth or rectum, had no effect. Dr. Christian also con-
cluded that the condition was due to disturbed pituitary function.
To the above group Dr. Hand added a sixth case seen recently.
This patient was a boy 4 years of age, from whom there was
removed at the age of 2 years a tumor-like swelling from the
left parietal region; there was absence of bone underneath the
tumor down to the dura. Section showed a slight degree of in-
410 American Pediatric Society
flammation, but mainly a myxomatous change. Since then other
svvelUngs had appeared, and exophthalmos which was greater
on the right, but as yet there had been no polyuria.
Analysis of these 6 cases seemed to render the theory of
dyspituitarism insufficient to explain the syndrome, although the
polyuria undoubtedly depended on a disturbance of the hypo-
physis ; the bone changes seemed to be the primary condition,
causing the exophthalmos mechanically by changes in the orbital
plates, and the polyuria by changes in the sella turcica. The cause
of the bone changes was not clear and further observations were
needed before this interesting and curious group of symptoms
could be satisfactorily explained.
USE OF FRESH VACCINES IN WHOOPING-COUGH.
Dr. Rowland G. Freeman, of New York, stated that the
vaccines for the prevention or cure of whooping-cough had been
used for the past 8 years, and while some enthusiasm had been
shown by certain writers, the general opinion had been that they
were of but little service in the treatment of whooping-cough, al-
though possibly of some value in its prevention. His own atti-
tude was that they did not modify the course of whooping-cough,
and he had never seen a case of whooping-cough apparently pre-
vented by their use.
Two years ago he saw Dr. Huenekens' paper on the applica-
tion of the complement fixation test for the detection of anti-
bodies after the injection of whooping-cough vaccines, in which
he showed that the antibodies were not present unless the vaccines
were freshly prepared and that after a week of storage but little
antibody production resulted from their injection even in large
doses. It seemed to him that this fact might explain the con-
tradictory reports from the use of whooping-cough vaccines in
the course of their work. He felt that it should be tried out.
He was, however, unable to report any institution work but had
brought together all the cases in which he had used it in private
practice, hoping to stimulate interest in these fresh vaccines and
thus render it easier to obtain them. If we were to have the
opportunity to give the vaccines a fair trial, we must have some
laboratory producing fresh vaccines every week.
The present series of cases which Dr. Freeman reported in-
cluded 16 children with whooping-cough in which the vaccines
American Pediatric Society 411
were used at various periods of the disease. In 5, no results
were obtained. Of these 5 children, 3 were early in the disease
and the other 2 very late. Of the 11 remaining cases, in 9 a
very material improvement took place and in 4 of these a prac-
tical cure was obtained. His confidence in the vaccines had been
somewhat shaken by the results in one family of 6 children, re-
ported in the paper, who failed to react, but the good results ob-
tained in other cases and the quite remarkable results obtained in
certain beginning cases convinced him that these vaccines should
have an extended use, particularly in institutions, where controls
might be used to demonstrate whether we might not have in
these vaccines a valuable method of reducing the large mortality
from whooping-cough.
SOME OBSERVATIONS ON RICKETS.
Dr. John Howland and Dr. Edwards A. Park, of Baltimore,
made this contribution which consisted in a lantern slide demon-
stration showing the alterations at the junction of the shaft and
cartilage in rickets as determined by the x-ray. A definite corre-
lation was shown between the x-ray signs and the actual patho-
logical conditions. Proof was adduced that the calcium deposits
in the cartilage cast well-defined shadows. The effectiveness of
cod liver oil as a therapeutic agent in rickets was demonstrated
by serial x-ray pictures. In animal experiments, a beginning
calcium deposit was demonstrated 2 days after beginning the
administration of cod liver oil. In human beings, the calcium
deposit in the cartilage was definitely demonstrable at the end
of 3 weeks after beginning the administration of cod liver oil.
The probable relation of cod liver oil to the process of repair was
discussed.
Discussion. — Dr. W. McKim Marriott, of St. Louis, said
that we do not yet know all the factors which cause a deposition
of lime salts to form bone. In order to gain some information
regarding the nature of the process, we prepared an "artificial
blood," that is to say, a solution containing all the inorganic con-
stituents of blood plasma. It contained phosphates, lime, mag-
nesium salts, sodium bicarbonate and carbon dioxide, the latter
being at a tension of 40 mm.. Such a solution was perfectly clear
but a precipitate occurred if a portion of the carbon dioxide was
412 American Pediatric Society
removed, or if more bicarbonate, calcium salts, or inorganic phos-
phate were added. The precipitates obtained in these various
M^ays each had different compositions. The only precipitate v^hich
had a composition the same as that of bone was obtained by in-
creasing the amount of phosphate in solution. A very small in-
crease in the amount of phosphate in solution caused a very con-
siderable precipitation of a substance having the approximate
composition of bone. It would, therefore, seem likely that the
method by which bone is laid down in the body is by an increase
in the amount of phosphate present at some point and that a mere
increase in alkalinity is insufficient. Such being the case, it would
be interesting to know whether or not the phosphate content of
the blood is increased following the administration of cod liver
oil.
Dr. Henry J. Gerstenberger, of Cleveland, said Dr. Howland
made the eradication of rickets seem possible. They had fed 1,200
babies or more on a synthetic milk, containing 10 per cent, fat
in the form of cod liver oil, and they had yet to see the first case
of spasmophilia or rickets among the children so fed. Their idea
had been to incorporate the cod liver oil in the food and thus
prevent rickets.
Dr. Clifford C. Grulee^ of Chicago, said that Dr. Femster
had been making observations on normal children, feeding phos-
phorus, and by this means he had been able to produce a thick-
ening of the ends of the bones very much the same as that pro-
duced by the cod liver oil. They had noted that with a longer
feeding of phosphorus there was a greater thickening at the
epiphyseal line. In these children the phosphorus was used alone
and not in combination with cod liver oil.
Dr. Rowland said that he and Dr. Kramer had done work
in which they had studied the phosphate content of blood after
feeding cod liver oil and had found it greatly increased. What
brought that about he could not say. In one case in which they
had found 13^ mgs. inorganic phosphorus per 100 c.c. of blood,
after feeding cod liver oil they had found 16 mgs. of inorganic
phosphorus. That result had been duplicated in other instances.
This was a subject that needed further investigation. It seemed
that cod liver oil had something to do with the utilization of
phosphorus.
American Pediatric Society 413
THE ARGONNE ASSOCIATION.
Dr. Royal Storrs Haynes, of New York, presented a lantern
slide demonstration of the work being done by the Argonne As-
sociation in caring for dependent children in France and ex-
plained the aims of this organization. The work had been begun
under the Red Cross, but, as it would require a period of years
to complete the demonstration, it was thought best to have a
separate organization. The work was divided into 3 sections,
the first being devoted to the care of children under 4 years of
age, the second to the care of those from 4 to 14 years, and the
third to the vocational training of older children. They believed
that the proper care of the dependent child should carry the child
under one control until he was able to emerge a self sufficient
citizen. In the first section, the children were placed in foster
homes under the supervision of a visiting nurse and a medical
director. The visitor became an older sister to the children and
looked after them not only in respect to their physical welfare
but also from the standpoint of moral discipline. Provision was
made for education in the second section and also for supervised
play. In the third section, special attention was paid to vocational
training for both boys and girls. Inasmuch as France was greatly
in need of agricultural workers special attention was being paid
to training the boys for this work, but the special aptitudes of
the children were studied and the occupation chosen in which they
would be happiest and most useful.
SARCOMA OF THE KIDNEY.
Dr. Rowland G. Freeman, of New York, stated that this
case was of interest because of the rapid production of metastases,
after operation and also because of the type of tumor. The child
was 25^ years of age and weighed 26^^ pounds. When she came
under observation, she had been failing in health for 2 months.
X-ray examination confirmed the diagnosis of tumor of the kid-
ney on the left side. Six weeks after operation, she was brought
back to the hospital in a desperate condition, with a temperature
of 102°. F., dyspnea, and rales over the entire chest. The x-ray
showed numerous metastases in the lungs.
414 American Pediatric Society
FOCAL INFECTIONS IN CHILDREN.
Dr. Oscar M. Schloss^ of New York, presented a report con-
cerning focal infections of the tonsils which were responsible for
2 types of disturbances. In one group of cases, the disturbances
were cyclic in character, were accompanied by fever and per-
sistent vomiting with a large elimination of acetone bodies in the
urine and an accumulation of acetone bodies in the blood. There
were 8 cases in this group.
The other types of disturbances was evinced by mild nephritis.
The urine contained albumin in moderate amounts, red blood
cells, hyaline and granular casts and some leucocytes. These
children were not especially ill. The symptoms were traced to
a tonsillar infection and subsided promptly when the infected
tonsils were removed. Two such cases were observed.
In most of the cases in both groups, the tonsils were not
large. In several instances the tonsils had been previously re-
moved and there remained only a small amount of tonsillar tissue
between the faucial pillars.
HYPERTROPHIC STENOSIS: FAILURE OF GRUEL
FEEDING: OPERATION: SLIGHT IMPROVE-
MENT: THREE CASES DOING NICELY
ON GRUEL FEEDING.
Dr. H. M. McClanahan_, of Omaha, stated that since June
1919 he had had under his care 6 cases of congenital hyper-
trophic stenosis complying with the following syndrome: loss of
weight, vomiting several times a day, frequently expulsive in
character, stools, small, dark and without any evidence of milk
digestion, visible peristalsic wave, and scanty urine. In 3 or 4
cases recovering without operation a movable tumor could be
palpated. In 1 of the cases not operated on, the diagnosis was
further confirmed by a roentgen plate. Four of the 6 cases re-
covered under gruel feeding, their ages being 5, 5, 7, and 11
weeks. These cases were placed on thick gruel in the manner
described by Dr. L. W. Sauer and later by Dr. Langley Porter in
the Archives of Pediatrics, July, 1919. The rate of gain varied
but all made slow but steady improvement. The fifth baby made
fair progress for 2 weeks, but the parents, seeing the results
on the next case reported, demanded operation. This baby was
American Pediatric Society 415
operated on and made a good recovery, but it was the writer's
belief that this baby would have recovered without operation. The
sixth patient was in desperate condition at the time of operation,
the walls of the stomach being dark in color, in striking contrast
to that of the intestines. This infant had congenital hyper-
trophic stenosis, a general staphylococcus infection and undoubt-
edly an acute gastritis. The case would undoubtedly have ter-
minated fatally without operation.
A CASE OF PORTAL THROMBOSIS.
Dr. Richard M. Smith, of Boston, stated that portal throm-
bosis was a rare condition in children. This patient, a child 3
years old, was admitted to the Massachusetts General Hospital,
December 22, 1919, giving a history of acute rise in temperature
with cough 7 days before. On the morning of admission, a small
ecchymotic spot was noticed on the forehead and another ,on the
sacrum. Physical examination showed an enlarged heart, with
a systolic murmur heard all over the precordia. The first sound
at the apex was loud. The spleen was palpable below the costal
margin. The blood count showed hemoglobin, 40 per cent. ; red
blood corpuscles, 1,960,000; white cells, 18,000; differential
polymorphonuclears, 60 per cent. ; small mononuclears, 24 per
cent. ; large mononuclears, 10 per cent. ; transitionals, 3 per cent.,
and neutrophile myelocytes, 3 per cent. The blood platelets were
normal. The blood pressure was 90 systolic, and 70 diastolic.
The roentgenogram showed the heart to be enlarged. The elec-
trocardiogram showed a sino-auricular tachycardia (rate 160),
but no auricular hyperthophy or ventricular prepondera:nce. The
temperature on admission was 102.8° F., pulse 160, respiration
25. The child was transfused with only temporary benefit. The
abdomen gradually distended with fluid, the superficial veins in
the upper portion became enlarged, the spleen increased greatly,
finally reaching nearly to the umbilicus, and assuming a trans-
verse position in the abdomen. The pulse remained rapid, and
respiration was 30 to 35 until just before death, when it rose
to 45 to 50. Six weeks after admission, the child vomited a large
amount of bright red blood. Transfusion was repeated but the
child died February 12, practically 2 months from the onset of
the infection.
The striking points in this case were the persistent fever, the
416 American Pediatric Society
enlarged liver and spleen, engorgement of the superficial abdomi-
nal veins, severe anemia and intestinal hemorrhage. No diag-
nosis was reached during life. At autopsy thrombosis of the
portal vein and its great radicles was found, with passive conges-
tion of the spleen, ascites, hypertrophy and dilatation of the heart,
edema of the lungs and anemia. Undoubtedly the thrombosis
was of infectious origin arising in connection with the initial
infection of the respiratory tract.
A CASE OF PARALYSIS OF THE RESPIRATORY
MUSCLES.
Dr. W. McKim Marriott, of St. Louis, said the chief inter-
est in this case was in the treatment applied. The patient was
a girl, 10 years of age, who had suffered from a severe attack
of diphtheria 6 weeks previously. She developed paralysis of the
palate, ocular muscles, legs, back and neck muscles, and partial
paralysis of the arms. Ultimately the diaphragm became in-
volved, so that it failed to move at all during inspiration. The
thoracic respirations were at first very active, later the intercostal
muscles began to lose and the child became cyanotic and semi-
comatose. The child was obviously dying from suffocation, and
it was thought that if the respirations could be maintained for
a sufficient period of time to allow for restoration of function
of the respiratory muscles that recovery would be possible. Arti-
ficial respiration was given by means of the Erlanger-Gessel air
current interrupter connected with a nitrous oxide mask. The
child failed to cooperate at first, but later it was possible to get
her to open the glottis at the right time so that air could be forced
into the lungs at the regular rate. The effect was immediate.
The cyanosis was relieved and after a period of about 10 minutes
of artificial respiration the child fell asleep and the mask was
removed. Cyanosis slowly developed and was again relieved by
a period of artificial respiration. This was kept up more or less
continuously for 5 days, at the end of which time, the function
of the respiratory muscles began to return and the child was able
to breathe without the aid of the apparatus. She made a com-
plete recovery and is now in perfectly good health.
CONGENITAL ATRESIA OF THE ESOPHAGUS.
Dr. Henry L. K. Shaw, of Albany, said he reported this
American Pediatric Society 417
case for the purpose of emphasizing the historical side more
than the clinical. This child gave a history of food coming out
of its nose, and on attempting to pass the stomach tube it only
went down a short distance. After giving barium, the x-ray
showed the esophagus filling but the barium did not pass through
to the stomach. Examination of the lungs showed them filled with
fine rales. The child died and at autopsy it was found that the
upper one-third of the esophagus ended in a cul-de-sac and had
no relation to the lower part which opened into the trachea.
A similar case was reported in 1682 and another in 1703 by
a Dr. Gibson, Physician General to the British Army, and a
grandson of Oliver Cromwell. Dr. Shaw read this description
which was so accurate that it would be difficult to improve upon
it today.
PRIMARY SARCOMA OF THE THYMUS.
Dr. L. Emmett Holt, of New York, said this patient was
a child, 6 months old, with symptoms dating back only 4 weeks.
The parents were healthy as were 2 other children. This child
was small, and gained in weight slowly, weighing 9}4 pounds
at the age of 6 months. The symptoms were merely an increasing
pallor and slight fever. There were minute hemorrhages over
the neck and extremities. The case was looked upon as one of
severe secondary anemia of unknown origin. The temperature
ranged between normal and 103° F. As the hemorrhages con-
tinued to appear, a transfusion of blood was given which was
of no permanent value. The child failed rapidly and died. At
autopsy, a thymus weighing 36 grams was found, which was very
large, the upper limit of the normal being 10 grams. Besides
the sarcomatous condition of the thymus, similar changes were
found in one of the lymph nodes, in the spleen and in the lungs.
The case was interesting because the child presented none of the
symptoms usually associated with enlarged thymus, and because
of the rarity of sarcoma of the thymus in infants and young
children, this case being perhaps unique,
A CASE OF CARDIOSPASM.
Dr. Godfrey R. Pisek, of New York, said that the occurrence
of cardiospasm in early life was still so rare as to make it
418 American Pediatric Society
justifiable to report this case. Since adult cases might trace their
inception to early life or to congenital defects, the pediatrician
might well consider these cases worthy of study. Neurotic or
primary cardiospasm was attributed by some authorities to a
contraction of the left crura of the diaphragm, by others to
defective innervation, or to localized atony of the esophagus.
The case reported was that of a girl, 12 years of age, who
first came under observation in September, 1919. The family
and past history were negative. When 3 or 4 years old, the child
developed a strong will and was said to be "temperamental". This
trait grew stronger as she grew older. Otherwise she was an
outdoor athletic child. She had a peculiar appetite, disliking vege-
tables, eggs and sweets. About a month before coming under ob-
servation, she complained that food choked her and at night she
had a similar difficulty, complaining of a strangling sensation. A
cough developed in connection with the night spasms, unconscious
as far as the patient was concerned, and upon which codeine had
no efifect. Physical examination revealed nothing abnormal ex-
cept some retraction of the supra- and infra-clavicular spaces, a
slight tremor of the upper eyelids, a tendency to relaxation of the
spine and bowing of the shoulders and evidence of orthostatic
albuminuria. Radiographic and fluoroscopic examination con-
firmed the diagnosis of cardiospasm. After an esophagoscopy
under general anesthesia, a moderate dilatation was done but no
anatomical basis was demonstrable. Bougies were passed at
about fortnightly intervals until her departure for Florida in
March of this year. In the South she did well at first, but she
then contracted "malaria", lost weight, going down rapidly to 80
pounds — 20 pounds below normal— and the original symptoms
of her cardiospasm returned. She was brought North and care-
fully examined again. The gastric contents showed retention,
and the fluoroscopic examination a considerable dilatation of the
esophagus with a smooth fusiform construction at the cardiac
end. Bougies were passed every fourth day. She was given
atropin and a measured diet of 3,000 to 3,500 calories per day.
She had gained 15 pounds in the last 29 days. Whether it would
be necessary to pass a duodenal tube and give the stomach a com-
plete rest for a time was still a question. This case showed that
it was not so easy to treat this condition as one was led to sup-
pose by the literature.
American Pediatric Society 419
A CASE OF LYMPHOSARCOMA.
Dr. Charles A. Fife, of Philadelphia, said the unusual
features which prompted him to report this case of lymphosarcoma
were: 1. The treatment by x-ray of an enlarged cervical lymph
node, the probable primary lesion, on the supposition that it was
tuberculous. The node had not been excised. There was no
other evidence of tuberculosis. 2. Wide metastases, within 5
months of the cessation of roentgenism. 3. The extensive involve-
ment of the tracheobronchial lymph nodes producing massive
exudation into the left pleura, but causing no other signs of me-
diastinal compression. 4. The high, irregular temperature, ex-
tending over a period of 1 year. 5. The polynuclear leucocytosis
in blood and lymphocytosis in pleural exudates. 6. The tremen-
dous enlargement of the spleen and of the liver. 7. The varieties
of previous diagnoses, including influenza, endocarditis, secondary
anemia, tuberculosis, adenitis, leukemia, Hodgkins' disease and
substernal empyema. 8. The rapid reduction in size of the
bronchotracheal lymph nodes, and the improvement in the condi-
tion of the patient after x-ray treatment to the mediastinal region,
9. The marked effect of x-ray and radium on the lymphosar-
comatous tissue as shown in the athologic specimens.
The patient was a boy of 9 years giving a negative medical
history until his seventh year when a slowly enlarging right cer-
vical lymph node was detected. Notwithstanding the removal of
tonsils and adenoids, the gland attained, in 10 months, the size of
a large Qgg. After 3 roentgen treatments given in the course of
a month, the mass became the size of a hickory nut, and after 20
treatments in 15 months, the disease was thought eradicated.
The boy was apparently in perfect health for a third of a year and
then during the next 5 months, before coming under observation,
had attacks of fever with remission. There was progressive
anemia, slight leucocytosis, but the red blood cells did not show
irregularity in shape until about 4 months after the onset of the
fever. When he came under observation, he had an irregular
temperature, ranging from normal to 103° F; pulse 130, respira-
tion 36. He was weak, mildly dyspneic, had a slight non-produc-
tive hacking cough on change of position, and no other symptoms.
He had a few palpable cervical and inguinal lymph nodes, buck-
shot size, no skin tumors, no cutaneous or mucous membrane
420 American Pediatric Society
hemorrhages, except in the left pleura which was entirely filled
with fluid. The heart was completely displaced, the right border
being in the right nipple line. There was also a mediastinal mass
displaced to the right. The liver was slightly enlarged ; the spleen
much enlarged. There was no demonstrable ascites. A quart of
dark amber fluid was removed from the left pleura after which
the heart returned to normal, the area of dullness corresponding
to the mass in the mediastinum receded and the heart assumed
its normal position. Within 48 hours the chest refilled. The fluid
contained about 3000 cells per c.c, but subsequent specimens were
highly leucocytic. No tubercle bacilli were found, guinea pig
inoculation was negative and the Wassermann was negative.
There was at first slight general improvement following the x-ray
treatment, but this improvement was only temporary. The x-ray
treatment, radium and 3 blood transfusions failed to stop the
progress of the disease. The child died about 6 months after
coming under observation. The hemoglobin had fallen to 13 per
cent., the red cells to 500,000, and the whites to 2000, 80 per cent,
being lymphocytes. The post mortem diagnosis was small and
large-celled lymphosarcoma. The structures involved were the
cervical, tracheobronchial and retroperitoneal lymph nodes, the
spleen and the liver. The chief histological interest lay in the
fact that the nodes, low down in the abdomen where they were
unafifected by radiation, were full of typical, active tumor cells,
while the lymph nodes in regions treated by x-ray or radium
showed retrograde changes in the tumor cells and thus many
tumor cells were replaced by dense connective tissue.
HEART DISPLACEMENT APPARENTLY DUE TO
MEDIASTINAL EMPHYSEMA FOLLOWING
ASPIRATION PNEUMONIA.
Dr. E. C. Fleischner, of San Francisco, stated that this boy,
3^ years of age, following a fall into a sandpile, became wheezy.
Four hours later he was brought to the hospital with sibilant rales
over the lungs, both anteriorly and posteriorly. The x-ray showed
no foreign body and no condition calling for surgical interference.
The heart was displaced slightly to the right. The boy developed
American Pediatric Society 421
a definite pneumonia on the left side involving the middle lobe.
The displacement of the heart did not seem to be due to fluid. At
the end of 48 hours, a subcutaneous emphysema appeared above
the clavicle and extended down to the pelvic bone. The pneu-
monia subsided to be followed by a bronchiectasis in the left lung.
He had a prolonged illness, but the x-ray, taken 5 months after
the accident, was to all intents and purposes normal. In this case
the heart had gone rapidly and completely to the right. It seemed
reasonable to believe that injury during the accident had caused
air to push through the lung and force the heart to the right, and
then work its way out into the subcutaneous tissues.
THE DUCT SIGN IN MUMPS.
Dr. David Murray Cowie, of Ann Arbor, reported that in
97 per cent, of 57 cases of parotid mumps a red spot was observed
at the orifice of the Steno's duct which developed and disappeared
under the influence of the disease. The duct itself became tea-
tulated. The detailed description of the color change and the duct
involvement was given, and illustrative cases cited. The sign
developed early in the disease, sometimes ahead of the swelling
of the parotid and disappeared when the duct returned to normal.
The sign was uninfluenced by the degree of fever. Submaxillary
ducts showed no redness when the submaxillary glands were
mvolved.
Whether the duct sign was pathognomonic of specific parotitis
or was present in other acute inflammatory conditions had not
been determined. Because of the occasional occurrence of teatula-
tion of Steno's duct in a certain percentage of apparently normal
persons and the occasional finding of redness of its orifice, care-
ful diflferentiation should be made. The duct sign should be re-
garded simply as corroborative evidence of parotid gland involve-
ment.
Discussion — Dr. Frederic W. Schlutz, of Minneapolis, re-
called having observed this sign, among negro troops in about 50
per cent, of the cases. He stated that he believed the contagious
period of mumps was longer than that given in the text books. It
was fully 21 days, though as a rule it was stated as shorter than
this.
422 American Pediatric Society
A CASE OF PRIAPISM RESULTING FROM RAPIDLY
SPREADING MALIGNANT MYXOSARCOMA
WITH GENERALIZED METASTASIS.
Dr. David Murray Cowie, of Ann Arbor, reported this case,
the unusual feature of the case being the early age of the boy, 9
years.
STREPTOCOCCIC ANGINA WITH PURPURA HEMOR-
RHAGICA AND MULTIPLE INFARCTS OF THE
SKIN AND SUBCUTANEOUS TISSUE IN A
CHILD TWO YEARS OLD, HEALING
UNDER DAKIN'S SOLUTION.
Dr. Walter R. Ramsey, of St. Paul, stated that this patient^
2>2 years old, was brought to the city from a distance of 200 miles.
His family and past history were negative. His present illness
began with a sore throat, 2 weeks before. After a few days there
was swelling of both legs and an offensive odor from mouth and
nose. Upon arrival at the office the child was moribund. The
skin and mucous membranes were extremely pale and there was
marked edema about the face, the eyes being swollen shut. The
legs and feet were markedly edematous. There were numerous
petechial areas scattered over the entire body. The fauces and
ionsils were covered with a foul gray membrane, and the entire
mucous membranes of the mouth, including those of the lips, were
gangrenous. The temperature was 104° F, and the pulse very
rapid and weak. The condition was so suspicious of diphtheria
that 20,000 units of antitoxin were given immediately. The cul-
ture, however, proved negative. The purpura cleared up under
this treatment. Deep sloughs developed in a few days on the right
wrist, on both ears, both elbows and on the perineum. The palate
sloughed off. The middle phalanx of the middle finger on the
right hand sloughed out, and later healed perfectly, leaving a
finger with 1 phalanx missing. A dark area over the occipital
region sloughed out and part of the bone also. All these areas
healed under Dakin's solution applied 4 times a day.
REPORT OF A CASE OF ANAPHYLAXIS FOLLOWING
INTRADERMAL PROTEIN SENSITIZATION TESTS.
Dr. Henry J. Gerstenberger, and Dr. J. H. Davis, of Cleve-
land, were called in July, 1919, in the absence of the family physi-
American Pediatric Society 423
cian, to see this child, 12 months old, who had a distinct dry eczema
of the face, chest and arms, with a decided emphysema accom-
panied by wheezing and a somewhat labored expiration. Under
dietetic treatment and atropin the child improved. The mother and
nurse felt that when the atropin was reduced or stopped the symp-
toms returned.
When the family physician returned in August, he found an
increased thymic dullness and requested an x-ray of the chest. A
wide shadow was found in the thymic area, which according to the
roentgenologist was due to an enlarged thymus. Consequently the
family physician stopped the atropin, and had the thymus exposed
every 3 or 4 weeks for a total of 5 exposures. The condition of the
child grew worse instead of better and the thymic shadow re-
mained the same. The family physician then reordered the atro-
pin and the child again improved. During the early days of De-
cember, the child developed a severe cold and as a result had a
severe asthmatic attack. He was then seen by Dr. Gerstenberger
together with the family physician, and admitted to the pediatric
service of the Lakeside Hospital. His condition seemed worse
than at any previous time. A diet was again built around skim-
med milk, the atropin was reordered in large doses, and cod liver
oil, which was being given, continued. Within 48 hours there was
a distinct improvement.
The child was given the tuberculin test which showed a slight
swelling uncharacteristic of the regular positive tuberculin test,
and this was considered to be due to trauma. As his brother had
been exposed to whooping-cough, he received 2 injections of per-
tussis vaccine.
On December 5, the x-ray picture showed a decidedly smaller
shadow than the last plate taken during October ; in fact, it was
quite like that of a normal child. The family physician attributed
the child's improvement to this and not to the influence of the atro-
pin. He was especially convinced of this in view of the fact that on
November 10 he had performed cutaneous scratch tests with dif-
ferent proteins in simple saline solution all of which proved ne-
gative. It was decided to try the intracutaneous method before
deciding that the entire clinical picture was due to enlarged
thymus. As these injections were given, it was noticed that the
child became mildly cyanosed, but no alarm was felt as it was
customary for him to show this symptom on slight exertion. After
424 American Pediatric Society
several proteins had been injected, egg albumin was administered.
During the injection the cyanosis suddenly became extreme and
severe. Adrenalin was immediately administered subcutaneously
in repeated doses, totaling about 1 c.c. While the respiratory dif-
ficulty was at its worst, a pale swelling about the size of a quarter
of a dollar was seen at the seat of the egg yolk allergen and egg
albumin injections. The other areas of administration were ne-
gative. It was decided after a few days rest to repeat the test.
Tests were carried out for several days with other proteins (cow's
milk and casein and albumin and vegetable proteins) as a result
of which it seemed as though after all the mechanical factor
of an acute emphysema produced as the result of prolonged
exertion might have been mainly responsible for the extreme
condition of the first day. Egg yolk allergen was then tried
and was followed by an extreme state of apnea and cyanosis. By
means of subcutaneous injections of adrenalin and the use of arti-
ficial respiration, the child was revived. A large urticarial wheal
was seen at the site of the injection. The child had never received
egg in any form so they felt justified in assuming that the hyper-
sensitiveness was congenital. Had adrenalin not been at hand at
the time of this test, a fatality and not a recovery would have been
reported.
On December 16, an x-ray photograph of the thymic region
again showed an abnormally wide shadow. The fluoroscopic exa-
mination demonstrated that this seeming contradiction in the x-ray
plate depended upon the phase of respiration when the x-ray pic-
ture was taken. A picture made during extreme inspiration gave
a practically normal shadow, and one taken at extreme expiration
a markedly abnormal one.
The following points in this case were of interest: 1. A boy
17 months old who had never received egg in any form developed
an extreme anaphylactic shock after an intracutaneous administra-
tion of egg yolk allergen and egg albumin in doses of 1 and 2 mg.
2. This child, who had received cow's milk from his third week
of life and who had suffered from eczema and asthma showed a
negative intracutaneous test to cows' milk casein and cows' milk
albumin. The intracutaneous injection of cow's milk allergen
responded within 24 hours with an indurated and red area of infil-
tration not unlike that of an ordinary positive von Pirquet test,
but entirely different from an urticarial wheal. 3. This same boy
American Pediatric Society 425
was not sensitive to other proteins. 4. The first severe anaphy-
lactic shock (Dec. 8) did not prevent the development (Dec. 13)
of a second following the administration of egg yolk allergen
5 days later. 5. The x-ray photographs made at different in-
tervals on the same day showed a definite wide abnormal thymic
shadow and again a perfectly normal picture. The former as
found by fluoroscopic examination occurred during extreme ex-
piration, the latter during extreme inspiration. 6. The thymus
gland, if it really were large in an abnormal sense, did not produce
the respiratory difficulty in a mechanical way. 7. This patient
might be a case of status lymphaticus and this condition might
be responsible in him for his congenital pathological sensitiveness
to egg proteins and his anaphylactic reaction. If, however, he
should be found not to be sensitive to other proteins, especially
horse serum and horse hair protein, the status lymphaticus could
hardly be accepted as a causative factor in his condition, for it
would be difficult to imagine how a status lymphaticus could
make a child sensitive solely to egg protein and not to oats, milk,
horse serum or horse hair proteins.
BLOOD FINDINGS IN A CHILD FIVE YEARS
AFTER SPLENECTOMY.
Dr. Howard Childs Carpenter, of Philadelphia, presented
in detail the average results of 13 blood examinations in a white
boy, 10 years of age, who had had his spleen removed 5 years
before for familial hemolytic icterus of the Chauffard-Minowski
type. The result of the operation was satisfactory and the case
was reported in the literature a few months later. The child's
present condition showed him to be an active, intelligent child of
nervous temperament, with good muscular development and scant
adipose tissue. He was 6 pounds underweight for his height and
age, had a faint mitral regurgitate murmur with no demon-
strable hypertrophy. The thyroid was not enlarged and there
was no jaundice or ascites. The external lymphatic glands were
moderately enlarged. The tonsils were enormously hypertro-
phied. The average of the 13 blood examinations made during
the last 6 weeks showed hemoglobin 82 per cent. ; red cells
4,288,000, and white cells 15,000. No Howell-Jolly bodies were
found. Prior to operation the hemoglobin was as low as 23 per
426 American Pediatric Society
cent., and the red cells were down to 2,020,000. There was still
present evidence of bone marrow regeneration as shown by
the high color index, the continued leucocytosis, moderate
chromatophilia and poikilocytosis, high transitional and eosino-
phile counts, and finally reticulation of the erythrocytes. There
was an unusually quick coagulation time in spite of a rather low
platelet count, indicating in this case either a rapid availability
of the platelets for the purposes of coagulation or an increased
amount of prothrombin in the platelets, or a large percentage of
macroplatelets. The low platelet count was simply the continua-
tion of the condition, which undoubtedly existed before the
splenectomy, as it was well known that cases of hemolytic icterus
showed low normal values, sometimes even less than 200,000.
There was also evidence of lymphatic activity shown by absolute
lymphocytosis, and by the enlargement of the external lymphatic
glands and the very large tonsils.
FURTHER DEVELOPMENT OF INFANTS'
HOSPITAL.
Dr. Henry I. Bowditch, of Boston, said the present day
tendency among hospitals was to develop the scientific side and
its laboratories so as to bring them closer to the clinics. This
valuable information must be properly weighed to be of true
service, for we were dealing with the delicate human body and
mind and not with test tubes, and common sense and experience
played an important role.
This idea was being exemplified in the "On Shore" Depart-
ment of the Boston Floating Hospital, which was being worked
out on the basis of a 10 bed clinic. This new development had
been made possible by the generosity of a few friends, which
had permitted the purchase of 3 small adjoining apartment
houses which he had had remodelled. The building and equip-
ment had cost $45,000. Ten patients they felt was the best num-
ber, as they could be more readily followed clinically, scientifi-
cally and socially. This clinic was held in 2 wards, and the neces-
sary isolation room, under the expert care of 3 nurses. The
wards were so divided that there was less noise and the children
were able to have perfect naps morning and afternoon ; symptoms
dependent upon restlessness, vomiting, etc., were markedly de-
American Pediatric Society . 427
creased thereby. The dinic was so manipulated as to give 5
new patients monthly. The scientific laboratories, chemical and
bacteriological, were brought into close proximity, making con-
sultation easy, but carefully separated so that noises, natural
odors, etc., did not penetrate.
On Tuesday afternoon of each week a health clinic was held
composed of 150 families, held under the guidance of an assistant
visiting physician. On Wednesday the return "family control"
clinic was held, in charge of a visiting physician. Two clinics
were held for weighing the children, getting clinical histories and
giving treatment.
Since opening on December 15, 1919, 30 patients had been
received, 23 of which were diagnosed as regulation of feeding
and malnutrition in different degrees. It was the plan to admit
only nutritional cases, infection being carefully guarded against.
The study so far had been to organize methods of attacking the
question of the different food elements in growth and lack of
growth. Each case was to be completely examined, clinically,
chemically and bacteriologically. The plan was to have patients
return at definite periods for chemical and bacteriological tests,
physical and mental examination, for 10 years. In this way they
followed the development of body and mind. A weekly clinic to
meet the parents had proved satisfactory, allowing personal touch
to impress the parents with the importance of physical care, proper
dietetics and discipline. In time groups of parents, developing
along natural lines, would be formed. In this way they hoped to
understand the mental capacity of the parental group and adapt
their ideas to their particular peculiarities ; thus comprehending
the good points of diet, life, etc., of the different races, and thus
they hoped to lead them to a better understanding of child life. It
was hoped that this beginning might lead others to establish
similar "small enough" institutions for the same study and for
the protection of their medical work.
THE EFFORT SYNDROME IN CHILDREN AND
YOUNG ADULTS.
Dr. Charles Gii.more Kerley, of New York, stated that
during the late international war English army surgeons learned
that when certain recruits were put to prolonged hard work at
428 . American Pediatric Society
drills, hikes, and other hard exertion, they failed to measure up
to the endurance standard required of the soldier in the field.
To this condition, Dr. Thomas Lewis applied the term "effort
syndrome". The condition was described by Friedlander and
Freyhof as "constitutional neuro-circulatory asthenia." The boy
or girl who might qualify for the "effort syndrome class" came
to the physician with the typical story, which condensed meant
that there was an absence of capacity for sustained effort, both
mental and physical. Wherever endurance was required he
failed. In girls these constitutional peculiarities might attract
less attention and be more readily excused when present. Among
animals those of defective capacity for economic reasons usually
had a short career. The defective functioning human, however,
if well born, was urged and forced and stimulated to accomplish
what was not in him. Millions of dollars were wasted on youths
who were physically and mentally unable to meet the standard
set up by ambitious parents and friends in an effort toward their
so-called higher education. The highly trained teaching talent
of our preparatory schools and universities was wasted in part on
poor student material, 25 to 50 per cent, of which should be
scrapped and put to productive occupation. Before a boy was
permitted to avail himself of unusual educational advantages it
should be determined that he was worth it. The high school
should serve as a ck^rijlg house. In addition to mental attain-
ments required for colfege entrance it should be required that a
candidate submit testimonials as to physical fitness and mental
capabilities from the head-master or high school principal. What
was needed was expert occupational diagnosticians who would
aid in placing the boys at work for which they were fitted. The
boy who belonged to the class under discussion should leave
school at the age of 15 or 16 years and take up business. In ordei
to make a reasonable success the occupation should be one whicL
was not strenuous.
It was unusual to find persons of this type the offspring oi
strong, vigorous young persons. In the majority of instances
they were the offspring of the weakly woman of little resistance
and of lessened endurance capacity. A strong, vigorous mother
would do much to offset the influence on progeny of a weakly
male. The progeny of vigorous males was greatly reduced by
inferior mothers. Frequent child-bearing had apparently been
American Pediatric Society A29
a factor in some instances. The necessity for a great deal of
attention to the physical development , of those who would some
day be mothers was a very urgent need. .
Discussion. — Dr. J. P. Crozer Griffiths, of Philadelphia,
said Dr. Kerley had described a class of people for whom there
really seemed to be very little future, entirely without any fault of
their own. The condition was clearly inherited. There was
another and larger class of the unfit in which there was a distinct
constitutional tendency to this condition, but in which careful
guarding in childhood and adolescence might develop individuals
fitted in the future to fill a useful place in society. He referred
particularly to that class of over-worked and over-trained school
children who found it difficult to keep up with their classmates
in school. This applied particularly to those who were not able
to send their children to private school, and who must depend
entirely upon public school training. Here there were hard and
fast rules insisted upon to which these children of inferior coi)-
stitutional character could not tolerate. Little allowance was
made for such children. It did not seem possible for the public
schools to have special classes for them, and yet they needed an
education and should have it. This was a matter well worthy
of consideration by all of us.
THE FOOD REQUIREMENTS OF CHILDREN
AFTER THE FIRST YEAR.
Dr. L. Emmett Holt, of New York, exhibited a number of
charts showing the results of an attempt to estimate the total
caloric needs of healthy children over 1 year of age. This total
was determined by the 4 factors which made it up, namely :(1)
basal requirements, (2) needs for growth, (3) for activit;>' (4)
loss by excreta. For basal needs, the curve of Bened.ct and Tal-
bot had been adopted. The per kilo requirement diminished
steadily trom 1 year to the completion of growth. Growth needs
were calculated from the rate of increase in height and weight for
the different years; these would naturally be greatest at periods
when growth was most rapid. The loss in excreta at all ages was
practically 10 per cent, of the calories taken. These 3 factors,
though subject to individual variation with different children,
were, as averages, uniform and irreducible. The only factor
430 American Pediatric Society
which differed greatly with different children is the needs for
activity. A child with average activity used up nearly one-half
his caloric intake in this manner ; the very active child much more
than this. The total caloric needs for the average child were
greatest during the period of most active growth in boys, 15 to
17 years; in girls, 13 to 15 years. At this period their needs
exceeded those of adults with moderate activity of both sexes. The
adolescent boy required 4000 calories daily. The average per kilo
needs for boys was 100 calories at one year ; this gradually fell to
80 at 6 years ; was then practically constant to 16 years, when it
gradually fell to the adult average at 19 years. In general, a little
more fat, a little more protein, and a little less carbohydrate was
required by the child than by the adult.
THE MISUSE OF MILK IN THE DIETS OF
INFANTS AND YOUNG CHILDREN.
Dr. B. Raymond Hoobler, of Detroit, stated that the value
of milk as a food both for adults and children had been exploited
during the past few years to such an extent that its use was being
much increased. This had inevitably led to many dietetic errors
particularly in the group of children between the ages of 1 and
6 years. These errors might be classified under the headings :
1. Prolonged use of milk as an exclusive article of diet. 2. In-
creased quantities of milk given along with other foods. Milk
might not only be used too long as an exclusive article of diet and
in excessive quantities with other foods, but its nutritional value
might be injured by boiling. The laiety were taught, and rightly
so, that milk was an ideal breeding place for germs, and that the
growth of these germs might be inhibited by keeping the milk on
ice, or the milk might be brought to a boil and then covered.
Through this teaching of the printed instructions accompanying
certain patent baby foods, he believed, the use of boiled milk v.^as
becoming more prevalent and many injuries to nutrition occurred
as rickets, scurvy and tetany, together with marked constipation.
In certain instances the milk was boiled without realizing ic.
Dr. Hoobler exhibited charts showing the diets usually fed
between 9 and 12 months, between 1 and 2 years, and between
3 and 5 years, and the relative proportion of the day's calories
supplied by milk when 1 quart was fed, viz : 80 per cent, between
^^..MNI ASSOCIATION
LEGE OF PHYSICIANS A^D^UR^tU
COLUMBIA UNlVBJkStiY
Nil w YORK -
American Pediatric Society 431
9 and 12 months ; 58 per cent, between 1 and 2 years ; 50 per cent,
between 3 and 5 years. The relative proportion of different food
elements which was fed when 1 quart of milk was ingested with
other foods was also shown, the fat proportion being relatively
high and the carbohydrate relatively low. The amount of over-
feeding above the basal metabolism which took place when 1
quart of milk was fed was also shown. Often the child would
refuse spoon feeding and take only milk, thus making a bad
matter worse, since this habit robbed the child of minerals which
should come to it in fresh fruits, vegetables and cereals, not to
mention the vitamine and antiscorbutic properties which these
foods possessed.
A second chart showed the caloric value and proportion of food
elements when 1 pint of milk daily was fed in addition to other
foods, the amount given being the same as in Chart 1. This
chart showed the total calories reduced to within normal require-
ments and that the proportion of fat and carbohydrate were
nearly interchangeable, thus giving the child ample calories to use
up its activities. It also showed lowering of the protein down to
the maximum for growth, wear and tear. Children fed such a
diet were free from vomiting and stupor accompanied by
acetonuria so prevalent in children who had been fed a quart of
milk daily in addition to a full diet. The propaganda urging the
use of a quart of milk daily was fallacious ; when followed it led
to overfeeding, an unbalanced ration, unhealthy nutrition and
frequent attacks of vomiting accompanied by acetonuria.
PRECIPITINS FOR EGG ALBUMIN IN STOOLS.
Dr. Clifford G. Grulee, of Chicago, stated that the prepara-
tion of the stools in this series of cases was the same as that
reported in a previous article. Egg-white rabbit serum of a titer
of 1-40,000 was used. The first series tabulated consisted of 100
stools from 21 cases, with 3 positive reactions; in both instances
the children received egg-white in the diet. The second series
consisted of 33 cases in which 242 stools gave 5 positives. This
series was carried out with an antiserum giving precipitins in a
dilution of 1 to 60,000. In this group some of the cases giving
positive reactions had had no egg albumin in the diet. It would
seem from these results that egg albumin was in nearly every
432 American Pediatric Society
instance completely broken down by the dig-estive processes in
infants and children. This held good not only for children and
older infants but also where egg albumin was used in small
quantity for the new born as well. There was only one other
possibility and that was that the egg albumin instead of being
broken down in the process of digestion was absorbed unchanged.
The writers did not feel that the specificity of the precipitin re-
action for egg- albumin was to any degree disproven by the fact
that it was found to be positive in stools where no egg had been
present in the diet. They were inclined to attribute such reactions
to the complexity of the stool.
SOME OBSERVATIONS ON THE ROLE OF CERTAIN
ANAEROBES IN THE INTESTINAL FLORA
OF INFANTS.
Dr. Langley Porter, of San Francisco, said the information
they had been able to obtain since their last communication re-
ferred entirely to the group of intestinal toxemias in which the
abnormal stool bacteria were resistant to dietetic measures usually
adequate to produce a change in the flora.
In the course of this study very rarely certain specialized forms
of colon bacilli had been encountered. These were highly faculta-
tive and extremely acid resistant, and so far no effective method
had been devised for overcoming their interference when they
were present in the stools. On the other hand, investigation of
the evacuations of the majority of patients, whose stools showed
a similar resistance to change in the floral balance, revealed the
presence of an unusual number of spore-bearing organisms, most
often anaerobes, usually Welchii, which interfered by virtue of
their facultative powers. This facultative function enabled them
to utilize any pabulum present. Because of their power in the
active stage to utilize carbohydrate, they were especially apt to
interfere when any attempt was made to shift a proteolytic flora
by feeding the patient a high sugar diet. However, by the method
suggested in this communication this interference could be over-
come and the disappearance of these spore-bearing organisms
from the stools insured. A diet limited in protein and rich in
carbohydrate would effect this change.
American Pediatric Society 433
SOME EXPERIMENTS TO DETERMINE THE PER-
SISTENCE OF EXTRANEOUS BACTERIA IN THE
GASTROINTESTINAL TRACT OF GUINEA-
PIGS AS INFLUENCED BY DIET.
Dr. a. Graeme Mitchell, of Philadelphia, stated that thus
far the proof of the implantation of organisms in the intestinal
tract rested upon incomplete evidence. Metchnikoff based his
claim of the implantation of the Bulgarian bacillus upon experi-
ments carried out by some of his pupils and followers. The work
of the latter investigators did not substantiate the theory of
implantation.
The present study was concerned only with the attempt at
implantation of an extraneous organism, the bacillus pyocyaneus,
in the digestive tract of the guinea-pig. The aim had been to
study the principles governing the implantation if such could be
accomplished. B. pyocyaneus had several advantageous char-
acteristics for a study of this kind: It was potentially patho-
genic ; it produced poisonous substances in culture which in its
pathogenic relationship it assumed in various character; it could
be fed in large numbers to the guinea-pig without causing ill
effects; above all, it was easy of recognition.
With the exception of one experiment in which the guinea-pigs
received the organism by stomach-tube, the technic of the experi-
ments was as follows : The guinea-pigs were offered various diets,
were fed the B. pyocyaneous for 3 days. At variable lengths
of time after this the pigs were killed and culture made from the
heart blood, the stomach, the duodenum, the ileum, the cecum,
and the colon.
The conclusions deduced from these experiments were that
when guinea-pigs were fed on a diet of oats, hay, bread and
green-stuff B. pyocyaneus when fed disappeared from the gas-
trointestinal tract within 3 days. When oatmeal was given as a
sole article of diet the B. pyocyaneus had been found at 7 and
9 days after the last administration. The addition of a small
amount of green-stuff, or of a certain amount of butter to the
oatmeal diet had apparently prolonged the period of persistence
of the bacterium. Pyocyaneus on these slightly amplified diets
had been found to persist about 2 weeks with considerable reg-
ularity. This increased persistence was probably apparent only.
434 American Pediatric Society
The animals on a strict oatmeal diet did not live long enough to
enable a complete experiment to be carried beyond 8 or 10 days.
The organism could not be recovered in any case after 16 days.
Judged by the amount of green color produced in the culture, the
number of surviving organisms became progressively less the
longer the interval following the cessation of its ingestion by
mouth. It was probable on the basis of these experiments that
there was an efifect of dietary deficiency which consisted in the
depression of a normal mechanism controlling the implantation
of extraneous bacteria in the gastrointestinal tract.
A BRIEF REPORT ON LACTIC ACID MILK.
Dr. DeWitt H. Sherman^ of Buffalo, gave a report on some
original work that he and his associate, Dr. Harry R. Lohnes,
had been doing this last winter on lactic acid milks.
As a therapeutic food of many years standing he discussed the
various accepted reasons for its beneficial effect. At first the
good results were supposedly due to the Bulgarian bacillus. This
idea has been stated to be incorrect. The second reason was that
the increased acidity of the gastric contents as it passed into the
duodenum stimulated the intestinal secretions. This has been put
aside. The third reason, which at present seems most rational, is
that lactic acid is efificient through Meltzer's law of "Contrary In-
nervation" ; that it is productive of good results through the in-
creased amplification of the peristaltic wave, and by this increased
motility function is iticreased.
In the infant, Meltzer's law is especially applicable because
lactic acid milk seems to act best in those cases that are undertone,
with weakened or dilated gastric musculature.
He compared the relative value of protein milk with lactic acid
milk and showed some of their differences. He questioned the ex-
tolled value of protein milk because its soluble salts were removed
and its insoluble salts, those of calcium and magnesium, were in
excess. He appreciated the value of protein milk in those infants
whose tolerance for sugars is broken. He laid stress on the
acidity of the lactic acid milks as a reason for the infants refusing
it or rejecting it. The desired acidity he placed at 70 to 90, as
measured by a decinormal sodium hydrate solution.
To keep this acidity, he gave 2 original methods for making
American Pediatric Society 435
lactic acid milk. The first was to. culture the boiled and hence
sterile milk and put it away, at a temperature of 85" F., in an ordi-
nary child's icebox so commonly found in the household. It was
to remain there over night, and in the morning would be found of
approximately the correct acidity. It was then to be boiled again
to destroy the activity of the Bulgarian bacillus, and put away on
the ice.
The second method was even simpler. Culture the boiled milk,
allow it to stand in a warm place, and in 24 hours the acidity
would reach 180 to 190, possibly 200, an acid reaction of sufficient
degree to destroy the Bulgarian bacillus. Dilute this very acid lac-
tic acid milk with an equal amount of sweet milk and the correct
acidity is secured. Upon adding the 2 a fine clotting occurs, and
when boiling the second time active stirring with a Dover egg-
beater is essential to retain a homogeneous mixture.
As regards the fat content and to make the formulae flexible in
reference to fat, a skimmed lactic acid milk was first used, and as
indications permitted whole lactic acid milk was gradually substi-
tuted for it.
THE URGENT NEED OF DIETETIC REFORM AND THE
DUTY OF THE MEDICAL PROFESSION TOWARD
ALL THE YOUNG OF THE NATION.
NEURODYSTROPHIA AMERICANA.
Dr. E. W. Saunders, of St. Louis, read this paper: Case 1.
Hazel S., seen with Dr. Poe, 10 years old, well proportioned, good
muscular development, perfect teeth, no history of injury ; lues and
alcoholism excluded. Recent history : Four weeks previously be-
gan to complain of pains in the legs. Was under the treatment of
various physicians, and of Dr. Poe for several days past. The
pains became so severe as to cause screaming, and anodynes were
given. Recently pains extended to the arms ; never afifected the
head or trunk. Status praesens: Careful examination revealed
normal condition of all viscera, glands, bones, mouth, and nose
and accessory cavities. Passive motion not painful. All functions
normal ; appetite good ; temperature normal. Dr. Main on x-ray
examination, reported perfect condition of the teeth, erupted and
non-erupted. Tonsils negligible. Spinal cord and intercostal
nerves painless on pressure. No tenderness along the course of
436 American Pediatric Society
the nerves of the extremities. No form of rheumatism in evi-
dence. Knee jerks present, but tardy on first visit, absent on sec-
ond visit ; increasing weakness of the legs, although walking was
still brisk during morning hours. Superficial reflexes normal.
Etiologic history : Family removed to the city 6 months previous-
ly from the farm, where the children were fed on natural corn
meal and soda biscuit, cabbage, potatoes, fresh butter and milk,
eggs occasionally, pork and some fresh meat. Since living in the
city, although the father earned good wages, from sheer ignor-
ance of the mother and perverted taste on the part of the child, the
diet was changed to white bread, white rice, commercial corn
meal, cookies and candy, with potatoes and meat, chiefly pork,
eggs very rarely, no greens and no butter, as the child refused to
eat creamery butter, milk in small quantities, apples eaten every
day. She had always been most strenuous at play and continued
to be so until a few days before I saw her, during the morning
hours only. Differential diagnosis : Lues, alcoholism, scurvy,
rickets, acute fatigue-myositis (of Filatov), rheumatism in all its
forms, periostitis, osteomyelitis, ordinary neuritis from exposure,
reflex pains from focal irritation, focal infections, poliomyelitis,
could all be excluded by the history and present findings. Diag-
nosis by exclusion. "Neurodystrophia Americana," confirmed
by results of dietetic treatment. Diet: Natural grain foods ex-
clusively. Greens with fat, vinegar and yeast. Abundance of
butter, yolks of eggs, malt extract, citrous fruits. Medicinally,
glycero-phosphates. Absolute rest in bed. Within 3 days, or
nights rather, there were no more screaming pains, and within a
week, no pains whatever.
Case 2. — Richard R. brought to my office July, 1919, age 5
years. Etiologic history : Six months before he had been the
leader of his companions in all strenuous play. Gradually he lost
his leadership until he would sit down and watch the other chil-
dren at play. Became peevish, disobedient, unreasonable ; his
mother was greatly afflicted by the complete change in her child.
Appetite nil, except for pufifed rice, which was eaten three times a
day, with cream and sugar. The legs grew progressively weaker
until the child fell down a flight of steps on 2 occasions. Aching
in the early part of the night, in the legs only, gradually becoming
so severe that his screams disturbed the family. Status praesens :
Child pale, somewhat wasted, listless, complaining every moment.
American Pediatric Society 437
combative to the last degree. All organs and functions normal,
and all known etiologic diseases excluded. Legs very weak, knee
jerks absent, superficial reflexes present, temperature normal.
Poliomyelitis excluded by history and subsequent course. The
anxious mother was told that the diagnosis was "American beri-
beri," and that diet would restore the child completely. However,
the treatment proved more difficult and protracted than that of any
of the cases which I have treated, owing to the psychic attitude of
the child. In order to introduce the proper food the stomach tube
had to be used internally, and the switch externally, and even so
the case proved very refractory. However, the pains speedily
ceased and the strength slowly returned to the lower limbs, al-
though the tendon reflexes had not returned when I last saw him.
Every morsel of proper food had to be administered by persuasion
or force.
Case 3. — John D., 5 years of age. Originally a very strong
and wholesome child, tireless at play. He had within the preced-
ing few weeks developed an inordinate appetite for sweets and
devitalized foods generally, eschewing most of the wholesome ar-
ticles of diet. He was anemic and tired looking. The invariable
history of severe "growing pains," occurring every night after
strenuous play. The mother was told that her fine boy had
American beri-beri, owing to her faulty feeding and that diet
would soon restore him. He was put to bed and after a few days
allowed to play in the forenoon only. The usual restorative diet
was ordered. The child cooperated well and reicovery was
prompt. The knee jerks returned vigorously within a month.
These 3 cases are not exceptional. They might be multiplied
greatly. I might also cite some instances of similar effects in
adults, fed upon the same insufficient diet, although in them the
use of tobacco, sometimes alcohol, hard labor and exposure to
weather, might vitiate the conclusions. I earnestly hope that this
short recital may stimulate many pediatricians to make extensive
researches in this direction.
HAS MALT SOUP EXTRACT AN ANTISCORBUTIC
VALUE?
Dr. Henry J. Gerstenberger, of Cleveland, reported that
while studying the respiratory quotient of scorbutic infants, it was
decided for definite reasons to feed these infants with Keller's
438 American Pediatric Society
Malt Soup, a mixture which had made for itself a record of pro-
ducing and never curing scurvy. During this study, 3 infants
with marked and severe scurvy recovered unexpectedly on a diet
of malt soup extract in a rapid and complete manner. Dr. Ger-
stenberger discussed the factors that might have influenced the
antiscorbutic content of this special lot of malt soup extract.
Discussion. — Dr. Joseph Brennemann, of Chicago, discussed
the difficulty of explaining why some food cured scurvy and
others did not and why some children were cured by almost any
change of diet. It seemed that individual susceptibility was a
large factor. The more one learned about scurvy the more keenly
he felt that the present hypothesis failed to explain many things
in connection with scurvy. Again, the question might be asked
how one was going to diagnose scurvy in mild cases if there was
no involvement of the gums or if the child was cutting teeth.
When it came to the question of the rosary that might be present
in either scurvy or rickets.
Dr. J. P. Crozer Griffith, of Philadelphia, said that those
who had been long members of the Society would remember the
oft quoted statistics of their collective investigation upon the cause
of infantile scurvy. In this there was nothing that became more
apparent than that there were various different dietetic conditions
which were capable of producing the disease. Some children
developed scurvy on pasteurized milk, some on boiled milk, and
some on raw milk. Some recovered when pasteurized milk was
changed to raw milk and some, curiously enough, when raw milk
was changed to pasteurized milk. Quite a number developed
scurvy on breast-feeding. It seemed in the report of the commit-
tee that the only conclusion justifiable was that there was some-
thing wrong with the diet, but just what this dietetic error was
did not appear clear. It was beyond question, however, that there
must be besides diet a peculiar disposition to develop scurvy seen
in a comparatively small number of infants. If this were not the
case we would find all the infants fed on a certain mixture or
proprietary food developing the disease. Thousands of children
were receiving without damage the identical food which in some
instances was followed by scorbutus. Dr. Griffith stated that malt
soup had been a favorite food with him for many years and he had
not seen more than 2 or 3 cases develop scurvy in spite of the fact
that no orange juice had been administered. It was again evident
American Pediatric Society 439
that there was some element other than diet, and malt soup was
not to be blamed more than any other foods.
Dr. Thomas S. Southworth, of New York, said he thought
this subject should be very thoroughly discussed before the im-
pression was conveyed that malt soup extract was an antiscor-
butic. In one institution they had used it quite steadily for some
years because they obtained better results than from lactic acid
milk. In making it up they had used pasteurized milk and cooked
barley, and had added the malt soup to it, suiting the preparation
to each individual child. They had had repeated outbreaks of
scurvy when the management of the institution had failed to pro-
vide sufficient orange juice or tomato. It was absolutely impera-
tive that infants receiving malt soup should have orange juice or
tomato in considerable quantities.
Dr. Gerstenberger agreed with Dr. Southworth that it would
be a mistake to give the impression that malt soup extract was an
antiscorbutic. He had merely reported the gases because they
were interesting and suggested the possibility that a malt prepara-
tion might be manufactured that possessed antiscorbutic proper-
ties, and that possibly growing the barley longer might have
something to do with it. The most plausible explanation of the
cure in these children was that this one lot of malt soup extract
happened to have this property.
MEDICAL SUPERVISION OF THE BOARDED-OUT
CHILD.
Dr. Maynard Ladd, of Boston, described the work of the
Boston Dispensary, which was started in cooperation with the
Boston Children's Aid Society and the Church Home Society, 2
of the large child-placing agencies, to demonstrate two principles :
L The value of expert continuous supervision of children in the
care of child-placing societies. 2. The value of utilizing for the
purpose the equipment and medical staff of an organized dispen-
sary, including specialists in all the chief branches of medicine, in
surgery, and in clinical and x-ray laboratories for modern medical
diagnosis and treatment.
After describing the organization of the Preventive Clinic, Dr.
Ladd presented a statistical study of 876 individual children.
About 500 a year were cared for. Of these, 15 per cent, were
440 American Pediatric Society
sufficiently ill from one cause or another to be admitted to the
children's hospital wards, which might be taken as a fair estimate
of the hospital requirements of such a group of children. A little
less than one-third of the hospital admissions were for necessary
tonsillectomies or adenectomies. The low death rate of 1.1 per
cent, undoubtedly was influenced by the prompt detection of seri-
ous cases of illness and the facilities provided for early and, if
necessary, prolonged hospital care. The mortality statistics were
interesting in the proof they offered of the practicability of reduc-
ing the death rate of a supervised group of children to a point be-
low that which was accepted as normal for the community. There
was a total of 17 deaths in 3 years among 1,551 cases, amounting
to 1 death per year for each 100 children under their care. Equally
interesting were the figures showing the effect of the special feed-
ing clinic in the nutritional development of the first and second
years. All the babies were fed on modifications of cows' milk
prepared in the foster homes and supervised by visiting nurses
under medical direction. Seven-tenths of these gained in weight
considerably above the normal rate of the average healthy infant
and three-tenths only failed to reach the normal rate by a small
margin.
The conclusion justified from this experience was that with
proper organization and intelligent direction the boarded-out
baby, even though deprived of its mother's milk, was a perfectly
good medical risk, and need not be deprived of its fair chance in
life. Incidentally, the clinic might be said to have demonstrated
also the possibility of such medical supervision for all children,
and the value of aiding it in an organized way. Expert pediatric
service ought to be made available to all children, but it was not
and could not be unless organized on some institutional basis and
made available on the payment of a moderate fee.
This clinic provided what every child ought to have but few
received: 1. A complete physical examination when accepted by
the society. 2. Correction of defects which had interfered with
proper nutrition and development. 3. Prescription and supervi-
sion under trained nurses, of proper diet, especially infants and
children in the second and third years. 4. Provision for meeting
promptly cases of acute illness occurring in foster homes and for
transferring cases to hospitals. 5. Examinations on discharge
with analysis of the history of the child under this care and trans-
American Pediatric Society 441
mission to parents and guardians through agency of social service
of the data in regard to the child's state of health and the subse-
quent care he should receive.
A TWENTY-FOUR HOUR SCHEDULE FOR BOYS.
Dr. Richard M. Smith, of Boston, recalled that in a previous
communication, "A Health Study of a Boys' School," he had
drawn attention to certain fundamental principles with reference
to the care of the health of school children and pointed out lines
for the .further extension of health supervision. There was re-
ported a table of the distribution of the boy's time during school
hours between study, activity and inactivity. They were now
convinced by a further use of the table that it gave a correct dis-
tribution of the boy's time.
The parent, the physician and the teacher were together re-
sponsible for the child's life and no part of that life could be
arranged intelligently without the cooperation of all 3 individuals.
For instance, the child's physical environment, such as buildings
and fresh air, was dependent not only upon the proper sanitation
of the school building, but also upon the room in which he slept
at home. His nutrition was maintained not only by the school
lunch and the dinner received at school, but also by the breakfast
received at home. His educational work in school must be ar-
ranged, bearing in mind not only the studies necessary for the
school curriculum, but also whether or not he was doing work at
home, such as music and languages. His exercise was made up
of what he did at home in the afternoon quite as much as upon
the carefully arranged athletics at school.
During the last year at the Rivers Open Air School for Boys
a study was made of the weekly 24 hours distribution of the time
of the boys. The matter of time distribution and the question of
instruction were the 2 most important factors in the health of
school children. There was no means at present of determining
whether a given child was distributing his time in conformity with
a healthful management. A table presented demonstrated what
appeared to be a healthful division of the hours of the week. The
data was obtained from the actual school schedules and statements
of the parents concerning time spent at home. These tables
showed that a boy of 6 years spent about 40^^ hours per week in
442 American Pediatric Society
study and exercise, and 127^ in recreation and sleep; a boy of 8
years spent 48^/2 hours in study and exercise and 119i^ in sleep
and relaxation; a boy of 10 spent 55 hours in exercise and study
and 113 in relaxation and sleep; a boy of 12 spent 62y^ hours in
study and exercise and 105^ in relaxation and sleep. These
figures represented what an average healthy boy of a given age
could do who was taking enough school work to advance in his
grade and who was having sufficient exercise to keep in good
condition. It was possible for a child to have a schedule different
in every respect from this average, yet be in normal health, and
progress satisfactorily in school. Such a child was obviously un-
usual and certainly could not be taken for a model for others to
follow. Dr. Smith believed the principles involved in these tables
were correct and hoped they would be used sufficiently so that cor-
rect principles might be inserted if those given needed modifica-
tion. The study represented cooperative effort on the part of the
teacher, parent and physician to plan the entire program of the
child as a unit, giving equal consideration to education and
health.
A STUDY OF BREAST FEEDING IN THE CITY OF
MINNEAPOLIS.
Dr. Julius P. Sedgwick, of Minneapolis, described a plan to
encourage breast feeding that he had been instrumental in putting
into effect in Minneapolis. The work fell into 2 parts: 1. That
of maintaining breast feeding. In their private work and in the
clinic they had been using certain principles described in a paper
presented before the American Medical Association in 1917 for
maintaining and increasing the supply of breast milk. They
wished to see if these principles could be applied on a larger scale.
2. They wished to ascertain what statistical results they could
show by a wider application of these principles as to the propor-
tion of mothers nursing their babies and the effect on infant
mortality.
In order to maintain and promote the milk supply they had
used the well-known methods, paying special attention to that of
making a demand upon the breast by expression. This he felt was
the most important factor in maintaining the supply of breast
milk and that it had enabled them to accomplish a great deal.
American Pediatric Society 443
The technique used in expression of the milk was not that of
going over the whole gland tissue and using massage but simply
of emptying the sinus back of the colored areola. Expression was
used for premature infants, where the mother had poor or in-
verted nipples, sore breasts, or if for any reason the baby could
not take the breast and they wished to maintain the milk supply.
The other part of carrying out their plan consisted in reaching
the public. This they had done by gaining the cooperation of the
medical profession, the health department, the Infant Welfare
Society and that of prominent citizens. The mother of every baby
born in Minneapolis during the year was either seen by a repre-
sentative of the organization or reached by mail or telephone.
Each mother was given information and literature. Each mother
was followed and seen or heard from every month or oftener if
necessary. As a result of this work, 96 per cent, of the babies
born in Minneapolis were on the breast, and the mortality had
dropped from 71 to 65 per cent, for that year.
THE FATE OF SUBCUTANEOUSLY INJECTED RED
BLOOD CELLS.
Dr. Rood Taylor, of Minneapolis, stated that former experi-
mental work had proved that subcutaneously injected red blood
cells are qualitatively capable of reaching the recipient's circula-
tion. In this work the usual clinical methods were employed to
show that the subcutaneous injection of large amounts of homo-
logous citrated blood into infants produces a decided hemoglobin
increase. Using Ashby's method of differential red blood cell
counting, the writer then determined that following subcutaneous
injection of homologous citrated blood there was no marked ab-
sorption of injected corpuscles into the recipient's circulating
blood.
THE CIRCULATORY SYSTEM IN NUTRITIONAL DIS-
TURBANCES.
Dr. W. McKim Marriott, Dr. H. McCullough and Dr.
K. Utheim, of St. Louis, made this contribution which was pre-
sented by Dr. Marriott. He stated that in that particular nutri-
tional disturbance known as athrepsia or marasmus, it was very
evident clinically that some changes in the circulation had oc-
444 American Pediatric Society
curred. This was recognized by the low surface temperature,
slow pulse and grayish color of the skin. It had seemed desirable
to estimate quantitatively the degree of circulatory changes and, if
possible, to determine the cause of the changes.
In measuring the circulation, they had used the colorimetric
method of Dr. G. N. Stewart. Before applying this method to in-
fants they had applied it to animals and compared the results with
those obtained by the Ludwig-"Strohmuhr." The method was
easily applied to infants. In a series of 29 normal infants, the
average flow of the blood was 17.2 c.c. per 100 c.c. of arm per
minute. In applying the method to 35 athreptic infants, the
volume flow of the blood was found to be greatly diminished,
sometimes being as low as 1 or 2 c.c. per minute. As these in-
fants improved the volume flow of the blood increased and in
some instances became normal.
The next question to answer was regarding the cause of the
decrease in circulation. One cause of diminished volume flow of
the blood is known to be a decreased blood volume. The next
step was to determine the blood volume of normal and athreptic
infants. In a series of normal infants, the average blood volume
was 9.1 per cent, of the body weight, the variations being from
8 to 10.8 per cent. The average blood volume of a number of
athreptic infants studied was 8 per cent, of the body weight. One
showed as low as 4.8 per cent. As adipose tissue is a relatively
non-vascular organ, none would expect a thin infant to have a
larger amount of blood per kilo of body weight than a fat one.
They found the reverse to be often the case. This indicated a
definite decrease in the volume of the blood. The lowered blood
volume was sufficient to account for the low volume flow in at
least some of these infants. Other factors, however, seemed
probably to be operative. The peripheral volume flow of the blood
would be increased if capillary or arteriolar constriction had oc-
curred. They found such a constriction to occur in these infants.
This was shown by the fact that there was a piling up of the blood
corpuscles on the capillary side. Blood obtained by a prick in the
skin of these infants showed a distinctly higher hemoglobin in red
and white cell counts than blood obtained directly from the veins.
This constriction of the arterioles leads to poor peripheral circula-
tion, and probably to the gray color of the skin. It also accounts
for the fact that some of these extremely athreptic and apparently
American Pediatric Society 445
riiiemic infants have normal red blood cell counts when deter-
minations are made on capillary blood.
They considered the arteriolar constriction as a compensatory
mechanism to maintain blood pressure when the blood volume was
diminished. They found this mechanism ordinarily sufficient to
maintain the blood pressure as they very rarely observed low blood
pressures in the athreptic infants studied. Having considered the
changes in the blood and in the vessels, they next turned to a
consideration of the heart muscle itself. This, it might be ex-
pected, would atrophy with the rest of the body, but at post
mortem very little change in the heart muscle could be made out.
It is possible, however, that functional changes might occur. To
determine whether or not such was the case electrocardiograms
were made and in a certain number of the infants, definite changes
in the functional activity of the heart muscle were demonstrated.
The variations from the normal most frequently observed were
low amplitude of all waves. The P and T waves were frequently
absent, especially in leads one and three. The P-R time was
found to be as long as 0.2 seconds, and the Q-R-S time was fre-
quently prolonged. The ventricular complexes were occasionally
abnormal in form, the R wave especially being notched. With
improvement in the clinical condition of the patients, tue form of
the electrocardiograms changed, and this suggested that the alter-
ations in the heart muscle were functional rather than organic.
They suggested that poor circulation through the coronary arteries
was in part responsible for the changes, a vicious circle being
thus established.
Some experiments were done on animals in an attempt to
reproduce the athreptic condition. After a period of complete
starvation the blood of rabbits was found to be definitely de-
creased, and also the volume flow. When the animals were again
fed, they maintained a constant weight for a considerable period
of time until the blood volume slowly increased. After this the
process of repair became more rapid. In some animals the blood
volume did return to normal and these animals failed to recover
their weight and finally died.
RECENT STUDIES IN BLOOD NITROGEN OF INFANTS
AND CHILDREN.
Dr. Frederic W. Schlutz, of Minneapolis, presented this
446 • American Pediatric Society
study which had for its object the establishment of normal figures
for the non-protein nitrogen content of the blood in infants and
older children. Practically no complete studies on normal children
were available; such figures were, however, available for normal
adults as the result of the work of Professor Folin. Determina-
tions of total nitrogen, urea, uric acid, creatinin, combined creatin
and creatinin and of blood sugar were made. The amino-acid
fraction was also being studied but the results were not yet ready
for presentation.
The methods used were those of Folin. The DuBoscq calori-
meter was used throughout. An effort was made to have the
material as nearly normal as possible. The blood was taken from
the head sinus in infants under 10 months and from the median
basilic or external jugular in older children. Ten c.c. was usually
taken, which was sufficient for all determinations and even al-
lowed of repeating some. All determinations were carried out
within 24 hours. The blood was taken from 2^ to 17 hours after
the intake of food. The children were arbitrarily divided into 5
age periods as follows : from 1 to 6 months, from 7 to 14 months,
from 2 to 6 years, from 7 to 10 years, from 11 to 14 years.
There were in all 88 cases. A chart indicated the maximum and
minimum figures for the different age periods, and there were all
gradations between. The total nitrogen ranged from 24.90 to
41.10 mg., the average being between 32 and 34; for adults Folin
and his co-workers found from 2 to 34 mgs. The urea ranged
from 10.80 to 20.40 mg., the average being about 15.50 mg. ; for
adults the average was between 10 and 23 mg. The uric acid
ranged from 0.55 to 4.75 mg., the average being about 2 mg. plus ;
the average for the adult was from 2 to 3 mg. Creatinin ranged
from 1.110 to 2.055 mg., the average being about 1.4 mg. ; the
average for the adult was 1.1 to 1.3 mg. The creatin and creatin-
in ranged between 4.74 and 8.92, with an average of 6.5 mg. ; the
average for the adult was 6.5 to 9.5. The blood sugar percentage
ranged between 0.05 and 0.14 per cent., with an average of about
0.09 per cent. ; the average for the adult was between 0.06 and
0.12 per cent.
These figures. Dr. Schlutz believed, corroborated for the
periods of infancy and childhood the findings for normal adults,
namely, the constancy of the non-protein nitrogen excretion. This
was true for all the components except for uric acid which showed
American Pediatric Society 447
the same variability it showed in adult blood. The study sup-
ported the explanation of Folin and Denis that the normal kidney
maintained a constant level of non-protein nitrogen and urea in
the blood. The figures found in infancy and childhood approxi-
mated very closely those found in adult blood and held for all age
periods.
In a study of the blood in reference to these substances in con-
stitutional diseases, a normal blood picture was found, especially
in respect to the uric acid content, which agreed with the results
of Liefman. A high total nitrogen and urea figure was found in
asthma, but there was no good explanation for it.
Observations were carried out on a large series of pathological
cases, the results of which showed in the absence of marked
hyperpyrexia, and any kidney involvement figures for the differ-
ent components about the same as in the normals. This was in
agreement with the results found by Leopold and Bernhard and
a recent extensive study by Chapin and Meyers.
ELECTROCARDIOGRAPHY IN CHII^DREN.
Dr. Frederic W. Schlutz and Dr. Max Seham, of Minne-
apolis, in this paper covered, first, the physiologic peculiarities of
the normal electrocardiograms of all ages of childhood, including
the premature, from 1 hour to 13 years; second, the pulse period
in SOths of a second in all ages; third, the transmission time of
both auricle and ventricle ; fourth, diseases peculiar to childhood.
The electrocardiogram at birth was constant. All of the new-
borns, 22 in number, showed similar curves. A right ventricular
preponderance was characteristic, showing a deep S, and a high
Rg. During the first 3 months this form persisted. During the
fourth month the S became smaller than the R in Derivation 1,
signifying a change from right to left ventricular preponderance.
From the fourth month to the end of the first year, it gradually
changed into the adult type. From the first year on the adult
characteristics persisted.
In the premature the form of the electrocardiogram was in-
complete. All of the deflections except S were not seen. After
birth all of the deflections in both the auricular and the ventricular
complex were well established, and in practically all instances
showed on the tracings.
448 American Pediatric Society
The pulse in new-borns was quite regular as was shown by
the electrocardiogram. Sinus arrhythmia was not complete until
the school age. From this time until puberty it occurred in about
50 per cent, of all normal children.
By measurement of the P-R intervals and the R-T intervals
the transmission time could be accurately studied. The average
P-R in new-borns was 0.10 of a second, from two to five years it
was 0,12 of a second, and from 6 to 13 years it was 0.28 of a
second. This included the Q-R-S period which in the respective
ages was from 0.03 of a second to 0.09 of a second.
The electrocardiograph was not only of value in pediatrics for
the normal, but it was a great aid in diagnosis in abnormal condi-
tions. A study of 22 congenital heart lesions, 2 of which came to
autopsy, showed that only in cases in which the right side of a
heart was involved, especially pulmonary stenosis, there was a
characteristic right ventricular preponderance shown. In 7 of
11 drop hearts, all of which were confirmed by x-ray the ventri-
cular complex in lead 1 was unusually low. Exudative diathesis
decomposition, hypertrophy of the heart when unassociated with
heart murmur spasmophilia, tuberculosis of the lungs, and other
miscellaneous diseases were studied in 300 cases.
Pyloric Stenosis in Infancy (Annals of Surgery, May,
1919, p. 531). F. O. Allen, Jr., cites a case in which he operated
when the baby was three months old. Instead of the usual tumor,
he found a distinct plication at the pylorus, the duodenum bent
forward and adherent to the stomach for a distance of almost
a quarter of an inch. The area was hyperaemic and there were
definite cobweb adhesions. Allen divided the adhesion with
scHsors, and straightened out the pylorus. — Journal A. M. A.
Archives of Pediatrics
AUGUST. 1920
HAROLD RUCKMAN MIXSELL. A.B.. M.D.. Editor
CHARLES ALBERT LANG, M.B.. M.R.CS.. Associate Editor
COLLABORATORS :
L. Emmett Holt, M.D New York Fritz B. Talbot, M.D Boston
W. P. NoRTHRUP, M.D New York Maynard Ladd, M.D Boston
Augustus CaillS, M.D New York Charles Hunter Dunn, M.D. .. .Boston
Henry D. Chapin, M.D New York Henry I. Bowditch, M.D Boston
Francis Huber, M.D New York Richard M, Smith, M.D Boston
Henry Koplik, M.D New York L. R. De Buys. M.D New Orleans
Rowland G. Freeman, M.D New York Robert A. Strong, M.D....New Orleans
Walter Lester Carr, M.D... New York S. S. Adams, M.D Washington
C. G. Kerley, M.D New York B. K. Rachford, M.D Cincinnati
L. E. La FfiTRA, M.D New York Henry J. Gerstenberger, M.D. .Cleveland
Royal Storrs Haynes, M.D... New York Borden S. Veeder, M.D St. Louis
Oscar M. Schloss, M.D New York William P. Lucas, M.D... San Francisco
Herbert B. Wilcox, M.D New York R. Langley Porter, M.D..San Francisco
Charles Herrman, M.D New York E. C. Fleischner, M.D....San Francisco
Edwin E. Graham, M.D Philadelphia Frederick W. Schlutz, M.D.Minneapolis
J. P. Crozer Griffith, M.D.Philadelphia Julius P. Sedgwick, M.D. . .Minneapolis
J. C. Gittings, M.D Philadelphia Edmund Cautley, M.D London
A. Graeme Mitchell, M.D.. Philadelphia G. A. Sutherland, M.D London
Charles A. Fife, M.D Philadelphia J. D. Rolleston, M.D London
H. C. Carpenter, M.D Philadelphia J. W. Ballantyne, M.D Edinburgh
Henry F. Helmholz, M.D Chicago Tames Carmichael, M.D Edinburgh
L A. Abt, M.D Chicago John Thomson, M.D Edinburgh
A. D. Blackader, M.D Montreal G. A. Wright, M.D Manchester
PUBLISHED MONTHLY BY E. B. TREAT & CO., 45 EAST 17tH STREET, NEW YORK.
ORIGINAL COMMUNICATIONS
THE EFFORT SYNDROME IN CHILDREN*
By Charles Gilmoke Kerley, M.D.,
New York
It has long- been my observation, that children divide them-
selves into groups as relates to their individual characteristics.
This tendency to grouping is not discernable to any extent among
infants. After the second year, individual traits, and a distinct
personality manifest themselves. At about this period the child
begins to individuate.
During the late international war, English army surgeons
learned, that, when certain recruits were put to prolonged hard
work, at drill, hikes, and other exertion, they failed to measure up
•Read before the 32nd Annual Meeting of the American Pediatric Society,
lield at Hyde Park, Chicago, Illinois, June 1, 2 and 3, 1920.
449
450 Kerley: The Effort Syndrome in Children
to the endurance standard required of a soldier in the field. These
recruits had passed the various physical tests, and had been put
to training. After a time it was found necessary to disqualify the
men, because of inability to perform the duties and bear the hard-
ships demanded, which others were able to meet. To this con-
dition. Dr. Thomas Lewis applied the term "effort syndrome."
As the most prominent symptoms involve the circulatory -and
nervous system, later writers have used the term "neuro-circula-
tory asthenia" or "neuro-circulatory myasthenia" (MacFarlane).
It was found that in some individuals the disability was due to
infection from the tonsils, teeth or other foci. Other cases appar-
ently were of endocrine origin. To describe the condition, as it
occurred, in a great majority of soldiers, Lewis applied the term
"constitutional." Friedlander and Freyhof, in the Archives of
Internal Medicine, December, 1918, reported on 50 cases of so
called "constitutional neuro-circulatory asthenia." Robey and
Boas (Journal of American Medical Association, August 17, 1918)
after an intensive study of a large number of soldiers, suffering
from neuro-circulatory disorders were obliged to recommend for
permanent discharge 87 per cent. These cases all belonged to the
so called "constitutional" class.
The boy or girl who may qualify for the "effort syndrome"
class, comes to us with a typical story, which, condensed, means
that there is an absence of capacity for sustained effort, both men-
tal and physical. It is stated that the child is backward in school,
behind in his classes. He is intelligent, but cannot apply himself
sufficiently to become an average student. In like manner, he is
physically unfit for the usual activities of boyhood. He tires
readily and prefers to be a spectator rather than an active partici-
pant in games and other amusements. Wherever endurance is
required, he fails. If he attempts, in later life, to make the foot ball
or base ball team, he is turned down by the coach or trainer.
Nevertheless, he is not ill, and even upon a very thorough physical
examination, will fail to show disease.
The weight and height apparently have little to do with the
condition. In my case records, this type of child has been hereto-
fore classified as a poor individual. One of the distinguishing
characteristics is a lack of nervous control. Tthe individual boys
and girls of this type are subjected to a good deal of unjust criti-
cism. They are accused of being lazy, indifferent, careless and
Kerley: The Effort Syndrome in Children 451
dull. The fact is, they are poor types of humans, of from 50 to
75 per cent, capacity.
It is important not to confuse these young people with those
who suffer from bad habits, as regards their sleep, rest and gen-
eral hygiene, or with those who are bodily ill, or with those, who,
because of rapid growth and arduous duties, are temporarily but
not permanently below normal. With suitable management in such
cases, there will always be a sustained response. It can be readily
understood that in girls the above mentioned constitutional pecu-
liarities may attract less attention and be more readily excused
when present.
Case 1. A young man, now 23 years of age, came under my
care at the age of 6 months. He was the oldest of 3 children and
the only boy. The father was in fair physical condition, the
mother was delicate in the sense that she had very little resistance
or stamina. Frequent rest cures were necessary. She had back-
aches and headaches habitually, was nervous, thin and pale and
always had been a care to her parents. The boy had the usual
illnesses of childhood. He suffered considerably from digestive
disturbances in the early years. He was irritable at home and
rather unhappy at school. His school life proved very strenuous
and was interspersed with frequent intermissions for one cause
or another. Meiital control was defective. Tantrums were not
unusual. As he grew to older boyhood, various boarding schools
were attempted, but he never remained longer than the Chri^-
mas vacation. It was uniformly found by the head master, that
the school was not suited to the boy.
When the United States entered the war, he volunteered in a
certain department and w'as accepted, passed the physical examina-
tion, and remained a few weeks. He was then advised by the
commanding officer, that he would do better work in another
division of the service. Thither he went and was examined and
again accepted, but in a short time was advised to apply to another
department. Again he was accepted and again he failed. The
boy was anxious to enter the service, as all his friends had volun-
teered and 2 younger sisters made his life miserable by their
anxiety to have a big brother hero. It was absolutely impossible
for this boy to do the wlork required of him in any of the positions
he attempted, although he was most anxious to serve.
452 Kekley: The Effort Syndrome in Children
These individuals finally drift into the right occupational
sphere, one that requires very little expenditure of effort.
Case 2. A boy who was a fine physical specimen, was fre-
quently ill. He had a tendency to be introspective and moody. He
did not like school and could not get along very well with the
other boys. His school attendance was interrupted by headaches,
attacks of indigestion and various nervous disorders ; he was in-
clined to hysteria and brain storms. When he was 12 years of
age, he was ashamed to go to school, because he was so far behind
others of his age. With private tutoring, he was able to enter the
primary department of a large boys school, at the beginning of the
autumn term. Just before the Christmas holiday, the mother had
a letter from the head master, telling her that in his opinion their
particular school was not suited to the requirements of her son.
Study made his head ache. Work in the garden produced dizzi-
ness. As a young lad he wiould ride his bicycle down hill 2 miles
to the village, and pay some public conveyance to take him and the
bicycle home. He suffered from palpitation if he rode up hill on
his bicycle. He is a well meaning, well spoken, kindly disposed
young man, without a trace of initiative. He has tried very hard
to be a real boy, but he tells me he cannot, and it has caused him a
great deal of worry. Thousands of dollars have been wasted on
him up to date. The mother was 46 years old when the boy was
born and the father 50.
Case 3. A young man of 20 years is still in the preparatory
school, preparing for college. I have known this boy since he was
an infant, and have exerted all the influence I possess, to have
him give up the college idea and go into business. His friends are
all in college, and there only will he be happy. He enjoys fairly
good health but has never been know<n to take part in any sport.
He prefers to be a spectator. Exertion makes him nervous and
any unusual event causes him to remain in bed the next day. He
is totally devoid of initiative. The mother of the boy is an habitual
invalid, but is never very ill. The father is an unusually able
business man.
Case 4. A girl, 18 years of age, large, well formed, mentally
alert, is in school about half the time. She has frequent headaches
and backaches and tires easily. Other girls make her nervous.
Parties tire her. An evenins: of dancing: could never be considered.
Kerlev: The Effort Syndrome in Children 45i
The girl is normal physically and has been examined and treated
by a goodly number of physicians. I have known her since she was
2 years old. She always has been and always will be just useless.
These few cases are given simply as illustrative of the type.
Similar cases and other less pronounced exist in all communities,
and all have one feature in common — a lessened capacity for sus-
tained effort. From the standpoint of treatment, they constitute
a most discouraging group. Rest cures, change of climate, and
various supporting measures are of little avail. As these individu-
als are fashioned, so they remain.
The poor individual exists throughout the entire animal world.
Among the lower animals, those of defective capacity, for econ-
omic reasons, usually have a short career. The defective func-
tionating human, if well born, is urged and forced and stimulated
to accomplish that which is not in him. It is i)}ipossiblc to i^et out
of any piece of machinery, work which the machine ttvi.s' not i)i-
tended to accomplish. Millions of dollars are wasted on youths
who are physically and mentally unable to meet the standards
set up by ambitious parents and friends, in an effort toward
their so called higher education. The highly trained teaching
talent of our preparatory schools and universities is wasted in
part on poor student material, 25 to 50 per cent, of which should
be scrapped and put to productive occupation. Before a boy is
permitted to avail himself of unusual educational advantages
it should be determined that he is zvorth it. The high school and
the preparatory school should serve as a clearing house. In
addition to the mental attainments required for a college entrance,
it should be required that a candidate submit testimonials as to
physical fitness and mental capabilities from the head master or
high school principal.
What is needed, for economic reasons, is expert occupational
diagnosticians, who will aid in placing the boys at work to which
they are fitted. I have had the opportunity to keep in touch with a
great many boy patients, through manifesting an interest in them,
and have been able to advise and assist them along occupational
lines. A boy, who belongs in the class we are discussing, should
discontinue school in the fifteenth or sixteenth year and take up
business. In order to make a reasonable success, the occupation
must be one that is not strenuous. Such boys often make fairly
good salesmen, clerks and l)ookkeepers. They never get very
454 Kerley : The Effort Syndrome in Children
far however, as they belong to that considerable class who watch
the clock. Advancement in salary, partnership, etc., go elsewhere.
It is exceptional to find children of this type the offspring of
strong, vigorous young persons. In a great majority of the
cases, they are the offspring of a weakly mother; the mother of
little resistance, of lessened endurance capacity. A strong vigor-
ous mother will do much to oft'set the unfavorable influence on
the progeny of a weakly male. The progeny of vigorous males
is greatly handicapped by inferior mothers. All of which applies
to the lower animals as well as the human. Frequent child bear-
ing has apparently been a factor in some instances. By far,
however, the chief cause of the 50 to 75 per cent, individual, is
a mother of lowered resistance, of inherent weakened constitu-
tion and inability for sustained effort, which defects she transmits
to her offspring. The necessity for a great deal of attention to
the physical development of those who will some day be mothers,
is a very urgent need.
Comment. — There are constitutionally inferior, substand-
ard (MacFarlane) children. Thus constituted, they enter the
world and thus they continue throughout perhaps a long life
regardless of attempts at improvement. A trait common to all is
inability for sustained effort. Physicians and educators and all
interested in the development of the young, should appreciate,
that what often passes for indifference, indolence, and inatten-
tion may be of constitutional origin and impossible of correc-
tion. Where such is found to be the case, the child's curriculum
should be made to fit the child and not the child to fit any cut and
dried curriculum. All such attempts mean energy wasted.
Surgical Lesion from Ascaris (Hospitalstidende, Jan. 8,
1919, p. 38). A. Holler's patient was an infant of 22 months
under treatment for ascarides. In one week he passed seventy.
Then symptoms of peritonitis compelled laparotomy, and an as-
caris was found in a pus pocket, but this pocket was encapsulated
and there was no peritonitis. The toxic effects of the masses of
ascarides were long felt. He was brought back to the hospital
four months later with further masses of ascarides. A second
course of santonin has apparently banished them completely. — ■
Journal A. M. A.
THE DIETETIC TREATMENT OF SUMMER DIARRHEA*
By J. P. Crozer Griffith, M.D.,
Professor of Pediatrics in the University of Pennsylvania.
Philadelphia^
Only a year ago it was my privilege to take part in a symposium
upon summer diarrhea, read before this Society, and to discuss a
topic covering that which is assigned to me for this evening.
Nothing new upon the subject has appeared in medical literature,
so far as it has come to my notice, and I can only reiterate and
emphasize what was said on that occasion.
The term "summer diarrhea" is a broad one and covers more
than one clinical and pathological affection. We might better
speak in the plural of "summer diarrheas." The treatment con-
sequently varies to some extent, depending upon the nature of
the disease — whether we are dealing with the simple congestive
condition of acute intestinal indigestion ; some one of the forms
of acute intestinal intoxication with its degenerative changes ; or
the inflammatory process of ileocolitis. Yet to a certain extent
the treatment of all of these can be considered at one time. It
resolves itself into (1) prophylactic, (2) dietetic, (3) hygienic,
and (4) medicinal and local. It is my province to discuss the
first of these, so far as diet is concerned, as well as the dietetic
treatment of the attack itself. It is impossible to avoid entirely
some reference to certain allied therapeutic procedures.
(1) Prophylactic. Acute intestinal indigestion and acute
gastroenteric intoxication are the most frequent varieties of diar-
rhea in infants, and, inasmuch as inflammatory forms usually
develop as a sequel to these, prophylaxis as applied to them will
generally include that of any other diarrheal disorder. Prophy-
laxis is of the utmost importance. Very numerous statistics from
difTerent countries agree in the much lesser mortality among breast
fed babies as compared with those who are bottle fed. They agree,
too, that a large proportion of deaths in infancy, and especially
in the first year; of life, are dependent upon gastrointestiial dis-
orders. George Still estimated that from 2000 to 4000 infants,
under 1 year of age, died annually in London from diarrheal
diseases, and Hermann, that over 33 per cent, of the deaths in the
1st year in Berlin were to be assigned to digestive disturbances.
*Read at a Symposium before the Philadelphia Pediatric Society, May 11, 1920.
455
456 Griffith : The Dietetic Treatment of Summer Diarrhea
It has been shown further that deaths from this cause m infancy
occur predominatingly in artificially fed subjects. In general terms,
the artificially fed infants show 5 times the mortality seen among
the breast fed. The inference is obvious. The very best method
of prophylaxis is to insist upon breast feeding whenever this is
possible. It is possible much oftener than supposed. Far too
frequently early weaning is solely the fault of the obstetrical nurse
or of the attending physician. Too early discouragement must
not be felt and yielded to, merely because the breast milk seems
insufificient or appears to disagree. It happens many times that
both of these difficulties will disappear when the colostrum period
is over, and the mother is up and is following her usual method
of life. Encouragement given to the mother by the physician
counts for much. Many a mother has lost her milk merely be-
cause she worried lest she should lose it. Moreover, a little breast
milk, helped out by the bottle, is far better than none at all, and
weaning should never be permittd merely because the mother's
secretion is scanty. If we can bring the baby through the first 3
months of life with breast feeding, we shall have made a good
start, and the infant will be less susceptible ; although, of course,
the longer we can maintain breast feeding during the first year,
the better it is for the child. Again, when the time of weaning
is left open to us, the summertime should be tided over, if pos-
sible, before nursing is brought to a close.
When artificial feeding is necessary, the character of and the
care of the food is of vital importance in securing prophylaxis.
Everyone knows the enormous difference in the numbers of bac-
teria present as seen in the most carefully produced and guarded
milk on the one hand, as compared with that, on the other, which
has not received this care. Those who have watched the lessened
frequency in the incidence of summer diarrhea connected with
the purification of the milk supply cannot share the view of
Jjiikelstein upon the little etiological importance of the bacteria
in milk. Further, it may be stated that the application of heat to
milk, although it does not destroy toxins, at least does destroy
and, with proper later precautions, inhibit the growth of bacteria,
and to this extent the procedure is a valuable prophylactic measure.
The danger from scurvy with heated milk is so much less than
is the danger of diarrhea from the use of raw milk, that it fades
into insignificance, particularly since the development of the
Griffith : The Dietetic Treatment of Summer Diarrhea 457
disease is so readily preventable by the giving of orange juice.
All but the best milk should be pasteurized, and even this should
be subjected to the process in summer weather. But by pasteur-
ization is not intended here commercial pasteurizaiton, which we
cannot supervise, and of the thoroughness of which we know
nothing, and which often gives to the physician and the mother
a false feeling of security.
Not only is the prevalence of bacteria in the food to be avoided
or counteracted, but care should be given to the proper composi-
tion of the milk mixture. This is too large a subject to be dis-
cussed here in detail. Merely may it be stated that always, and
especially in summertime, underfeeding is certainly a less grave
error than is overfeeding. A moderate degree of imperfect develop-
ment of weight and of growth in general is to be preferred to a
severe and perhaps fatal diarrhea. What has been said is, how-
ever, not to be considered a brief for underfeeding ; although at
least in the spells of torrid weather which occur from time to time
in the summer season, both the strength and the amount of the
infant's food may well be reduced for a period. The efifort should
be to make the food digestible and sufficiently nourishing, and no
more than this.
As to the elements of the food chiefly to be guarded against
lest diarrhea develop, the precautions doubtless vary with the case.
In general, protein is less liable to give trouble than is an excess
of fat or sugar. Opinions are divided as to which of these two
is oftener the cause. In my own experience, more difficulty is
encountered in the digestion of the fat of cow's milk than of any
other element ; less often, although still not infrequently, an excess
of sugar is not tolerated.
(2) Diet During Diarrhea. For the treatment of the attack
itself, the correct management of the diet is by far the most im-
portant factor in treatment. The first and most vital step in this
direction is the immediate and complete withdrawal of food at
the beginning of the attack. It is a little difficult tO' teach mothers
this; even those of the better class. The fear seems to exist
that the baby will starve. That the initial starvation should be
immediate is of importance, and mothers should be instructed
that, with any digestive disturbance whatever, food is to be with-
drawn at once, without waiting to get into communication with
the physician.
458 Gkiffith : The Dietetic Treatment of Summer Diarrhea
Combined with the withdrawal of food should naturally be
the removal of any already in the intestinal canal. This is to be
accomplished by the prompt exhibition of a purgative, such as
castor oil for young infants, and magnesia in some form for older
ones or for children, since castor oil is very liable to be rejected
by them. If vomiting attends the diarrhea at the beginning, it
may be necessary to wait before a purgative can be safely ad-
ministered. In any case, a large intestinal douche may be given
with advantage.
How long the initial starvation shall continue depends u^xin
the case. Breast fed infants may well have the breast withdrawn
for 24 hours, and those bottle fed require usually a longer time.
Water, of course, should be administered freely, and it will relieve
the mother's mind if barley water is used instead of simple water.
While fever continues, showing that an infection is still present,
return to a milk food should be delayed, and the resumption of it
finally be made very carefully, giving small amounts diluted, and
preferably skimmed, the original strength of the mixture being
only very gradually resumed. As already stated, an excess either
of fat or of sugar may cause diarrhea; but which is the agent
in any individual case and which element must be most cautiously
returned to the diet, must, of course, be determined for the in-
dividual. Broths, thickened with an amylaceous substance, or
even thicker unirritating porridges, are extremely serviceable
when the time for food has come but while one still fears the
action of milk. It seems odd that the milk upon which the child
has previously been thriving, and which would seem to be nearest
to its natural aliment, should become an active poison when sum-
mer diarrhea has once developed.
When cases have proven tedious and obstinate, it is often
best to abandon eflforts to return to the former milk mixture, and
to make a complete change in the diet, using whey, casein milk,
buttermilk, or the like. Sometimes the thick gruels, to which
reference has been made, are of great value as a food ; bearing
in mind, however, the occasional danger of producing a starch-
edema when no protein or an insufficient amount of it is given.
In some cases nothing will be of service but the administration of
human milk.
With regard to the administration of starchy food, so often
of so much value in the treatment of diarrhea, it is well to remem-
Griffith : The Dietetic Treatment of Summer Diarrhea 459
ber that in not infrequent cases the greater part of it is passed
from the bowel completely midigested. It shows under these
circumstances some resemblance to mucus or even to milk ; but
that it is starch can, of course, be readily determined by the
iodine test. In such cases, where starch is undigested, sugar in-
creases the diarrhea, and fat is eliminated as curds, the only re-
maining element is protein, which can often be given in com-
paratively large amount and with relatively little of any other
food element employed. Such a diet is not one suitable for long
continuance, and fortunately the need for this does not very
often arise.
The great* danger of relapse and recurrence is not to be for-
gotten. It may exist through the whole of the summer, and it
may be necessary to maintain a restricted diet until the hot
weather is over. Particularly should the mother be made to under-
stand that a gain of weight after an attack of summer diarrhea
is a matter of entirely minor importance. After the summer is
over and the digestive power fully re-acquired, the obtaining of
the desired gain is usually a simple matter. Yet in this connec-
tion the converse must be emphasized. I have repeatedly seen
infants, both younger and older, allowed to emaciate badly, merely
because the physician was without the courage to increase the
diet when it could and should have been thus increased.
What has been said applies particularly to the diet in acute
intestinal indigestion and in the ordinary type of acute gastro-
enteric intoxication. Some slight modification of it must be made
in other forms. In acute milk poisoning, it is even more important
to institute a total abstinence from food, and the return to it
should be made with the greatest caution. Meanwhile nothing
whatever but watef should be given, by the stomach if it can be
retained, if not then in other ways. The water may be in the form
of a normal saline solution, or, better, of a 1 per cent, solution
of bicarbonate of soda, since acidosis is one of the great
dangers in this condition. On the other hand, in the diarrhea
occurring in severely marantic subjects, prolonged starvation is
inadmissable, and here it may be necessary to feed in some way
earlier than one otherwise would. Again when gastrointestinal
intoxication has passed into an ileocolitis, as it often does, or
when the attack has been of this nature from the beginning, we
are probably in for a prolonged illness ; and after the initial
460 Griffith : The Dietetic Treatment of Suinmer Diarrhea
starvation care must be taken to maintain the strength by a
suitable dietary. All efforts in this direction must, of course, be
made cautiously, and it may .be necessary to maintain the with-
drawal of milk for some weeks and to use other sufficiently
nourishing food in place of it.
Another form of summer diarrhea is not infrequently seen ;
or at least one which is liable to owe its origin to an acute attack.
I refer to the condition of chronic diarrhea frequently a sequel to
an ileocolitis, or especially to the form of recurrent or more
persistent looseness of the bowels existing as a symptom of chronic
intestinal indigestion. This is a condition with symptoms so
characteristic, so troublesome, and so prolonged, and with dietetic
treatment requiring in all particulars so much detailed study of
the individual case, that time does not permit of an extended dis-
cussion of it. Only trial can eventually determine what sort of
food will be tolerated best, guided by a careful study of the past
history of the case, and the relation which symptoms bore to
changes in the food. This study cannot be too minute. There
may be faults in the frequency of feeding or in the amount of
or the composition of the food. The examination of the stools
may show the passage of too much fat, or irritation of the but-
tocks may, point to an excess of sugar. There is a large choice
among the foods we may try. The high protein foods, such as
casein milk or the ordinary buttermilk mixture, may serve well.
Sometimes the latter will not agree until the amount of sugar
is reduced ; or one form of sugar may be better tolerated than
another. The large amount of unconverted carbohydrate in the
buttermilk mixture and the small amount of fat are factors which
make it often suitable. Where fat is tolerated in a moderate, al-
though reduced amount, malt soup may prove serviceable, the
carbohydrate making up for the diminished quantity of fat and
of protein. Casein milk may answer well where, it is desired to
keep the sugar low, the protein high, and the fat in, fair amount.
When milk in any form is not tolerated, we must depend largely
upon albumin water or upon animal broths fortified with a cereal
addition and with the finely divided meat fibre retained.
In the case of older children, the problem is increased by the
number of articles of diet among which one has to determine the
cause. In these cases, diarrhea may occur only during the
exacerbations, or may alternate with constipation. The treatment,
GRTFFfTTi : llic Dietetic Treatment of Summer Diarrhea 461
however, is the same, since it must be directed to the cause. As
regards the choice of food, only general suggestions can be consid-
ered here. The most frequent cause is an excess of carbohydrate
in the diet ; that is to say, an amount more than the child can
digest, although it may not in itself be unduly large. Next in
order stands an excess of fat. In bad cases it may be necessary
for a time to eliminate largely both of these elements. Con-
sequently a diet rich in protein is often the best. Naturally all this
must be determined for the individual case, and there is little
which presents a greater therapeutic problem to a physician in
caring- for a sick child.
Pathogenesis of Chorea (Pediatria, Naples, Sept., 1919).
P. Foti relates that syphilis was unmistakable in 13 out of the
17 cases of chorea given treatment at the children's clinic at Naples
during the last five years. It was probable also in 3 others, and
only 1 of the 17 children seemed to be entirely free from the taint
in every way. He insists that this 95 per cent must be more than
the mere coincidence which Comby thinks it is. He regards it as
a predominating influence in the pathogenesis of chorea as the
principal predisposing factor, entailing such instability of the
nervous system that the most diverse causes, infections, emotional
stress or metabolic disturbance may bring on the chorea. — Journal
A. M. A.
Vaccine Therapy of Dysentery in Children (Pediatria,
Naples, Sept., 1919). F. P. Borrello gives full details of 24 cases
of dysentery in young infants and children up to 10 years old.
The disease is more common in children than generally recognized,
and seems to be graver the younger the child, and in the Shiga
form, but the Flexner form is liable to prove fatal also, especially
when secondary to other disease. Treatment is principally with
the specific vaccine, and this is more effectual the earlier it is
begun. Its efficacy is most striking in the Shiga form, which with-
out it is almost invariably fatal. — Journal A. M. A.
THE BACTERIOLOGY OF SUMMER DIARRHEA.*
By D. H. Bergey, M. D.
University of Pennsylvania.
Philadelphia.
Infantile diarrhea is generally due to infection with members
of the typhoid, paratyphoid, and dysentery groups of bacteria,
most frequently the latter. Occasionally other bacteria are the
causative agents of this disease, namely the Gaertner group, the
proteus group, or the Welchii group. It is sometimes difficult to
differentiate between infection by these different groups of bac-
teria and diarrhea due to disturbances of digestion induced by
unsuitable foods.
In the greater proportion of instances the summer diarrheas
of children are caused by the invasion of the intestinal tract by
members of the dysentery group of bacteria. The expression
"dysentery group" is used because we recognize 4 or more types
of organisms which can be differentiated from each other but
which show close relationship when subjected to cultural and sero-
logic tests and they are found, moreover, in allied pathologic con-
ditions in the intestines of human beings.
The recognized types of the dysentery group of bacteria in-
clude the type first discovered by Shiga in Japan and later found
to be disseminated over the whole world ; the type discovered by
Flexner in the Philippines, but since found in all countries ;the type
discovered by Hiss & Russell in Maine and the type discovered by
Strong in the Philippines. Other types have been distinguished
by different investigators but no practical advantage has been
derived from further differentiations into types so it will not be
necessary to give additional details.
The Shiga type of the dysentery bacillus is the most virulent
of the entire group and causes the more serious epidemics, though
there appears to be no other marked difference in pathogenesis
except in greater virulence. All the different types of the dysen-
tery organisms seem to produce similar pathologic lesions and
clinical symptoms, so that the particular type of organism affecting
a patient can not be foretold and is ascertained only by isolation of
•Read at a Symposium before The Philadelphia Pediatric Society, May 11, 1920.
462
Bergey : The Bacteriology of. Summer Diarrhea 463
the causative organism and study of its cultural and serologic
characters.
The main difference in the dysentery organisms consists in
the absence of motility in the Shiga type while all the others are
generally regarded as being motile. The Shiga type ferments dex-
trose with acid formation while the others ferment some of the
other carbohydrates, especially mannite. A further cultural differ-
ence is found in the ability to form indol. The Shiga type does
not form indol while the others have this function. The presence
of tlagella and indol production brings 3 of the types of the dys-
entery organism into closer relationiship with the colon bacillus.
The Shiga type, on the other hand, is not so closely related to the
colon bacillus as are the others, but stands nearer to the typhoid
bacillus.
All the dysentery organisms show still another relationship to
the colon bacillus in that they also have their habitat in the colon
of man. They have a distinct predilection for this part of the in-
testinal canal. When the living organisms are injected intra-
venously into a rabbit the principal lesions are found in the colon.
Even cultures killed by heat or otherwise, when injected intra-
venously, produce alterations in the colon.
The dysentery bacilli form exotoxins in addition to endotoxins.
The exotoxins are characterized especially by the alterations they
induce in certain nerve structures, whereby they give rise to
paralysis. This paralysis is caused by neurotoxin which is elabo-
rated by the dysentery organism. This property is especially pro-
nounced in cultures of the Shiga type. The other types of the
dysentery organism produce smaller amounts or a less active exo-
toxin than is formed by the Shiga type.
The pathologic changes in the colon in dysentery are caused
by the endotoxins. Wherever the bacteria are localized in the
intestine they produce edema, followed by necrosis and an exuda-
tion of serum and cells leading to the formation of the so-called
diphtheritic membrane which covers the inner surface of the bowel.
The necrosis of the intestinal wall accounts for the blood-stained
mucus and the blood thrown off in the bowel discharges.
The dysentery organisms are found only in the intestinal con-
tents of the patient, in the intestinal mucosa, and less frequently
in the mesenteric lymph nodes. The organisms do not ordinarily
464 Bergev : The Bactcrioloj^y of Siiuuncr Diarrhea
invade the blood stream, hence our efforts to find and isolate the
bacteria must be applied to the intestinal discharges.
The bacteriologic diagnosis of dysentery is usually accomplish-
ed without difficulty, during the acute stage of the disease. Par-
ticles of mucus in the feces, washed in sterile salt solution, are
planted on agar plates or on some of the special plate media that
have been constructed for the isolation of the pathogenic bacteria of
the intestines, such as Endo, Conradi, or MacConkey agar medium.
Suspicious colonies are transplanted into liquified mannite agar.
Jn this medium the ordinary intestinal organisms produce gas
while the mannite fermenting" types of the dysentery group pro-
duce only acid. The Shiga dysentery organism leaves the mannite
unchanged. From the same colonies plain agar cultures should
also be prepared for the study of the morphology and to determine
their agglutinability with dysentery serum. For this purpose both
monovalent and polyvalent sera should be at hand so that the type
of dysentery organism may be determined for each patient.
The dysentery organisms are found in the intestinal discharges
from the very beginning of the symptoms and continue to be given
off in the feces in considerable numbers until convalescence is es-
tablished. At times the organisms persist in the intestinal canal
even after all symptoms have abated and the patient has returned
to apparently normal health. In such instances the patient has
become a carrier of the dysentery organism. Carriers of dysentery
organisms are also encountered in which there is no history of a
previous infection.
The reason for the development of the carrier state is not clear.
It appears, however, to be due to lack of marked immunization
during the course of the disease. Since the dysentery organisms
do not invade the blood stream it seems that in this disease there is
less opportunity for immunization to be brought about than in
some other infections.
In dysentery, as in all other infections, it is the carrier, adult
or infant, that is the greatest menace to the public health. Because
of this fact, no dysentery patient should be released from observa-
tion until bacteriologic examinations have shown the absence of
the organism from the intestinal content on 3 successive examina-
tions at intervals of 5 days. These examinations should be made
only after all symptoms have abated and the patient is convales-
cent.
Bkrcjf.v: The Bacteriology of Summer Diarrhea 465
The diagnosis of dysentery infection by the agglutination re-
action is not as reUable as in typhoid fever because the agglutinins
do not always appear in the blood as early nor in as high propor-
tions. This method of diagnosis has, therefore, a confirmatory
value of less importance in dysentery especially in the earlier
stages of the disease. When agglutinins have developed they may
serve to aid in determining the type of dysentery organism affect-
ing the patient.
In carriers of the dysentery organism without a history of an
attack of the disease, the agglutination reaction is usually absent
so that this test is of little or no value in detecting this type of
carrier. Cultural studies can alone determine the carrier state.
The definite establishment of the fact that, at least, the Shiga
type of the dysentery organism produces an active exotoxin,
suggests the advisability of preparing immune serum that combines
the antitoxic and antibacterial properties. Such a serum, if used
early in the disease, should prove more efficacious than an anti-
bacterial serum. Moreover, immunity tests on animals indicate
that monovalent serums are of greater efficiency than are poly-
valent serums prepared by immunizing animals against all the dif-
ferent types of the dysentery group. If the type of dysentery or-
ganism is known, then a monovalent serum for that particular type
of organism would prove more helpful than a polyvalent serum.
Jf the type of dysentery organism is not known, then a polyvalent
serum should be used until such time when the particular
type is determined and then the corresponding monovalent serum
can be employed.
It is possible to use vaccine txD actively immunize persons
against the dysentery organisms. This procedure is of special im-
portance in combating an epidemic of the disease in an institution
where many children are closely associated. In this manner,
epidemics may be checked when other measures have proven un-
successful. The use of vaccine for the prevention of dysentery
has not been generally adopted because this disease, in recent
years, has not appeared in such widespread outbreaks as was the
case some years ago, hence there has been less need for wholesale
immunization, even in the Army. It is well to remember that it
is possible to immunize against the disease by injecting the dead
organisms. Where such vaccines have been used, it has been
466 Bergey : The Bacteriology of Summer Diarrhea
found that the reactions produced are more severe than in im-
munization against typhoid and paratyphoid fevers.
Since summer diarrhea in children is not a specific disease,
it is necessary to hear in mind that the dysentery organisms are
not the only causative agents of this disease. A certain propor-
tion of these infections are caused by the typhoid, paratyphoid and
Gaertner groups of bacteria. The bowel discharges in typical
dysentery infections are usually characteristic, but atypical cases
are also common and in these the bacteriologic examination must
reveal the nature of the infection.
In the typhoid infections, a variety of media has been suggested
to aid in the isolation and identification of the causative organisms.
Preliminary cultivation of the fecal organisms in bile, lactose bile,
or malachite green broth and subsequent plating on Endo agar
have proven helpful for the isolation of the bacteria. From the
Endo plates suspicious colonies are transferred to Russell's double
sugar agar and to plain agar, and the suspicious cultures are tested
as to their agglutinability with specific immune serum.
Patients suffering from the typhoid infections should be kept
under observation until they have been found free of the infecting
organisms by bacteriologic tests on 3 examinations at 5 day
intervals.
The other groups of bacteria which may be the causative
agents of summer diarrhea are all traceable to either contaminated
foods or to direct transmission by flies. These forms of diarrhea
are less likely to terminate fatally than those caused by the dysen-
tery and typhoid groups of bacteria, and, as a rule, they are
checked by the substitution of uncontaminated foods and by care-
ful protection against flies.
Diarrheal conditions caused by improper foods are also of
short duration and easily checked by the substitution of proper
foods.
The summer diarrheas are diseases that are not peculiar to
infants, but, on the other hand, they are disseminated amongst
the infant population through a variety of agents. Contaminated
foods, especially milk, is a most important factor in the spread of
these diseases. Flies also play a large part in the spread of these
diseases. The carrier, who is not actually suffering from the dis-
ease but who carries, in one way or another, the infecting organ-
isms to the healthy and unprotected infant is perhaps, today, the
Bergky : The Bacteriology of Sit turner Diarrhea 467
most important agent in the dissemination of the diarrheal diseases.
The infections by the dysentery and typhoid groups of bacteria
call for the most rigid care of the intestinal discharges. These
discharges are all potentially, if not actually, contaminated with
the causative organisms and may contain millions of the organ-
isms. The discharges, the clothing and the bodies of the infants
must be disinfected to prevent the further spread of the disease.
This is a task that requires the intelligent oversight of one who
has had the necessary training in the management of these diseases.
Our efiforts to control the infantile diarrheas should be directed
toward the regulation of the environment of the infant population.
This can be accomplished only through the education of those
who are concerned with the care and management of infants. The
mother, the nurse, as well as the other attendants, must be brought
to realize the possibility of the transmission of the diarrheal dis-
eases through different channels.
The control of infantile diarrhea becomes largely a problem
of personal hygiene for those who are responsible for the care
of the infant. If they themselves are free from the infecting or-
ganisms attd exercise due care with regard to the feeding, clean-
liness and clothing of the infants, and to the exclusion of flies,
much will be accomplished in the control of these diseases.
Inherited Syphilis and Rachitis (Pediatria, Naples, Sept.,
1919). Cannata relates that he has been studying during the last
five years the possible connection between inherited syphilis and
rachitis. There were 1,285 rachitic infants among the 10,000
that passed through the children's clinic in that period, and 37.27
per cent of the rachitic children had inherited syphilis. Excluding
those with tuberculosis or chronic skin disease, there were 58
breast fed infants in whom the rachitis seemed to be connected
with the inherited syphilis, and the latter dominated the clinical
picture. The set of symptoms described by Marfan (craniotabes,
pronounced anemia, and splenomegaly) as characteristic of rachitis
with inherited syphilis, was found equally pronounced in 18 in-
fants under 6 months old who seemed to be free from all inherited
taints. — Journal A. M. A.
WEIGHT AND HEIGHT IX RELATION TO
MALNUTRITION
By William R. P. Emerson, M.D., and Erank A. Manny/''
Malnutrition is a clinical entity with characteristic history,
definite symptoms and pathological physical signs. The mal-
nourished child is a sick child, and should be so classed. With
this clinical picture in mind we have a check on the various weight
tables in common use. The mere fact that a child is under-
weight according to a certain table does not necessarily mean that
he is malnourished or even undernourished. The relationship
between the individual child's weight and any table of average
weights is evidence, but not conclusive evidence, of his physical
condition. If the tables are based on proper data they should be
not only a means of diagnosing malnutrition, but an aid in mea-
suring its degree.
Proposed tests. In dealing, then, with any condition requir-
ing correction in the individual child it is important to know,
not only the actual facts of present status, but also the standard
which ought to be met. In matters of growth various tests for its
measurement have been proposed. Many of these are suggestive,
and the field is well deserving of further investigation. The sub-
ject has been presented in another article^ in which it is shown
that none of these studies have as yet given much direct help
except those concerned with development in terms of weight and
height.
Weight and age. The basis most frequently used in discus-
sion hitherto has been weight in relation to age. But in the
clinic we were early impressed with the practical difficulties of a
program which called for great eflfort on the part of the child
to come up to the average weight for his age. The standard
set was in many instances so far beyond his present achievement
as to appear unattainable. He therefore became discouraged and
made no progress at all. To attempt the impossible is not a
reasonable means of reaching any goal but failure.
Height and age. The basis of height for age is even more
confusing because many of the children most in need of care are
above the average scale of height for their years.
JV eight and height. One general physiological principle, how-
* Formerly Director of Nutrition Studies, Association for Improving the Condition
of the Poor, New York City.
'F. A. Manny, Indexes of Nutrition and Growth. (See References.)
468
Emekson-Manny: IV eight and Height Tables 469
ever, seems to be applicable to all cases ; that is, however tall
or short a child may be, he requires sufficient body weight to
sustain that height. In the many thousands of cases that have
come under our observation we have never found an instance
in which this basis has proved to be impracticable.
The malnourished. With this as a starting point the next
step was to find what range of variation in the relation between
weight and height was compatible with conditions of reasonably
good health and growth. Ten per cent, underweight was taken
as a working hypothesis, but it was soon evident that many chil-
dren needing care did not come within this rule. After considering
all the clinical evidence, we have found that an habitual 7 per cent,
underweight for height is the most satisfactory dividing line.
This marks off the lower boundary of the safety zone. It does
not indicate an ideal weight for height because children are
found to be better off if they run 10 per cent, higher than this
minimum.
The obese. A consideration of the upper boundary was
aiiforded by the cases of children so much overweight that they
showed impairment in activity and disposition, as well as a gen-
eral lowering of their health, convenience and comfort. A study
of our cases indicates that 20 per cent, overweight serves to dis-
tinguish the children who may be called obese.
The normal zone — stunted variants. This zone lying between
7 per cent, underweight and 20 per cent, overweight, separates
the fairly normal group from those who should be under treat-
ment at one extreme for malnutrition, and at the other for obesity.
There are, however, a considerable number of children still left
in the central zone who are definitely stunted ; that is, not only
underweight but also underheight. With proper health condi-
tions these children soon prove that they have capacity for growth
in both weight and height not heretofore realized. In this group
are included those who are constitutionally affected by such con-
ditions as syphilis, deficient thyroid, the effect of drugs such as
caffeine and nicotine, and those recovering from such long con-
tinued illnesses as tuberculosis.
Indii'idual diagnos's. We make it a rule to use the weight-
height ratio for the purpose of selecting that large group of mal-
nourished children most urgently in need of attention, and then
470 Emerson -Manny: iV eight and Height Tables
depend upon individual diagnosis to identify other cases not
reached by the general rule. Any child who is clearly below the
height and weight measurements usual at his age receives special
consideration even though his ratio may be normal. In such a
case an actual condition of good health and proper growth factors
must be proved before it is fair to assume that the child is devel-
oping as well as it is possible for him to do.
Extent of malnutrition. The tests which we have applied to
large numbers of children indicate that from 20 to 40 per cent,
of the children of school and pre-school age in this country
are habitually underweight for their height, and present both
physical and mental signs of malnutrition. The results accom-
plished in nutrition classes show that under proper treatment and
care practically all of these children can be made well in their
own homes. The expression "made well" is used advisedly,
for children who are ha1)itually underweight for their height,
are really sick, and present, practically without exception, in their
history and on physical examination other distinctive signs of
impaired nutrition which indicate that they are not only under-
nourished but malnourished.
The clinical picture. In the history we find the malnutrition
coming on after a certain illness, or as a result of overfatigue,
or of faulty food or health habits. At the same time the child
becomes irritable, tires easily, lacks physical and mental control,
and exhibits other indications of nervous disturbance.
Among the physical signs, besides the weight to height ratio,
are lines under the eyes, anxious expression, pallor, mouth-breath-
ing and other signs of nasopharyngeal obstruction ; the anterior
cervical glands are apt to be enlarged; the muscles flabby (tested
by feeling the upper arm) ; there may be ptosis, fatigue posture,
round shoulders, lateral curvature, flat chest, rigid spine, promi-
nent abdomen and pronated or flat feet. By fatigue posture we
refer to an appearance similar to the senile stoop due to weak
muscles.
As the child approaches the normal there is clinical evidence
of a transformation that is both physical and mental. There is a
return of color and a glow of health that is unmistakable. Prac-
tically every parent states that the patient has "become a dif-
ferent child." Normal reactions appear, restlessness and
irritability diminish, and the child ceases to be "finicky" and
Emekson-Manny : Weight and Height Tables 471
"nervous." These are the same changes we look for after a long
rest or a vacation.
Ezndcnce of stunted groivth. When conditions have been
corrected for a malnourished child, nature apparently gives a
strong initial impetus to his development. This is evidenced
by the first rapid advance in growth, the rate of which is grad-
ually reduced as he approaches normal condition. After the
increase in weight has well started thei:e is an increase in height
also. This is more rapid than the rate of growth in the normal
child — a sudden making up of the retarded growth following
the removal of the causes which first made the child stunted. This
is illustrated in Chart I.
When a child is becoming malnourished, the loss of weight is
very evident, but frequently the gain in height continues. The
place of these two factors in practical work is suggested by
Robertson in the following statement : "llie variability of stature
is much less than the variability of weight, from which we may
infer that as a criterion of abnormality the measure of stature
is more reliable than that of weight, while as a sensitive indicator
of the efifects of environmental, physiological or dietetic fluctua-
tions, provided statistical methods of investigation are employed,
the measure of weight is to be preferred to stature."
Vitiated tables. All tables of weight and height now in use are
vitiated by the fact that they contain the measurements, not only
of those who have accomplished normal growth, but also this
20 to 40 per cent, group who are habitually underweight for their
height, as well as an undetermined number less underweight, but
presenting other definite signs of malnutrition. It may be argued
that the subnormal children are balanced in the tables by those
who are overweight, but experience shows that the compara-
tively small number of cases sufficiently overweight to be con-
sidered abnormal are more than overbalanced by the borderline
cases, without taking into account any of those who are clearly
underweight for their height.
We need a record which has ruled out as far as possible, by
physical examination, the groups described above. The remainder
would furnish us data for physiological norms showing the range
of normal children within a zone of healthy growth.
The foregoing paragraphs present the clinical evidence lying
back of the tables which are here published.
472 Emerson-Manny: Weight and Height Tables
CVlQvtX
vAvcyoQe HciqWi iov Qoe ^| in.
CXveracje Vle.c^Vit i^of )\eic|U+ 55* lbs.
Ifn Now. ^ Ue.^ ' lin • r»t
n AH- \ 8 /y 5JL ,?<} 5 /^i /9 <3t a
■ReifRri.dJ* ^ * ^fc
C«\,T-.«s. a<^oo Xioo- lil%o i3.Sl I97i
y-lii'
iinT aosro
Chart I sliows the record of a boy of 9 years and 7 months, wlio was 17 per cent,
underweight for his height. During 14 weeks he gained 14 pounds in weight and 1
inch in height. Line A indicates his expected gain line as worked out when he first
came to us. The fact, however, that during the time in which he was gaining rapidly
in weight he also made twice as much gain in height as would be expected at his age
is good evidence that he was below normal in height, which has to do with skeletal
growth, as well as in weight for height. This would indicate that he was stunted and
had capacity for growth beyond what he had attained. Further evidence of this state-
ment appears clinically, for the boy was not up to normal when he had gained the 9.4
pounds which he lacked at the start. His gain in height required a new expected
weight line (see line B on the chart) and it was only on reaching this new ratio that
he became clinically well.
The constant occurrence of this change seems strong evidence that all children
habitually 7 per cent, underweight for their height are retarded about a year in
growth. The 7 per cent, by itself does not amount to this but the additional weight
necessitated by the extra gain in height makes up the difference.
Emerson-Mannv: Weight and Height Tables 473
Sources of our tables. For the early years we have used for
some time Holt's revised figures which he kindly furnished us
before publication. These are now available in the latest edition
of "The Diseases of Infancy and Childhood." The figures for
children of school age we have taken for the most part from the
basal studies of Boas and Burk which incorporate the work of
J>owditch, Peckham, Porter and others, aggregating in all some
90,000 measurements. The results of their studies have appeared
in two forms. One of these takes the mean of all measurements
for each year of age at the half year\ while the other, counts all
those of a given year as if they were made at the beginning of
the year-. This places the weights and heights of the latter ver-
sion 6 months in advance of those of the former.
Tables set forivard. The general correctness of the first form
of the table is evident in any study which includes all the children
examined, without excluding the 20 to 40 per cent, who are
clearly below par. This is illustrated in Charts II and III. The
wide use made of the latter form of the table, in which the figures
are set forward half a year, has been due, no doubt, to the fact
that it represents better than the other the measurements of fairly
normal children.
On this account we have deliberately set the figures forward
half a year in our tables because clinical work conducted both
in the hospital and with so-called well children in school has
shown that the curves on that basis represent better working
standards than do any others now available. It will be observed
that this form of the Boas-Burk figures articulates well with
those of Holt's table for younger children, while the other form
leaves a break in the line.
Such studies as those of Baldwin and Robertson, made on
smaller groups of selected children, indicate results which run
much higher than even our "set forward" figures. (See Charts
IV and V^). We have tested our tables by the various records
referred to in Baldwin's bibliography and also by later investiga-
tions such as those made by the Metropolitan Life Insurance
Company in their study of candidates for working papers, and
that of Greenwood which includes 350,000 measurements of
English school children.
* B. T. Baldwin, Pliysical Growth and School Progress, p. 150.
-J. Iv. Morse, Case Histories in IViliatrics, p. 1,?.
474 Emerson-Manny: Weight and Height Tables
NUTRITION CLINICS FOR DELICATE CHILDREN
TABLE OF AVERAGE WEIGHTS OF CHILDREN AT VARIOUS HEIGHTS
Also Showing Weights 7% and 10% Underweight for Height
BOYS
GIRLS
Aver aye
7%
10%
Average
7%
/o%
Weight
Under-
Under-
Weight
Under-
Under-
Height
for Height
weight
weight
for Height
weight
weight
Height
Inches
Pounds
Pounds
Pounds
Pounds
Pounds
Pounds
Inches
*21
8.2
7.6
7.4
■ 7.9
7.3
7.1
21*
*22
9.7
9.0
8.7
9.4
8.7
8.5
22*
*23
11.1
10.3
10.0
11.0
10.2
,9.9
23*
*24
12.5
11.6
11.3
12.5
11.6
11.3
24*
*25
13.9
12.9
12.5
14,0
13.0
12,6
25*
*2G
15.3
14,2
13.8
15,5
14.4
14.0
26*
*27
16.9
15.7
15.2
17.2
16.0
15.5
27*
*28
18.5
16.2
16.7
18.8
17.5
16,9
28*
*29
20.2
18.8
18.2
20,5
19.1
18,5
29*
*30
21.7
20.2
19.6
22,0
20.5
19.8
30*
*31
23.2
21.6
20,9
23.4
21.8
21.1
31*
*32
24.5
22.8
22,1
24,8
23.1
22.3
32*
*33
25.9
24.1
23,3
26,0
24,2
23.4
33*
*34
27.3
25.4
2-1,6
27,3
25.4
24.6
34*
*35
28.7
26.7
25 , 8
28,6
26.6
25.7
35*
*36
30.0
27.9
27.0
30,0
27.9
27.0
36*
*37
31.6
29.4
28.4
31,5
29.3
28.4
37*
*38
33.2
30.9
29.9
32.7
30.4
29,4
38*
39
36.3
33.8
32.7
35.7
33.2
32.1
39
40
38.1
35.4
34 . 3
37.4
34.8
33.7
40
41
39.8
37.0
35.8
39.2
36,5
35.3
41
42
41.7
38.8
37.5
41.2
38,3
37.1
42
43
43.5
40.5
39.2
43.1
40.1
38.8
43
44
45.4
42.2
40.9
44.8
41,7
40.3
44
45
47.1
43,8
42.4
46.3
43.1
41.7
45
46
49.5
46,0
44,6
48.5
45.1
43.7
46
47
51.4
47,8
46,3
50.9
47.3
45,8
47
48
53.0
49.3
47.7
53.3
49.6
48.0
48
49
55.4
51.5
49.9
55.8
51.9
50.2
49
50
59.6
55.4
53.6
58.3
54.2
52 . 5
50
51
62.5
58.1
56.3
61.1
56.8
55 . 0
51
52
65,8
61.1
59.2
63.8
59,3
57.4
52
53
68.9
64.1
62,0
66.8
62,1
60.1
53
54
72.0
67.0
64,8
70.3
65.4
63.3
54
55
75.4
70.1
67.9
74.5
69.3
67.1
55
56
79.2
73,7
71,3
78.4
72.9
70.6
56
57
82.8
77,0
74,5
82,5
76.7
74.3
57
58
87.0
80.9
78,3
86.6
80,5
77.9
58
59
91.1
84.7
82,0
91,1
84,7
82,0
59
CO
95.2
88.5
85,7
96,7
89,9
87,0
60
61
99.3
92.3
89.4
102,5
95 , 3
92.2
61
62
103.8
96.5
93.4
110,4
102.7
99.4
62
63
108.0
100.4
97.2
118,0
109.7
106.2
63
64
114.7
106.7
103.2
123.0
114.4
110.7
64
65
121.8
113.3
109,6
130,0
120.9
117.0
65
66
127.8
118.9
115,0
137.0
127.4
123.3
66
67
132.6
123.3
119,3
143 . 0
133.0
128.7
67
68
13S.9
129.2
125,0
146,9
136.6
132.2
68
^Without Clothing.
Emerson-Manny: Weight and Height Tables 475
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476 Emerson-Manny: Weight and Height loobies
TABLE SHOWING INCREASES IN WEIGHT AT VARIOUS AGES BY YEARS
QUARTERS, AND WEEKS
BOYS
Year — S^ Weeks
Quarter —
13 Weeks
Week
Age
Pounds
Ounces
Pounds
Ounces
Pounds
Ounces
Birth to 1 year
13.45
215.2
3 . 3625
53.8
.259
4.14
1 to 2 years
6.3
100.8
1.575
25.2
.121
1.94
2 to 3 years
5.2
83.2
1.3
20.8
.100
1.60
3 to 4 years
4.3
68.8
1.075
17.2
.083
1.32
4 to 5 years
4.0
64.0
1.0
16.0
.077
1.23
5 to 6 years
4.0
64.0
1.0
16.0
.077
1.23
6 to 7 years
4.3
68.8
1.075
17.2
.083
1.32
7 to 8 years
5.0
80.0
1.25
20.0
.096
1.54
8 to 9 years
5.1
81.6
1.275
20.4
.098
1.57
9 to 10 years
5.8
92.8
1.45
23.2
.112
1.79
10 to 11 years
5.3
84.8
1.325
21.2
.102
1.63
11 to 12 years
6.2
99.2
1.55
24.8
.119
1.91
12 to 13 years
7.9
126.4
1.975
31.6
.152
2.43
13 to 14 years
10.4
166.4
2.6
41.6
.200
3.20
14 to 15 years
12.2
195.2
3,05
48.8
.235
3.75
15 to 16 years
13.6
217.6
3.40
54.4
.262
4.18
GIRLS
Year— 52 Weeks
Quarter —
IS Weeks 1
Week
Age
Pounds
Ounces
Pounds
Ounces \
Pounds
Ounces
Birth to 1 year
13.34
213.44
3.335
53.36
.257
4.11
1 to 2 years
6.0
96.0
1.50
24.0
.115
1.85
2 to 3 years
5.0
80.0
1.25
20.0
.096
1.54
3 to 4 years
3.8
60.8
.95
15.2
.073
1.17
4 to 5 years
3.6
57.6
.9
14.4
.069
1.11
5 to 6 years
3.6
57.6
.9
14.4
.069
1.11
6 to 7 years
4.3
68.8
1.075
17.2
.083
1.32
7 to 8 years
4.8
76.8
1.2
19.2
.092
1.47
8 to 9 years
4.9
78.4
1.225
19.6
.094
1.51
9 to 10 years
5.5
88.0
1.375
22.0
.106
1.69
10 to 11 years
6.6
105.6
1.65
26.4
.127
2.03
•' 11 to 12 years
9.2
147.2
2.3
36.8
.177
2.83
12 to 13 years
10.0
160.0
2.5
40.0
.192
3.08
13 to 14 years
9.6
153.6
2.4
38.4
.185
2.95
14 to 15 years
8.4
134.4
2.1
33.6
.175
2.59
15 to 16 years
5.6
89.6
1.4
22.4
.108
1.72
The tables on pages 1 and 4 are based upon those on pages 2 and 3. The material of
the latter for the first four years is taken from Holt's Diseases of Infancy and Childhood
(1919) — -that for the succeeding years is derived principally from the work of Boas, Burk,
Bowditch and Smedley. The weights and heights in Holt's table are without clothing,
while those of the later years are with indoor clothing but without shoes.
It will be noted that the figures for the later years differ from the Boas-Burk tables
by six months. Our reason for setting the figures forward half a year is that in their
original form they represent averages which include the very large number of children
whom our clinical experience and studies of entire school groups find to be seriously mal-
nourished. The tables in their present form run lower than those made in studies con-
cerned mainly with normal children. As they are here printed they afford the best work-
ing standard for use until such a time as sufficient data are secured from weighing and
measuring a large number of children who are normal.
NUTRITION CLINICS FOR DELICATE CHILDREN
44 DwiGHT Street Boston, Massachusetts
Emkrson-Mannv : JVcii^Itt and Height Tables 477
The zone standard. Wood has done valuable service in em-
phasizing the use of the zone system as opposed to any single
line as a standard of reference. In the latest revision of his
figures his results agree very nearly with the standard which we
have adopted, although, as will be seen in Chart VI, he does
not allow as wide a range of variation.
7 t
When we turn to age variations (see Chart VI i) his range
is less consistent, and we know of no clinical data which justify
such modifications. For instance, according to Wood's latest
table a girl of 7, with a height of 47 inches, should weigh 50
pounds, while a girl of 9, of the same height, should weigh 53
pounds. In his tables published in 1910 this was reversed, and
ihe expected weight for the girl of 7 at the height given was
478 Emerson-Manny: Weight and Height Tables
50 pounds, while the girl of 8 and 9, having the same height, had
an expected weight of only 49 pounds. As Cannon states, "There
is no physiological law which shows that a child should grow in
height out of proportion to his weight. Furthermore, the average
child has an average relation of height and weight."
Within normal variations, therefore, we repeat that a given
w«,c(Wt
Gr, ■=■ &vavv,«vc.U.
Charts II and 111 show how closely the nieasurcnients of height and weight of
the pupils in four New York City schools, taken in 1917, agree with the averages in
the original Boas-Burk tables. The pupils were in two groups — the Gramercy and
Bowling (ireen districts — and numbered in all about 2500, of whom one-fourth to one-
third were malnourished. Similar results are shown by including measurements of
350,000 English school children compiled by Greenwood in 1914.
height requires a certain body weight to sustain it at any age.
The increase in weight which a child may be expected to make
is, of course, modified by his age no matter what his nutritional
condition because of the factor of adolescence. The relation be-
tween retardation of adolescence and malnutrition is a subject
needing further investigation.
Retan has recently worked out a chart showing the zones of
Emerson-Manny: Weight and Height Tables 479
VJt.^V'+ .-
V.i,l,V ,
Charts IV and V afford a comparison of the tables used in our nutrition rlinio
with the results obtained by Baldwin and Robertson from selected children nuasurecl
without clothing. The former used some 30,000 measurements and the latter 900.
Note that even with the advance of half a year the line on which we base our standard
runs with clothing below the lines of the more normal children measured without
clothing.
480
Emekson-Manny : fVcight and Hc'v^ht I'ablcs
Chart VI shows the relationship between the zone boundaries which we use — 7 per
cent underweight and 20 per cent, overweight for heiglit — and those made by Wood
for the use of the Child Health Organization. Note how closely Wood's lines follow
the "set forward" Boas-Burk figures which we use as a basis. Wood's zone of health
is much narrower than our clinical evidence justifies.
Emerson-Manny: Weight and Height Tables
481
i r:r'n;.::i-i :\n-n
r\ ^^wTfTwdeX o ir rtVtt-Vvoy, Vsetvot^'n vMt.o^WT
V),i>|-= V/o
i,. Vs.
It /o Kfi-^^
*^io
In Chart VI the comparison was kept to the relationship between weight and
height, but in Chart VII the factor of age is also used. The weight and height
factors are combined by using an index secured by dividing the weight in pounds by
the height in inches. In addition to the figures prepared recently by Wood we have
also included those which he published in 1910. Note that both his lower and upper
zone boundaries are, on the whole, much higher in the later edition.
482 Emerson-Manny : Weight and Height Tables
Chart VIII shows the zone boundaries determined experimentally by Retan. In
plotting all children examined he made use of our general boundaries and then laid
out his zones according to the actual location on the chart of obese and malnourished
cases. The general agreement of the two sets of boundaries is here well illustrated.
J'^meksox-Mannv : IVciglit mid Height Tables 483
nutritional condition. Starting- with our tables, he has classified
in zones all the children examined. The result reveals the mal-
nourished children collected in the range of unsatisfactory rela-
tion between weight and height. Chart VIII shows how closely
his evidence agrees with the boundaries we have worked out.
Sex and race variation. Sex variation is an interesting study
in itself, but in the practical consideration of children up to the
age of adolescence there is no reason for discussing the subject
in this article. Therefore space has not been taken to publish
parallel charts for the two sexes. To make comparison easier all
the charts used are those showing the heights and weights of
boys.
An objection frequently raised is that no single range of aver-
ages can serve for the various nationalities in an American city.
We have tested our tables on the mixed population of several
schools, and find that our range makes suflficient allowance in
dealing with even the Italians and other types considered farthest
below the average.
Seasonal grozvth. A section of this subject deserving special
study is the matter of seasonal growth. It is commonly held that
during certain parts of the year growth in weight leads, while
growth in height is especially characteristic of other seasons. A
summary of the literature of the subject is found in Hall's
'"Adolescence." Reference is made in the latest edition of Holt's
"Diseases of Infancy and Childhood" to a study of 700 observa-
tions made on boys ranging in age from 9 to 16 years in a New
York private school. This showed the period from May to
November to have a decided advantage over the other 6 months
in both weight and height increases. This result is ascribed to the
greater freedom from illness and the larger opportunities for out-
door life during the open months. Added interest is given to this
statement in the light of our exi>erience which shows naso-
pharyngeal obstruction to be the most seriously disturbing physi-
cal factor with which we have to deal.
SUMMARY.
(1) Malnutrition is a definite clinical entity with character-
istic history, definite symptoms and pathological physical signs.
(2) Clinical evidence shows that the physical sign which may
484 Emekson-Manny: IVcighi and Height Tables
best serve to identify this group of malnourished children is the
relationship existing between weight and height.
(3) The age factor is of secondary importance and is mainly
serviceable in selecting cases stunted by constitutional disabilities
such as syphilis, tuberculosis, deficient thyroid, the effect of cer-
tain drugs, convalescence from long illnesses, etc.
(4) The tables derived from the studies of Boas and Burk
represent the most extensive records of weight and height
measurements made. Recent studies show that they are essen-
tially true averages of unselected groups of American children.
(5) The Boas-Burk and other tables in general use are
vitiated by the fact that they include a large number of mal-
nourished children whose measurements lower the averages of
weight and height, thus making them of relative value only
as standards.
(6) As a working basis it has been found necessary to set
forward the Boas-Burk figures half a year, thus offsetting to a
considerable extent the depression of averages stated above.
(7) Individual variation in the relationship of weight to
height is of sufficient importance to make it necessary to use
a zone system rather than any single line as a basis of reference.
(8) After various experiments at determining zone boun-
daries, clinical evidence is best satisfied by lines lying between
7 per cent, below and 20 per cent, above the "set forward" Boas-
Burk figures. Outside of this central zone are found, on the
one hand, the malnourished, and, on the other, the obese. Within
the zone are still a considerable number of malnourished children
requiring individual diagnosis.
(9) The malnourished children selected by this rule ' of
habitual 7 per cent, underweight for height form, almost without
variation, 20 to 40 per cent, of any group of children in school
and pre-school periods.
(10) When tables have been constructed from a sufficient
number of children proved to be normal, the line of average
weights and heights will lie somewhere between the "set for-
ward" Boas-Burk figures and those represented by a line drawn
Emerson-Manny: Weight and Height Tables 485
midway between the 7 per cent, underweight and 20 per cent,
overweight boundaries of the zone described above. Special
studies of somewhat more carefully selected children, for ex-
ample, those made by Baldwin and Robertson, confirm this
statement.
LIST OF REFERENCES.
Bird T. Baldwin: Physical Growth and School Progress, U. S. Bureau of Education
Bulletin No. 10, 1914. (Historical summary of nearly 200 studies of weight
and height. Bibliography of experimental studies in physical growth — 300 titles).
C. 'R. Bardeen: The Height-Weight Index of Build in relation to Linear and Vol-
umetric Proportions and Surface-Area of the Body During Post-Natal Develop-
ment. Carnegie Institution Publication No. 272, pp. 483-554.
Francis G. Benedict: Energy Requirements of Children from Birth to Puberty. Bos-
ton Medical and Surgical Journal, July 31, 1919.
Franz Boas: The Growth of Children. Science, N. S. No. 937: 815-8. See also U.
S. Bureau of Education, Report of Commissioner, 1896-7, vol. 2:1541-99, and
1904, vol. 1:25-; 32.
Henry P. Bowditch: The Growth of Children. Massachusetts Board of Health, Re-
port, 1875 and 1879.
Henry P. Bowditch: The Relation Between Growth and Disease. American Medical
Association, Transactions, 1881, vol. 32:370-6.
Frederic L. Burk: Growth of Children in Height and Weight. American Journal of
Psychology, vol. 9:253-326.
Arthur Greenwood: Health and Physique of School Children. Ratan Tata Founda-
tion, University of London, 1915.
G Stanley Hall: Growth in Height and Weight. Adolescence, Vol. 1:1-50.
L. Emmet Holt: Diseases of Infancy and Childhood. 1919.
Frank A. Manny: Indexes of Nutrition and Growth. Modern Hospital, November,
1916. (References to discussions of indexes, signs, formulae, etc., on. growth
and physiological development).
Frank A. Manny: Defective Nutrition and Growth, A Selected Bibliography. Ameri-
can Journal of School Hygiene, June, 1918. (140 titles).
Frank A. Manny: A Comparison of Three Methods of Determining Defective Nutri-
tion. Archives of Pediatrics, February, 1918.
Frank A. Manny: Defective Nutrition and the Standard of Living. Survey, March
20. 1918.
Nutrition Clinics for Delicate Children. Weight and Height Tables. I. Average
Weights of Children at Various Heights. II. .Average Weight and Height
Measure;nents at Various Ages. III. Increases in Weight at Various Ages by
Years, Quarters and Weeks.
George M. Retan: The Measurement and Development of Nutrition in Childhood.
Archives of. Pediatrics. January, 1920.
T. Brailsford 'Robertson: Studies in the Growth of Man, IV. The Variability of the
Weight and Stature of School Children and Its Relationship to Their Physical
W^elfare. American Journal of Physiology, vol. 41:547.
F. W. Smedley: Report of Department of Child-study and Pedagogic Investigation of
the Chicago Public Schools, Chicago, 1900. Vol. 2:10-48.
Wm. Stephenson: On the Rate of Growth in Children. Transactions International
Medical Congress, Washington, 1887, Vol. 3, pp. 446-452.
Thomas D. Wood: Health and Education. Ninth Year Book, National Society for
the Study of Education, 1910. (See also revised form of his tables issued by
Child Health Organization, New York City).
Case of Intussusception Treated by Resection (Lancet,
May 31, 1919, p. 938). E. R. Flint's patient was aged one day
less than three months. He believes that this is the youngest case
on record in which recovery took place. The ileum (4 or 5 inches
of it) had slipped tip into the cecum and colon. This portion of
the ileum was removed in the usual way. — Journal A. M. A.
FURTHER STUDIES IN THICK CEREAL FEEDING IN
MALNUTRITION IN INFANCY.
By Harold R. Mixsell, M.D.
New York
In August, 1919\ I reported 12 cases of malnutrition in in-
fancy, fed by means of a modified thick cereal formula. Since
then I have been making further studies along these lines, and
am recording in particular from a series of 10 cases, 2 cases re-
ferred to me in private practice, both of which started as diffi-
cult feeding cases, and resolved themselves into easy normal
feeding problems.
In regard to the preparation of the thick cereal formula, some
essential modifications have been made. A fat free milk, or
one which averaged under 1 per cent, in fat was used as the
liquid basis of the mixture. It was assumed, empirically to be
sure, that these babes would not tolerate or assimilate fat. No
laboratory work, with the exception of examination of the stools,
was done to confirm this, but the fact remained that clinically,
high fat and whole milk fat had been previously used in the
majority of the cases, and that the babies had not done well on
it. Another factor which influenced me in using low fat skimmed'
milk was its comparatively high proteid and salts content, in
addition to the actual food value of 10 or 11 calories per ounce
which the mixture gained. If the cereal is made up in water,
these needed calories and salts are lost. The cereal used by
preference was farina on account of its colloidal qualities. The
reason for this follows ; Starch in solution acts as a protective
colloid and in this way prevents the formation of hard casein
curds with possible difficult digestion. This action is due to
the soluble starch itself and not to the salts or the cellulose in
suspension. In a previous series of cases, rice flour, as recom-
mended by Porter^ in pyloric stenosis, was used in a few of
my cases. This was abandoned in spite of the fact that it was
more soluble and had better protected colloids than farina. The
reason for abandoning it was the increased tenaciouness of farina
over rice flour, and the fact that to get the same thick mixture
almost twice as much rice flour was needed.
The proportion of this present mixture used was increased
486
Mixsell: Further Studies in Thick Cereal Feedinij; 487
to 1 tablespoon of farina to 5 or 6 ounces of the skimmed or
fat free milk. Cane sugar and dextri-maltose were added in
equal quantities, using 2 level tablespoons of each to 30 ounces
of the mixture. All this was cooked from 30 to 60 minutes, or
until the resulting mixture was thick and tenacious. Thorough
cooking is most important and will clear up many cases of loose
stools which may have occurred from undercooking.
As a rule, however, there is not the increase in the number of
stools that one would expect to find from the high sugar and
starch content. The reverse, or a tendency to constipation, is gen-
erally the rule. This is probably due to the following factor :
It has long been a recognized fact that a combination of several
carbohydrates in the same food can be given without taxing the
power of the organism to utilize sugar, whereas when a single
carbohydrate is used this may not be the case. The farina mix-
ture, being a "polycarbohydrate" mixture of milk sugar, malt
sugar, cane sugar, dextrins, and starch, comes under this cat-
egory. The malt sugar is absorbed first, then the cane sugar and
milk sugar, next the dextrins, and finally the starch. This ab-
sorption is slow and will continue for a long time. The organism
is thus enabled to utilize the sugar without a sudden overdose,
and accordingly the child gains and there is not the tendency
towards a carbohydrate diarrhea which we might expect to get
with a single carbohydrate. In this connection I may state that
the fear of feeding high sugar in most cases is groundless. I
have seen children fed on as high as a 16 per cent, sugar with no
ill results. To quote Morse and Talbot^: 'The probable reason
that babies can take carbohydrate in the form of starch (farina)
when they cannot take it in the form of dextrins and sugar, is
that the molecular structure of starch is more complicated than
that of the dextrins and sugars. The more complicated the
structure of a carbohydrate is, the more numerous are the steps
in its breaking down to its end products. There is therefore, less
fermentable material in the intestine at one time, and less op-
portunity is afiforded for fermentation to get the upper hand."
When first put on this mixture, there is usually some difficulty
in getting the baby to take the spoon feeding. To solve this
problem, the cane sugar, being much sweeter than the dextri-
maltose, should be increased accordingly, and the child will
generally take it. There also may be gagging, and in some
488 MixsELL : Further Studies in Thick Cereal Feeding
cases vomiting until the infant is thoroughly accustomed to such
a radical change in its diet. I have found that a good many of
these slow gainers have signs of pylorospasm. In a large percent-
age of the cases seen by me, this has ceased after a few weeks
use of the cereal, and the vomiting stops. In these cases there is
always difficulty in getting the child back on milk formulae, so
much so that they tolerate milk badly for a long while.
When the child is well accustomed to the mixture and has
started to gain, from 2 to 6 ounces of a green vegetable puree
is added. This may be used as early as the 6th month. Celery,
string beans, spinach, carrots and young turnips were the vege-
tables of choice. These supply not only a few extra calories,
but also salts, and the anti-neuritic or water soluble B. vitamine.
The combination of these, plus the high starch, may very well
be a factor in increased growth and nutritional improvement.
Here again my observations are clinical and not sustained by
laboratory findings. Byfield*, in a series of experiments, reaches
these conclusions :
1. The addition of the anti-neuritic vitamine, obtained from
wheat embryo to the diet of babies supplied with food furnish-
ing an adequate number of calories, stimulated growth.
2. The beneficial influence of adding a specially prepared
vegetable soup in sufficient quantity as part diluent of the milk
modifications for infants is apparently due to the presence of
the anti-neuritic vitamine contained therein. Both the alcoholic
soluble material of the dried soup vegetables, and the water ex-
tract (soup) stimulated growth.
3. The fact that the artificially fed infant requires a larger
amount of food than the breast fed infant appears to be due to
the relative paucity of cow's milk in the anti-neuritic vitamine.
4. It is probable that the failure to gain in infants and
young children is often the result of an insufficient amount of
the anti-neuritic vitamine in the food.
Hess^, in his studies of infantile scurvy, has also noted the
same phenomenon. He used a cereal of wheat middlings and
farina, and remarked on the immediate and striking improvement
in the turgor, and noted that there was a gain in weight for the
first time in many months. In the cases I have seen, these find-
ings are somewhat obscured by the high caloric value content of
the thick farina, skimmed milk, high sugar mixture. It is ob-
Mixsell: Further Studies in Thick Cereal Feeding 489
viously more reasonable to attribute the gain to the cereal feed-
ing rather than to the vitamines contained in the green vegetables.
The combination of the two undoubtedly helped, and the vita-
mines must not be lost sight of in spite of their intangibility. Of
greater interest is the extremely high calories these babies can
take, in many cases over double the number of calories required
by their weight. It is my personal feeling that infants may also
be kept on thick cereal for a much longer time without an upset
than they can on other high caloric feedings, including the whole
lactic acid milk, corn syrup method of Marriott.
Both methods, however, add to our feeding armamentarium.
The idea is not altogether a new one but is an adaptation of, or a
reversion to early methods of infant feeding. Harking back to
the Elizabethan age, and to the centuries preceding it, breast feed-
ing was practically the only means of nourishing a young infant
or child^. Cow's milk was only mentioned to be condemned.
Feeding bottles had not been invented, and the artificial foods
were limited to water pap (bread and baked flour soaked in
water) and pulse, which was a combination, or porridge of peas,
beans and lentils. Here we have a similar combination to the
one employed in our farina and vegetable soup mixture, and one
on which the children of that age thrived.
I have picked out the following 2 typical cases. The other 8
are all very similar in character :
Case No. 1. C. H. Born April 11, 1919. 4th child. All
living and well. Father and mother living and there are no
familial diseases of any sort. Easy, normal, noninstrumental
labor, and child was normal at birth. Birth weight, 7 pounds, 11
ounces. Seen on June 6, 1919, when the weight was 10 pounds
and 4 ounces. Examination revealed an apparently normal
baby, the only abnormality noted being large tonsils and adenoids.
Feeding history: Breast fed since birth, 10 minutes on each
side, 6 feedings, 4 hour intervals. As the breast milk was dim-
inishing in quantity and in quality, the baby was gradually
weaned until on June 26 he was on whole milk, 15 ounces ; boiled
water, 14 ounces; lime water, 1 ounce; and milk sugar, 3 level
tablespoonsful. 5 ounces were given 6 times a day, every 4
hours.
July 12. As the baby had been spitting up a little bit he
490 Mixsell: Further Studies in Thick Cereal Fcediiii^
was put on a skimmed milk mixture. The weight was 10 pounds
and 5 ounces, a gain of only an ounce in over a month.
July 16. Not satisfied. Increased to 2 per cent, milk, same
formula. Same weight. Still spitting up small fat curds after
every nursing.
July 18. Weight still stationary. As milk was from a Jersey
herd, formula was changed to Dryco dry milk, 4 tablespoons;
dextri-maltose, 1 teaspoon, to 5 ounces of boiled water, 6 feedings
every 4 hours.
July 25. Weight, 10 pounds, 15 ounces, a gain of 10 ounces
in the week. This gain unfortunately was only temporary for
in the following 10 weeks the baby only gained 21 ounces. Many
formulae were tried, including Walker-Gordon milk, cereal, beef
juice, orange juice. He was overfed and underfed in milk cal-
ories, with low fat and high sugar, and high fat and low sugar,
and a combination of them both. He was always somewhat con-
stipated, although his foods were all well digested.
When seen on October 1, the chief complaint was failure to
gain properly, and a very occasional spitting up. Weight was
12 pounds and 4 ounces. Having the experience of my first
series^ in mind, I put the baby on the following formula :
Two per cent, milk, 28 ounces.
Farina, 6 level tablespoonsful.
Dextri-maltose No. 3, 2 level tablespoonsful.
Cane sugar, 2 level tablespoonsful.
This was boiled together for 30 minutes, divided into 6 feed-
ings, and the baby was fed it with a spoon. The required cal-
ories, figuring on 45 per pound were about 550, the estimated
calories being almost 800. There was an immediate change for
the better, almost startling in character. The weights for the
next 3 months follow :
October 3. Weight, 12 pounds, 11 ounces.
October 12. Weight, 13 pounds, 11 ounces. This is a gain
of 23 ounces in the past 11 days. Is taking cereal well. ,
October 19. Weight, 14 pounds, 7 ounces. 2 to 4 ounces of
either spinach or string bean puree was added to the cereal.
November 4. Weight, 15 pounds, 10^/^ ounces.
November 20. Weight, 16 pounds, 8 ounces.
December 5. Weight, 17 pounds, 2 ounces.
December 12, Weight, 17 pounds 14 ounces.
December 26. Weight, 19 pounds, 7 ounces.
Mixsell: Further Studies in Thick Cereal Pecdiiii^ 491
This is a gain of 110 ounces in 86 days, or an average of about
9 ounces a week. During November, orange juice; beef juice
and baked potato were gradually added to the diet. At no time
was there any edema, or any evidence of water retention. The
urine was always free from sugar, and the stools were normal,
well digested, pasty stools. The only fluid allowed was water,
and this was given twice a day in amounts varying from 4 to 8
ounces. The child weighed 25 pounds when 1 year old and was
normal for his age.
This case is typical of a great many. Having observed 2
series of cases, comprising 22 in all, I feel that this method of
feeding will prove of great value in selected cases who gain
badly or extremely slow. I have had cases in which improve-
ment was very slow, and where the cereal was not well tolerated.
At the same time, in at least 8 cases out of 10, it worked splen-
didly. The 2 cases which did not gain well on it were types
which would not gain well on other diets. In one hospital case
and in the case report which follows, it will be seen that the
child did better on the cereal than on anything else, although the
final result was somewhat disappointing.
Case No. 2. G. E. Born June 10, 1919. Father and mother
are living and well. Mother is 40 years old. Labor was diffi-
cult, high forceps being used. Baby was normal at birth, as far
as the mother knows. Birth weight, 7 pounds, 7 ounces. Nega-
tive familial history for either tuberculosis or syphilis.
Feeding history: Breast fed for 2 months. Weight at 2
months, 9 pounds. Was then weaned and was put on a formula
of milk, water, and cane sugar. At 10 weeks of age, was put on
a Horlick's malted milk mixture. Was a vomiting baby from
birth. From 11 weeks of age. until seen by me on October 24,
1919, has been on a formula of milk, 3 ounces ; water, 2 ounces ;
and granulated sugar, ^ teaspoon, 7 feedings, every 3 hours.
Stools have always been constipated, with a foul odor, and with
small white curds. Has frequent colic, and vomits after almost
every feeding.
Physical examination, October 24, showed a marantic baby
weighing 9 pounds, 8 ounces, otherwise perfectly normal. An
opinion was given of indigestion from too much at a feeding, too
concentrated food, and high fat, and a formula was given her of
skimmed milk, 18 ounces ; boiled water, 10 ounces ; lime water, 2
492 MixsELL : Further Studies in Thick Cereal Feeding
ounces and clextri-maltose, No. 1, 3 level tablespoonsful. 5
ounces, 6 feedings.
October 27. Weight, 9 pounds, 9 ounces. Vomiting im-
proved but is very hungry and fretful. 5j/4 ounces were advised
with 6 feedings. This was continued until November 5, when
the weight was 9 pounds, 9^^ ounces. Vomiting had entirely
ceased, and the baby looked somewhat better. In the next 2
weeks, the milk was gradually increased to 2, 3 and 4 per cent,
milk as the baby was always hungry. On November 14, a change
was made to Dryco dry milk, and 2 teaspoons of farina were
given twice a day. Weight was 9 pounds and 12 ounces. This
was kept up until November 24, and as there had been no gain,
a thick cereal feeding was ordered of :
Two per cent, milk, 28 ounces.
Farina, 5 tablespoonsful.
Dextri-maltose, 2 tablespoonsful.
Cane sugar, 1 tablespoonful.
This was cooked 30 minutes and divided into 6 feedings. On
December 1, as the cereal seemed to gag the baby and she was
taking it badly, the cane sugar was increased to 2 tablespoonsful,
and the dextri-maltose decreased to 1 tablespoon. Two days later
the cereal was increased to 6 tablespoons. Weight then was 10
pounds.
December 8. Weight, 11 pounds, 3^ ounces. Whole milk
used.
December 15. Weight, 11 pounds, 8 ounces.
December 22. Weight, 11 pounds, 11 ounces. Baby is satis-
fied in every way, and has gained for the first time in 2 months.
December 29. No gain. Thinking that the baby had per-
haps been overfed, I advised taking her off the cereal, and putting
her on a 2 per cent, milk mixture, with double strength barley
water, and the same amount of sugar.
December 31. Baby started to vomit again. Sugar cut down
to 1 tablespoon of dextri-maltose.
January 2, 1920. As baby was still vomiting, she was put
back on a 1 per cent, milk, farina mixture. From this time on a
slow but sure gain followed|. The child was seen monthly
and on May 27, when she was not quite a year old, she weighed
16 pounds, and 9 ounces, and had progressed well physically in
ever way.
Mixsell: Further Studies in Thick Cereal Feeding 493
Here is a case which looks like a failure at first glance. How-
ever, various elements enter into the case, the mother's age (40),
the long protracted difficult labor, and the bad previous feeding
history. The home hygiene was carefully looked into ; the mother
was a sensible woman who took complete charge of the baby
herself, so that the hygiene cannot be blamed. Certainly the
child gained better on the cereal feeding than on anything else,
and its vomiting has stopped. Incidentally the green vegetables
were added in February in a similar manner to that used in case
No. 1. It is possible that this particular child may be one of
those indefinite forms of malnutrition due to a slight brain injury
at birth, which presents a symptomatology which is recognized,
but about which little is known. The case is cited to prove that
this feeding method is not a panacea for all feeding ills, and does
not work in every case.
CONCLUSIONS.
1. A method of feeding difficult cases is reported,
2. In selected cases marked gain in weight, and improvement
physically has been noted.
3. It is not a cure-all, but is a valuable adjuvant in infant
feeding.
BIBLIOGRAPHY.
1. Mixsell, IL R. : Archives of PedjAtrics, 36:449 (August) 1919.
2. Porter, L. : Archives of Pediatrics, 36:385 (July) 1919.
3. Morse, J. L,, and Talbot, F. B. : Diseases of Nutriti<\n and Infant Feeding, 1915,
p. 198.
4. Daniels, A. L., Byfield, A. H., and Loughlin, R. : Am. Tour. Dis. Chil., 18:546
(December) 1919.
5. Hess, A. F.: Jour. A. M. A., 65:1003 (September 18) 1915.
6. Mixsell, II. R.: Archives of Pediatrics, 33:282 (April) 1916.
Vitiligo Mask with Inherited Syphilis (Rivista di Clinica
Pediatrica, Florence, May, 1919). Lutati reports two cases in
which children of 7 and 11 presented vitiligo of the face alone,
with some asymmetry of the face. The parents of both were
syphilitic. The vitiligo had begun to develop three and five years
before, and at date of writing formed as it were an actual mask
over the face. The Wassermann reaction was positive only in
one of the children, but both showed other stigmata of syphilis.
Journal A. M. A.
SOME EXPERIENCES WITH MALARIA AMONG CHIL-
DREN IN PALESTINE*
By Sophie Rabinoff, M.D.
New York
In June, 1918, a group of physicians and nurses, comprising
the American Zionist Medical Unit, left here to do medical work
among the civilian population of Palestine.
After over 2 months of traveHng, our unit finally reached
Palestine, and I was detailed with a group of physicians and
nurses for duty in Jerusalem. We arrived at the height of the
summer heat and the malarial season. I shall never forget the
warm reception we received from the mosquitoes, sand-flies and
other insects. Our mosquetaires had not yet arrived, and sleep
was absolutely out of the question. The city of Jerusalem is
situated about 2700 feet above sea level, on dry stony land, and
the climate is delightful except for a couple of months during
the year, when it becomes very hot, but the nights are invariably
cool. Whence then the mosquito? Jerusalem has no water
supply of its own, and the inhabitants depend for their supply
on what is collected during the rainy season. This is stored in
cisterns underneath the houses and must last throughout the dry
season. Where the cisterns are small, or when there has been
inadequate rainfall, the cisterns run dry, and water becomes a
luxury which must be purchased. Needless to say, when such
a contingency arises, the use of water except for drinking and
cooking purposes, is considered superfluous. The cisterns them-
selves furnish an ideal breeding place for mosquitoes, and a fine
source of infection for typhoid epidemics and other water borne
diseases. While malaria is present to some extent the year around,
there is a marked increase in spring, beginning in April. There
is a rapid rise for about 2 months, then a short period of decline
followed by another rise toward the end of July, lasting until
about the middle of October. The health conditions during the
winter months or the rainy season, are as a rule good.
My work commenced the second day after arrival, in a small
children's hospital which had been opened during the war. There
were 25 beds, and at that time, the service consisted of cases of
*Reafl before the Section on Pediatrics, New York Academy of Medicine, De-
cember 11, 1919. For discussion see page S3, January, 1920, .Archives of Pediatrics.
494
Rabtxoff: Malaria Atnorii;; Children in Palestine 495
malaria, dysentery, gastrointestinal conditions, pneumonia, ty-
phoid, and influenza. Clinics were held daily, and were filled
to overflowing, this being the only children's clinic in the city,
and we saw daily from 100 to 200 patients. Under the circum-
stances, it was impossible to make anything more than the most
superficial kind of examination, weeding out and giving more
care to those children who appeared very ill. I spent 2 months
altogether in Jerusalem, and then as Palestine was opened up
by the rapid and spectacular advance of General AUenby and his
forces, detachments of physicians and nurses were sent north
to take care of the civilian population in the newly opened ter-
ritories. Stations were opened in Tiberias, Safed, Haifa and
Jaffa, and I was sent to the latter city. A composite picture of
my impression of the babies that I had left in Jerusalem, can be
summed as a something that bore only the rerrtotest resemblance
to an infant. It consisted of a tremendous abdomen, filled mostly
by spleen, with a tiny chest, a head and little thin extremities
stuck on as accessories.
In Jaffa, the first few months of our work was also purely
relief work among the refugees who had been driven out of their
homes by the Turks. Many of these had gone up to Galilee,
and were now returning to their homes as fast as they could
get there. They came down on foot, in rickety old carts and
wagons, on donkeys and camels, bringing their few rags and the
remains of their worldly goods. Before the war, there had been
very little malaria in Jaffa, but the majority of those who had
been exiled in Galilee, were infected. The disease had been
aggravated by the hardships they had endured, when left with-
out homies, shelter or food, and also by the lack of quinine at
various times during this stormy period. An emergency hospital
and clinics were immediately opened to take care of these ref-
ugees, and I took charge of the children's work here. Later a
small children's hospital of 20 beds was opened, which was quite
a model for that part of the world, and here as well as in the
clinic, we commenced to keep a more or less detailed record of
work. This was no easy task, as we had only a very small staff
at our disposal. Altogether we treated over 2000 cases of malaria
among children.
Our clinic routine was as follows: Each patient, on its first
visit, had a complete physical examination, blood smear taken,
496 Rabinoff: Malaria Among Children in Palestine
and if under 2 years of age, was also weighed. Notes were made
of any abnormality, and the size of spleen indicated in every case.
The frank, open, classical cases of malaria offered no difficulty
in diagnosis, but we soon found that malaria offered every symp-
tom and symptom complex conceivable, and simulated almost
every disease known to pediatrics. Not only that — cases of pneu-
monia, typhoid and influenza caused a lighting-up of latent ma-
larial processes, often obscuring the entire clinical picture. It
was no unusual thing for a child to be brought into the clinic
with a temperature of 105° or 106° F., and we soon found that
there was such a thing as a typical malarial facies, that was
almost diagnostic. The pinched ashy blue or yellow color, blue
lips, anxious drawn nostrils, and beads of perspiration on the
forehead were unmistakable, and in walking through the clinic
waiting room, I would pick out these acutely ill patients for im-
mediate attention.
In comparing the symptoms of malaria in children with those
in adults, there were several outstanding features. The chill is
less frequently an initial symptom. On the other hand, there is
a greater tendency to convulsions and other nervous manifesta-
tions such as restlessness, twitchings, fretfulness, or drowsiness.
In addition, in the children under 2 years, there were very fre-
quently gastrointestinal symptoms such as vomiting, constipa-
tion, diarrhea, and occasionally bloody stools. Also the interval
between the attacks was, as a rule, marked by a striking return
to normal appearance. It was not at all unusual to see a child,
who at the height of the attack appeared desperately ill, seem
in a few hours to be perfectly well. There was a much greater
tendency to irregularity in temperature than in adults.
The youngest patient was an infant only a few hours old.
The mother had suffered from chronic malaria for several years,
with acute exacerbations from time to time. During this present
pregnancy, she came to the clinic while in her seventh month
and had received quinine hydro bromide together with morphine
sulphate in very small doses. This seemed to keep the fever in
check, although her blood would from time to time show tertian
organisms. I was called to the patient's home by the midwife in
attendance, when the baby was 12 hours old. It looked blue and
cold, jface drawn and pinched, pulse feeble and very rapid. In
view of the mother's history, a blood smear was taken at once.
Rabtnoff: Malaria Among Children in Palestine 497
A few tertian parasites were found. Four hours after I saw the
infant, its temperature rose to 105 °F, and quinine was ordered
immediately in doses of one grain every 2 hours. There was only
a sHght rise of temperature on the third day, and no recurrence.
The majority of authors do not believe that congenital malaria
occurs, although a few cases have been reported. Altogether
there were treated 59 cases in infants under 1 year, and of these,
7 were under 1 month.
In the group with gastrointestinal symptoms, a good many
had simple diarrhea as the outstanding feature. Three cases had
bloody mucous stools as the only important symptom, and the
history of 1 of these is of special interest because of the number
and type of relapses. A sturdy, well-nourished youngster of 3
years was brought to the clinic with a history of bloody mucous
stools, 8 to 10 daily, tenesmus, and afternoon temperature for
the past 4 days, lie had had malaria 6 months previously. On
examination the child appeared pale, temperature 101 °F., spleen
2 fingers below rib margin; otherwise abdomen and rectum
negative. Blood smear negative for malaria ; stool showed no
dysentery. In the hospital the child ran an irregular temperature
up to 102° F., and showed absolutely no response to any treat-
ment directed to the local condition. Finally, it was decided to
give the child quinine, in spite of the negative blood smear. He
would not tolerate it by mouth, so it was given by hypo. x\fter
the second dose, the temperature dropped to normal, and re-
mained so, the stools diminished in number and improved in
appearance, and after 6 doses were perfectly normal except for
traces of mucus. As the child appeared anemic, it was given
Fowler's solution and quinine in small doses togdther with
licorice, which he was able to retain. When he was discharged,
the mother was instructed to continue the quinine and Fowler's
solution, and to bring him to the clinic once a week for observa-
tion. This she did for 3 weeks, and then we saw nothing of the
youngster for 4 months, when he was brought in with a recur-
rence of all his previous symptomis. He had received no quinine
for over 2 months, and had been apparently quite well during
that period. At this time the examination of the blood revealed
a few tertian parasites. Treatment with quinine was immediately
instituted together with other measures, and the attack was
promptly controlled. The child was brought back once tnore.
498 Rabinoff: Malaria Aynoui^ Children in Palestine
shortly before I left Palestine, with another recurrence of the
same type.
Another case with gastrointestinal symptoms, simulated an
attack of appendicitis. A boy of 8 years was brought to the
clinic suffering from intense pain in the abdomen, nausea, vomit-
ing and constipation. The patient had been ill 2 days. He ap-
peared quite prostrated, face ashy and pinched, extremities blue
and cold, pulse rapid and feeble, temperature 104° F. Spleen
was only slightly enlarged, but there was decided rigidity on
the right side, and tenderness over the appendix. He was ad-
mitted to the hospital with a diagnosis of acute appendicitis,
and expectant treatment ordered. We had no ice, so cold com-
presses were applied, while advisability of immediate opera-
tion was considered, but it meant either bringing a surgeon
down from Jerusalem, or transferring the patient over 40 miles
of the roughest kind of roads through the hills, so I decided
to watch and wait. Blood smear examined immediately showed
no malaria, and a blood count gave 15,000 leucocytes with 68
per cent, polys. This seemed to confirm the diagnosis as in
malaria there is usually a leukopenia. After a few hours, how-
ever, the child showed some signs of improvement, and the
temperature fell to 102° F. At the end of 6 hours, temperature
was normal ,and the child appeared perfectly comfortable, his
color was good, although there was still considerable rigidity
and tenderness. Food and medication by mouth were withheld,
and at the end of 36 hours, child again became restless, com-
plained of pain and vomited. Temperature rose to 103.8° F,
Another blood smear taken at this time showed tertian parasites.
Injection of ^ gram quinine was given immediately. After a
few hours the temperature again dropped, child began to im-
prove, and 24 hours after the second dose of quinine, there was
practically no rigidity or tenderness. Although the temperature
rose on the following days to 101° and 100°F., there was no
further recurrence of the previous symptoms.
The group of cases with pulmonary symptoms offered many
difficulties in diagnosis, especially as the influenza epidemic ap-
peared at the height of the malarial season, and one condition
complicated the other. Of course, where malarial organisms
were found in the blood there was no question, but in a certain
percentage of the cases, where the indications pointed to ma-
RABrNOFF : Malaria Auioni:; Childr.en in Palestine 499
laria, or where temperature and symptoms did not clear up,
quinine was given despite the negative smear with prompt relief
of symptoms. Many of these were latent cases lighted up dur-
ing the period of lowered vitality attendant on the influenza. On
the other hand, there were cases with signs simulating pneu-
monia, which were undoubtedly malarial in origin. One of these
cases is that of a well nourished little girl of 4 years, who was
taken suddenly ill with convulsions. On admission child had
temperature of 105°F., pulse 160, respiration 60. Spleen was
slightly enlarged, area of dullness at left apex, with broncho-
vesicular respiration. The following day there were a few fine
crepitant rales in this area, temperature had dropped to 99.4° F.,
but respirations were about 45, and the child appeared ill. On
the third day there was another convulsion, with temperature
rising to 105.8°F. At this time a blood smear was examined
and organisms found. Quinine was immediately given by hypo
in doses of j/2 gram twice daily. Following the administration
of quinine, there were no more convulsions, though the tempera-
ture rose to 101° and 102°F. on the following two days, and the
rales persisted. The third day after the administration of quinine,
there were no rales, temperature was normal, and the patient
felt perfectly comfortable. Two months later the patient had
a recurrence with almost identical symptoms, and another 3
months after that. In the interim the child appeared perfectly
well, except that he became pale. After the third attack I ad-
vised the mother to take the child up into the mountains for
change of air, and at last report he was doing well and had had
no more recurrences.
A case of cerebral malaria occurred in a child of 11 years.
He was brought in during a convulsion. Examination of the
blood was negative. After the convulsion, temperature was
104.8° F., child appeared stuporous, cried when disturbed, or
from time to time emitted a sharp cry. The head was retracted,
there was a Kernig and exaggerated reflexes. The pupils were
equal and reacted promptly to light and accommodation. Lumbar
puncture gave clear fluid under moderate tension, and laboratory
examination was negative. On second day the condition was
practically unchanged, although toward evening the temperature
rose to 105.6°F., and child became very restless. Blood smear
taken at this time revealed the aestivo-autumnal parasite. Quinine
500 Rabtnoff : Malaria Among Children in Palestine
was given by hypo and 24 hours later the child appeared quite
normal, although there was still some rigidity of the neck, and
Kernig was still present. Altogether there were 60 cases ushered
in by convulsions in our series.
The blackwater fever cases are not common in the lower part
of Palestine or Judea, but we had 4 cases of the malignant form
of malaria associated with hemoglobinuria. There is a tradition
among the laity and a good many of the physicians there that
quinine taken during the height of the fever will cause this
condition. In reviewing the literature, I find there are still 2
distinct schools, one of which gives quinine during an attack,
and the other absolutely forbids its use. One of my cases pre-
sented an interesting phenomenon. A girl of 14 was brought
down from Galilee, having traveled 3 days in an old rickety
wagon with her family. They were refugees who were returning
to their home in Jafifa. They had all suffered from malaria, and
the patient had had a chill followed by fever while en route.
When seen, she was extremely ill, comatose and delirious by
turns, temperature 103 °F., rapid and sighing respirations, rapid
pulse, skin and conjunctivae jaundiced, and the extremities cold.
The bowels had not moved in 3 days, and she has passed small
quantities of bloody urine. She was given a dose of castor oil,
a high soapsuds enema, warm bath, heat was applied to the
extremities, and caffein sodium benzoate and camphor by hypo ;
also calcium chloride 30 grains. On the first day she passec":
300 c.c. of dark red urine. Examination showed high specific
gravity, heavy albumin precipitate, and loads of red cells. The
case gradually cleared, but there was a temperature of 100^,
or 100.5 °F., which persisted, the spleen was enlarged almost to
the umbilicus, and there was extreme pallor. Small doses of
quinine hydro-bromide and Fowler's solution were given. Tem-
perature became normal and the spleen decreased somewhat
in size. She continued to improve until discharged from ihe
hospital, and the nurse was directed to give her a suY^ily of
quinine hydro-bromide. The mother was given instructions on
the general care, and was told to bring the child to the clinic
weekly for observation. At about 10 o'clock the following even-
ing, the child was brought into the hospital, and I was hur-
riedly summoned. I found her again in a state of collapse, with
rapid feeble pulse, cold extremities, anxious pinched face, and
Rabinoff: Malaria Among Children in Palestine 501
subnormal temperature. The mother stated that she had given
the child 2 of the pills and at about the time the third one was
due, the child passed some bloody urine, and shortly after that,
had become ill. It developed subsequently that the nurse had
given the mother 5 grain pills of quinine sulphate, and the attack
had come on after having taken 10 grains of this preparation.
Enlarged spleens were noted in 70 per cent, of the children
treated, the spleens varying in size from those that were easily
palpable below the rib margin, to those that extended into the
pelvis. In some cases the rapidity with which the spleen increased
and decreased in size and consistency was remarkable. The
chronic cases all had tremendous spleens and were hard to treat.
Many of these ran a daily temperature of 100° to 101 °F. and
were extremely anemic. But one of these was particularly grati-
fying. A boy of 12 was brought from the orphanage, complain-
ing of pain in the back. The attendant stated that the boy com-
plained constantly and would not participate in any of the boys'
games or exercises. Nothing was known of the boy's previous
history. He was a very pale, thin child, with a spleen reaching
2 fingers below the umbilicus. Examination of his blood showed
tertian parasites. He was put on a course of quinine and
Fowler's solution. A suspensory belt of adhesive was applied
to the spleen region and an abdominal binder put on. He was
brought back in a week with the spleen at the umbilicus. The
pain was considerably decreased, and the boy's color was slightly
improved. At the end of a month the spleen was 2 fingers below
the rib margin, and at the end of 2 months, the spleen was
scarcely palpable. His color was good and the pain was com-
pletely gone.
In the treatment of our cases, quinine was given by mouth
in all the simple cases. Where it was tolerated at all, it was
given in fairly large doses. In a certain group of cases, it upset
the stomach when given in simple solution, but when made up
with a simple syrup or with licorice, it was better tolerated. A
small percentage do not tolerate the quinine at all when given
by mouth, and in these it was given in suppositories or by hypo.
In all the cases where the attack was ushered in by a convulsion,
or the symptoms were very severe, and in all cases of malignant
tertian or aestivo-autumnal malaria, the quinine was given by
hypo in doses of y^ gram. All the quinine preparations are
502 Rabinoff: Malaria Among Children in Palestine
very irritating when given in this way, although the hydro-
chloride and dihydrochloride are the best, but it must be care-
fully given. When we first came to Palestine, we saw many
cases of abscesses and sloughing following the administration
of quinine by the local druggists and other attendants. In one
case particularly, a slough was removed leaving a cavity as
large as a fist. In our series, we had 2 cases where sloughing
occurred, and in both instances, the injection was given with a
short needle into the fatty tissue of the buttocks. In the majority
of cases, there was no difficulty in controlling the acute attack,
where the quinine was taken regularly, and attention given to
other measures such as rest, proper hygiene, and simple nourish-
ing food. Often cases treated at home did not respond, but on
admission to the hospital would clear up promptly. I am con-
vinced that many of the relapses are due to insufficient treat-
ment, or improper treatment or lack of rest in bed. In this con-
nection, I will say that it is very difficult to make the patients
continue the quinine after they are over the acute attack, and
the result is that they continue to harbor the organisms some-
where until such time as their vitality is lowered, and a lighting
up occurs. Besides, these cases act as carriers, and keep up a
vicious circle. The chronic cases are very resistant, but in some
instances where quinine by mouth did not help at all, a course
of 6 or 7 doses given intramuscularly, and then followed by
quinine and arsenic, given in the ordinary way, showed marked
and rapid progress. In 10 cases we used neosalvarsan intra-
muscularly, with apparent immediate benefit, but relapses oc-
curred when they were not followed by quinine. Change of
climate was found to be a very good adjuvant to the quinine.
In closing, it is necessary to emphasize the importance of
making a very careful study of these cases in infants and young
children, especially in known malarial districts, where the symp-
tom complex of every disease may be obscured by a latent or
complicating malaria.
SOCIETY REPORT
THE NEW YORK ACADEMY OF MEDICINE.
SECTION ON PEDIATRICS.
Stated Meeting, Held February 12, 1920.
Charles Hendee Smith, M.D., in the Chair.
ENCEPHALITIS LETIIARGICA,
Dr. Stafford McLean presented this child, whose family
and personal history he said were of no interest. The child had
been entirely normal until January 27, when it was noticed that
she was drowsy. The following day the drowsiness had increased,
and she remained in this condition until she was brought to the
outpatient department of the hospital on January 30. The child
was admitted to the hospital on January 31, and had remained
in this condition for the past 13 days. The condition had changed
but little from the time of admission except for an increased
drowsiness. The child had a tendency to fall backward and to
the left. There was a very feeble response to normal stimuli. The
pharyngeal reflexes were normal. The heart and lungs were
normal.
The physical examination showed a mask-like facies and
a coarse tremor. The knee jerks were increased. There was
no opisthotonos and no rigidity of the neck. The child would
swallow food, if it was put into its mouth. The child had not
spoken since in this condition. Two spinal fluid examinations
had been made, both of which were normal, having about 5
cells, all lymphocytes. Two von Pirquet tests were made, both
of which were negative. The eye grounds were examined 3 times
and were negative. The blood count showed 10,000 leucocytes,
66 per cent, polymorphonuclears and 34 per cent, lymphocytes.
The temperature had been above 100° F. only once, remaining for
the greater part of the time around 99°F, In other words, tem-
perature was not a feature of this condition. The child had not
vomited. There were occasional periods of apnea such as one
saw in meningitis. The child was spastic at times and relaxed
at other times.
503
504 New York Academy of Medicine — Section on Pediatrics
Discussion. — Dr. Frank J. Bevan stated that with reference
to the mask-like expression of the face, when the child first be-
came ill, the mask-like expression was more decided than dur-
ing the past 3 or 4 days when it had begun to show some ex-
pression. The child now cried and had some expression which
Dr. Hunt regarded as evidence of improvement. During the
first 10 days they had used gavage, but during the past 4 days
this had not been necessary, so they felt that there was a tendency
toward recovery.
Dr. Smitpi said that they had had 2 such cases that recov-
ered and apparently those children who recovered were just as
sick as those that died. They had had 3 or 4 of these cases at
one time. They were strikingly like tuberculous meningitis.
Dr. McLean said this was the third case they had had. The
other cases were 1 and 2 months old. The earlier case had been
in the hospital 6 or 7 months ago, and he had had a letter from
the mother stating that the child was entirely normal except
for a "weakness of the back."
In reply to the question as to how he would confirm the
diagnosis of encephalitis lethargica, Dr. McLean said it was a
very difficult matter to make a diagnosis in these cases, and he
had arrived at a diagnosis largely by exclusion. It was not a
tuberculous meningitis because the von Pirquet was negative, and
the spinal fluid had no tubercle bacilli. It was not a brain
abscess because there was no vomiting. The onset was too acute
for a brain tumor; if it were an abscess, fever would be present
and the blood count would be different. The onset did not sug-
gest a polioencephalitis nor did the spinal fluid findings, and the
lethargic state had lasted too long. Hence he had put the case
under encephalitis for the lack of a better group. In reply to
the question as to how the child was being treated Dr. McLean
said the only thing .they were doing was trying to keep up the
nutrition.
Dr. Eli as H. Hartley said it was unusual to find a normal
spinal fluid in these cases. He had usually seen an increased
cell count but it did not correspond to that of tuberculous menin-
gitis, but was somewhat similar to that found in poliomyelitis.
Sometimes it was difficult to make a differential diagnosis
between this disease and the cerebral form of poliomyelitis. While
Nezu York Academy of Medicine — Section on Pediatrics 505
it was unusual to find a normal cell count in encephalitis lethar-
gica, he had no criticism of the diagnosis.
Dr. Smith said it was quite true that some of these cases
had an increased cell count, but again some did not. It was
interesting to see how many more of these cases there were this
year than last. With the severe form of influenza, there were
very few of these cases, while this year with the mild form of
influenza they were seeing mjany more cases of encephalitis
lethargica.
Dr. Henry Dwigiit Ciiapin said it would be interesting
to make the differentiation between this disease and tuberculous
meningitis but he would find it difficult to do this as he had seen
only 4 or 5 cases.
Dr. McLean said if the child lived long enough that would
decide the diagnosis ; if the child lived, it did not have tuberculous
meningitis.
Dr. Chapin said that in tuberculous meningitis one fre-
quently did not get a positive von Pirquet reaction.
Dr. Smith said he wondered if some of the cases diagnosed
as tuberculous meningitis in the past might not have been this
disease.
Dr. Oscar M. Schloss said he did not know a definite way
of differentiating encephalitis from tuberculous meningitis in
the early stages, but that disease was more chronic than tuber-
culous meningitis. The cases all ran a long course and often
showed some form of paralysis or paresis. Two out of 3 showed
some paresis on one side of the face, not enough to be called a
paralysis. The thing that was striking was thai they slept all
the time ; they went on that way for weeks and months, which
was not true of tuberculous meningitis. The spinal fluid changes
might be almost the same except that the count was apt to be
lower in encephalitis. In some cases, however, there is no in-
crease in the count at all.
Dr. Bartley said that in the cases of encephalitis lethargica
that he had seen there was not the irregularity in respiration
and pulse that one sees in tuberculous meningitis. In tuberculous
meningitis there were pressure symptoms which were absent in
these cases. The cases of encephalitis lethargica went along
without change in about the same way, while tuberculous menin-
gitis progressed from day to day. Perhaps it was not always so,
506 New York Academy of Medicine — Section on Pediatrics
but in the cases he had seen there were no symptoms of intra-
cranial pressure and no strabismus such as were almost always
seen, sooner or later, in tuberculous meningitis. Paresis might
be present in both conditions, so it seemed to him that the sig-
nificant thing was the pressure symptoms. In tuberculous menin-
gitis the time from the onset of symptoms until death was on an
average 14 days.
Dr. Smith said it seemed to him then that the great difiference
between encephalitis lethargica and tuberculous meningitis was
the failure to progress. If one watched a case for 3 days and
there was no change in the condition it was more likely to be
one of encephalitis lethargica. The average length of life after
coma set in was about 5 days ; a coma lasting 10 days was very
long in a case of tuberculous meningitis.
A member stated that in regard to the catatonic phase there
was something characteristic in the cases they had seen at
Bellevue. The catatonia usually appeared within 5 days after
the onset of symptoms. In encephalitis lethargica there was not
so much a paralysis as a weakening of the facial nerve so that
the face and jaw assumed a wax-like appearance. This and the
characteristic catatonia were the 2 signs that dififerentiated the
condition so far as he had noticed.
Dr. Smith said he had seen 7 cases of encephalitis lethargica
and they all had catatonia. If one put the hands of the child in
a certain position they remained in that position for a long time ;
that feature had been very interesting and striking.
TUBERCULOUS ARTHRITIS.
Dr. Frank J. Bevan presented this case, a female child, 13
months old, brought to the Babies' Hospital because of swelling
of the left knee. The swelling was noticed 6 weeks before this
time and had been increasing. There was a discharge from the
left ear for 1 week. The family history was interesting in that
there was no other pregnancy, no miscarriages, and no exposure
to tuberculosis. The feeding history was normal. The child had
had nothing but a soft diet and had never been sick before.
Six months ago the child had begun to walk and was able to
take a step or two, but gradually became less inclined to try to
walk and after about 3 weeks would not try to walk at all. The
swelling of the knee had increased and when the knee was
New York Academy of Medicine — Section on Pediatrics 507
handled the child always cried out. She had never had fever
or night sweats, and had had no vaginal discharge. One week
ago the ear broke. This was not preceded by fever. The dis-
charge was very foul.
The child was seen for the first time in the outpatient depart-
ment of the hospital. She gave a positive von Pirquet reaction
and the physician who saw the case a week before considered it
one of scurvy and had given the child orange juice. The tonsils
were enlarged but otherwise negative, and the cervical lymph
nodes were enlarged. The lungs, heart and abdomen were nega-
tive. One could barely feel the spleen, the liver was not en-
larged and there was no mass suggestive of adenitis in the ab-
domen. The left knee was enlarged and the left hip, though
not enlarged, was rather tender. There was a typical chronic
dactylitis. The case was interesting because the baby was only
13 months old and showed a typical tuberculous arthritis.
Discussion — Dr. Schloss asked if the otitis media was a tuber-
culous one.
Dr. Bevan said they had not yet worked out the bacteriology
as regarded the tuberculosis. The pus from the ear had a very
foul smell.
Dr. Schloss said the reason he asked whether the otitis
media was tuberculous was because tuberculous otitis media
was not uncommon. He had seen 3 children under 3 months of
age with tuberculous otitis media in whom a radical mastoid
operation was done. Two of these children had recovered and
were perfectly well ; he did not know about the third.
Dr. Smith stated that he had seen 3 cases of tuberculous
otitis media in 1 ward in a maternity hospital, and all had de-
veloped within 3 months. They were all submitted to radical
mastoid operations.
MYOSITIS OSSIFICANS.
Dr. Miner C. Hill presented this patient, a boy about 12
years of age. He had been nursed for 9 months, had had measles,
whooping-cough and mumps, and at 2^/^ years of age swelling
on one side of the neck. This swelling had persisted and became
progressively harder. Following this, the muscles of the back
began to show areas of ossification and also those of the arms
and legs, until at the present time the boy presented many de-
508 New York Academy of Medicine — Section on Pediatrics
formities, and furnished a striking example of the condition
known as myositis ossificans.
Discussion — Dr. Gaylord W. Graves said that this was a boy
with whose history he was famihar to a certain extent, as the
boy had come to his office about 5 years ago, referred by another
physician. At that time no such complete changes were to be
observed. There was, however, a very noticeable lesion extend-
ing along the posterior surface of the right chest, which re-
sembled periostitis of the ribs; and although the examiner was
not familiar at that time with "myositis ossificans," mention by
the boy's mother that a doctor at Bellevue had told her the boy's
muscles were turning to bone had recalled the term to mind
and had led to the correct diagnosis.
The boy later came to Roosevelt Dispensary, where his his-
tory was looked up and it was found that at Bellevue Hospital
a study of the tissue pathologically and also an investigation of
the patient's calcium metabolism had been made. X-ray pic-
tures, taken at Roosevelt Hospital, if compared with those taken
at the present time, would show the progressive course of the
disease. These Roosevelt radiographs had been turned over to
the Bellevue investigator to facilitate completion of his report
of the case but it was uncertain whether this report had been
finally published.
The case thus had a long history and was interesting because
there were only 100 to 125 such cases on record and also because
it emphasized that when one saw 'this condition a second time
he might be observing the same case he had seen before.
MASSIVE CONGENITAL DIAPHRAGMATIC HERNIA WITH DEXTRO-
CARDIA.
* Dr. H. W. Mayes reported this case and presented the speci-
men. He stated that the infant was born spontaneously in April
20, 1919, and was apparently normal. In a short time, the child
became dark blue and remained so until death, which resulted
apparently from pulmonary edema 7 hours after birth. Judging
froiTi, the cyanosis the child was considered a blue baby but no
murmur was detected over the precordium. At autopsy the ex-
ternal appearance was that of a normal child except for bluish
discoloration of the skin. On opening the chest and abdomen,
the left thoracic cavity was filled with the stomach, spleen, pan-
New York Academy of Medicine — Section on Pediatrics 509
creas, one-half of the left kidney, part of the duodenum, ileum,
and greater part of the colon. These organs were free in the
pleural cavity with the exception of the kidney. A very small
rudimentary left lung, showing division into 2 lobes was found
in the upper part of the thorax. The heart was completely on
the right side. Between the auricles was a small patent foramen
ovale. The pulmonary artery was almost as large as the aorta
and, lying almost in front of it, was continuous with the ductus
arteriosus, which was also patent. The right lung was made up
of 3 lobes and had a large depression filled by the heart. The
thymus was normal. The abdominal cavity contained a large
liver, which extended down to the brim of the pelvis, a right
kidney normal in size and position, one-half of the left kidney,
and the sigmoid, which extended in a straight line from the
rectum to opening in the diaphragm. The right side of the
diaphragm was normal. The left side showed good muscular
tissue, normal attachments anteriorly and laterally, but no at-
tachment to the posterior chest. This left an opening 2x5 cm.
in size through which passed the cardiac end of the stomach, a
loop of the duodenum, the colon, and the left kidney, making a
false diaphragmatic hernia. The kidney was retroperitoneal and
formed the posterior boundary of the opening. Dr. Mayes stated
that the hernia in this specimen was undoubtedly formed during
the early life of the fetus or they would not have the rudimentary
lung on the left side. The dextrocardia was secondary to the
hernia. The patent foramen ovale and the ductus arteriosus were
due to the fact that the heart was out of its nornial position.
Dr. Mayes, in discussing diaphragmatic hernia, stated that the
condition was rather common and that the true diaphragmatic
herniae were more frequent than the false. They occurred more
frequently on the left side because the liver was on the right side.
Most of the patients died before the correct diagnosis was made.
Some were operated on successfully. After referring to the lit-
erature on this subject, Dr. Mayes expressed the opinion that
judging from the cases reported by Gross and Morgan, as well
as his own, the dextrocardia must have some influence in caus-
ing the patency of the foramen ovale and the ductus arteriosus.
A CASE OF BACTERIEMIA TREATED BY BLOOD TRANSFUSION.
Dr. Jesse F. Sammis reported this case (to be published in a
later number of Archives).
510 Neiv York Academy of Medicine — Section on Pediatrics
TRUE CONGENITAL DIAPHRAGMATIC HERNIA.
Dr. Henry R. Muller reported this case which came under
observation at the Nursery and Child's Hospital. He stated that
the child was a white male, 8 months old, who weighed on ad-
mission to the hospital 11 pounds, 6 ounces. The child's weight
at birth was 7^ pounds. Vomiting, described as projectile, and
taking place immediately after the ingestion of food, had oc-
curred since birth.
At the age of 6 months and while still on breast feedings, he
improved somewhat and gained 3 pounds, 2 ounces in weight ;
that is, he increased in weight from 11 pounds, 3 ounces, to 14
pounds, 5 ounces.
Three weeks before admission to the hospital, at about the
age of 7 months, he began to vomit all his feedings, even water.
Up to this time he had been entirely breast fed, but he. was
now put on mixed feedings, consisting of 3 breast and 4 bottle
feedings a day, with irregular additions of zwieback. For a day
or 2 his vomiting stopped, but it recurred and his condition since
then had grown gradually worse. For the past 4 days the child
had been drowsy and lost, during that time, 3 pounds, 5 ounces in
weight. There had been no convulsions, but the child had been
coughing and sneezing, and this was followed by vomiting.
Physical examination showed a fairly well developed but
undernourished child. His eyes were sunken and he appeared
acutely ill. His respirations were deep and sighing and he was
semi-comatose. The lips were' dry and cracked, the tongue
coated, and the mucous membranes of the mouth dry. There
was no evidence of cerebral irritation. Examination of the heart
showed the beat in the fourth interspace in the left middle line.
The abdomen was scaphoid and symmetrical. The skin wrinkled
and inelastic. No tumor mass was palpable nor were peristaltic
waves observed. The liver and spleen were not felt and there
was no fullness in the epigastrium.
In the admitting room, the child was given 3 ounces of water,
which was taken greedily, but vomited at once with a great gush.
The entire mass of water seemed to reach the mouth at one time ;
the vomiting was not projectile. In the ward the same type of
vomiting was observed on attempting to feed the child milk.
He could retain only 2 ounces of albumin water every hour.
When an attempt was made to increase the quantity, vomiting
New York Academy of Medicine — Section on Pediatrics 511
recurred at once. Intraperitoneal saline injections in large
amounts were administered, and glucose solution was given in-
travenously.
The blood examination showed 13,000 leucocytes, of which
52 per cent, were polymorphonuclears. Examination of the
spinal fluid and the von Pirquet test were negative. A slight
trace of albumen, and marked traces of acetone and diacetic acid
were present in the urine.
On admission, the temperature of the child was 99° F. The
child died of coma 48 hours after admission ; the temperature
just before death reaching 106° F.
Briefly, what was found at autopsy was a diaphragmatic
hernial sac, 5 cm. in diameter, situated in the thorax posteriorly
and to the right of the heart. The outer surface was covered
with a layer of parietal pleura, and the inner surface was covered
with a layer of parietal pleura, and the inner surface was lined
with peritoneum. The neck of the sac, corresponding in position
with the normal esophageal opening of the diaphragm was circu-
lar and 2 cm. in diameter. The muscular layer of the diaphragm
could be distinguished up to the neck of the sac, and ended there
abruptly. There were no muscle fibres in the wall of the sac,
but only connective tissue. This hernial sac contained the entire
stomach, doubled up and collapsed, and the omentum. There
were no adhesions present. The esophagus, markedly dilated,
had its new covering in the upper left hand corner of the sac,
where it emptied into the stomach. The condition then was that
of a true congenital diaphragmatic hernia through the esophageal
opening. Such hernias were generally considered to be formed
late in embryonic development, after the closure of the trans-
verse septum.
Discussion — Dr. Schloss said that this case which Dr.
Muller had reported was particularly interesting cHnically. The
child was seen on account of persistent vomiting which was the
prominent symptom. During the comparatively short period that
the child was receiving solid food it gained 3^2 pounds. The
diagnosis of pyloric stenosis had been considered but was elimi-
nated. As frequently happened in this condition, the diagnosis
was not made. The case furnished a strong argument for the
use of the fluoroscope in all vomiting babies. By that means
the diagnosis would be made in many more of these cases.
BOOK REVIEW
The American Illustrated Medical Dictionary. A new and
complete dictionary of the terms used in Medicine, Surgery,
Dentistry, Pharmacy, Chemistry, Nursing, Veterinary Science,
Biology, Medical Biography, etc., with the Pronunciation,
Derivation, and Definition, including much collateral informa-
tion of an encyclopedic character. By W. A. Newman Dor-
land, A.M., M.D., F.A.C.S. Member of the committee on
nomenclature and classification of diseases of the American
Medical Association ; Editor of "American Pocket Medical
Dictionary." Together with new and elaborate tables of
arteries, muscles, nerves, veins, etc. ; of bacilli, bacteria,
diplococci, micrococci, streptococci, ptomains and leukomains,
weights and measures, eponymic tables of diseases, operations,
signs and symptoms, stains, tests, methods of treatment, etc.
Tenth Edition, revised and enlarged. Philadelphia and London.
W. B. Saunders Company, 1920.
The tenth edition of this dictionary, which was first placed
before the medical profession exactly 20 years ago, has been
thoroughly revised and amplified. Several hundred new terms
have been added and defined, and the general plan of the previous
editions has been maintained. Little need be said in regard to
the volume itself. It has in its maturity reached the stage of be-
coming a classic. Although a dictionary proper, yet it is almost
encyclopedic in character and may to advantage be used for
reference in a great many conditions. It is a highly convenient
desk size in spite of its 1201 pages. For the man who wants the
precise meaning of both old and new terms, it is absolutely
invaluable.
Juvenile Diabetes (New York Medical Journal, Aug. 30,
1919). Of the 3 cases reported by P. Horowitz the oldest patient
was only 3 years of age, and the youngest slightly more than 2
years old. The cases show the value of institutional over home
treatment. Two patients were treated in the hospital and improved
very much more rapidly than did the patient who was treated
at home. In each case there was a definite history of an intestinal
toxemia preceding the onset of the disease. — Journal A. M. A.
512
Archives of Pediatrics
SEPTEMBER. 1920
HAROLD RUCKMAN MIXSELL. A.B.. M.D.. Editor
CHARLES ALBERT LANG. M.B.. M.R.CS.. Associaie Editor
COLLABORATORS :
L. Ehmktt Holt, M.D New York Fritz B. Talbot, M.D Boston
W. P. NoRTHRUP, M.D New York Mavnard Ladd. M.D Boston
Augustus Caill£, M.D New York Charles Hunter Dunn, M.D. .. .Boston
Henry D. Chapin, M.D New York Henry I. Bowditch, M.D Boston
Francis Huber, M.D New York Richard M. Smith, M.D Boston
Henry Koplik, M.D New York L. R. De Buys, M.D New Orleans
Rowland G. Freeman, M.D. ...New York Robert A. Strong, M.D New Orleans
Walter Lester Carr, M.D... New York S. S. Adams, M.D Washington
C. G. Kerley, M.D New York B. K. Rachford, M.D Cincinnati
L. E. La FiiTRA, M.D New York Henry J. Gerstenberger, M.D. .Cleveland
Royal Storrs Haynes, M.D... New York Borden S. Veeder, M.D St. Louis
Oscar M. Schloss, M.D New York William P. Lucas, M.D... San Francisco
Herbert B. Wilcox, M.D New York R. Langley Porter, M.D..San Francisco
Charles Herrman, M.D New York E. C. Fleischnbr, M.D....San Francisco
Edwin E. Graham, M.D Philadelphia Frederick W. Schlutz, M.D.Minneapolis
}. P. Crozer Griffith, M.D.Philadelphia Julius P. Sedgwick, M.D. . .Minneapolis
. C. Gittings, M.D Philadelphia Edmund Cautley, M.D London
A. Graeme Mitchell, M.D. .Philadelphia G. A. Sutherland, M.D London
Charles A. Fife, M.D Philadelphia J. D. Rolleston, M.D London
H. C. Carpenter, M.D Philadelphia J. W. Ballantyne, M.D Edinburgh
Henry F. Helmholz, M.D Chicago Tames Carmichael, M.D Edinburgh
L A. Abt, M.D Chicago John Thomson, M.D Edinburgh
A. D. Blackader, M.D Montreal G. A. Wright, M.D Manchester
PUBI.ISlIEn MONTIILT BY E. B. TREAT A CO.. 45 EAST 17tH 8TBEET, NEW TOBK.
ORIGINAL COMMUNICATIONS
ACRODYNL^.*
By William Weston, M.D.
Columbia, S. C.
This paper is based on a series of 8 cases in the practice
of Dr. W. F. Patrick of Portland, Oregon, who has very
kindly permitted me to use them. Dr. Patrick referred these
case reports to Dr. John Lovett Morse of Boston for diagnosis
and advice, and Dr. Morse in turn referred them to me, feeling
that there was a definite suggestion of pellagra in each one. I
agree with Dr. Morse that there is a suggestion of pellagra,
but I felt that a diagnosis of pellagra would not be justified
for reasons that will be given later.
• Read before the Section on Diseases of Children, A.M. A., held at New Orleans,
April 28, 29 and 30, 1920.
513
514 Weston : Acrodynia
Befoce writing to Dr. Morse, I consulted Dr. Babcock of
Columbia^ S. C, who is probably the foremost authority in this
country on pellagra. Dr. Babcock has given as his definite opinion
that these cases are not pellagra, and suggested that I look up an
article by Dr. Henry Strachn of Kingston, Jamaica, in which
he reported. a number of cases which he described as "malarial
multiple peripheral neuritis." Both Sir Patrick Manson and
Dr. F. M. Sandwith of London disagreed with the diagnosis
made by Dr. Strachn. Dr. Sandwith, in his effort to arrive at
a diagnosis, considered pellagra, beri beri and malarial neuritis,
and each was eliminated, and he finally suggested that the cases
might be acrodynia. After a diligent search of the literature
both Dr. Babcock and I feel that the cases reported by Dr.
Strachn and those reported by Dr. Patrick are most suggestive
of acrodynia, and the purpose of this paper is to suggest to
the profession that they be on the lookout for this disease and
record similar cases that may occur in their practice in order
that we may study the disease with the advantage of additional
light which may enable us to arrive at a more definite con-
clusion.
Dr. Patrick's letter to Dr. Morse is as follows : "During
the last 9 months we have had a series of cases, 8 in all, ranging
from nine months to 2 years, with one bigger boy of 5 years, all of
which seem to belong to the same general class.
"They begin with loss of appetite, get listless ; some have
infections of the upper respiratory tract, some do not ; some have
intestinal symptoms, some do not ; but all have loss of appetite,
lose weight and have diminished reflexes at times (probably
following increased reflexes earlier). Some have absent knee
jerks for weeks. They all want to lie around, very listless.
All have profuse perspiration all over their body with scratching
and more or less maceration of skin. In every case the hands
and feet have been cold, bluish red and swollen, tender, and
about half painful to touch. One had photophobia and red
conjunctivae, the same one having a small area of necrosis about
2 erupting teeth. Two have had necrosis of the gums and alveolar
processes in both upper and lower jaws, losing in one case 6
teeth and in the other 8 teeth, with accompanying salivation and
stench. All have lost a great deal of weight and with but 2
exceptions have been too sick to treat as office patients. They are
Weston : Acrodynia 515
very listless and don't want to be handled. They have all gotten
well except 2 that are being seen now.
"The big boy began to imprcve coincident with adopting a
diet of vegetables, cereals, etc., excluding all meat, eggs, fish and
milk (he was never as bad as the others). Of the remainder
I cannot feel that anything we have done has been of any use.
One began to improve coincident with tincture of nux vomica, one
minim, t.i.d.
"In a general way they have all been kept on a rather well
balanced diet. They came from widely scattered sections of
Oregon, only 2 from Portland.
"They have all been negative to the von Pirquet reaction and 3,
whose history might be regarded with some concern, were nega-
tive to the Wassermann reaction. We have consulted skin men
and nothing worth while has been ofifered by way of treatment.
Urines of course were looked after and all were negative. We
can find nothing in the literature about it. They seem to get
well after awhile all by themselves. They are miserable cases
to deal with and most pitiable to behold.
"None of them have ever had a temperature of more than
102°. They have all had head colds, some not at all well marked.
All have sweated profusely. All had swollen, cold, bluish-red
feet and hands. Knee jerks have been sluggish or absent in
all at some time, returning to normal as the child approaches
normal. All have had extensive involvement of the skin of the
body, scratching, listless but sleepless. I am writing hoping that
you can tell me about them and what to do for them. I am
sending copy of office notes on one case that I "treated" as an
office patient. In his case the lesions of gums were not more
marked than I have seen many times in erupting teeth.
"Case history : March, 1919. Child's name, Richard ; date of
^birth, June 2, 1918. Family history negative. No deaths and
no miscarriages. No history of T. B. No asthma, and no
eczema. Full term, normal pregnancy, normal delivery. Weight
at birth 9^^ pounds. Breast fed for 4>4 months, then on cow's
milk mixture with barley water and cane sugar. Food increased
from time to time. Grew and did well. Sat alone at sixth
month, first tooth at seventh month and was beginning to stand
by chair at eighth month. At about this time began to have
'bronchitis' and has not been well since. One week later, began
516 Weston : Acrodynia
to have rash on body, and in another week rash was quite
marked. Hands and feet became cold and clammy and soon
turned red and became swollen and tender. He scratched con-
tinuously, and cried, acting as though his hands hurt. An in-
testinal upset about this time occurred, with 6 to 8 offensive stools
daily for 2 days. Then continued to have small, frequent bowel
movements of good consistency. Came in aged 9 months, weight
22y2 pounds, temperature 97°. Had probably lost 2 pounds dur-
ing the previous month, and was droopy. Paid little attention
to anything except his scratching. Did not try to creep or stand.
Was taking 1 quart of skimmed milk, orange juice, prune juice
and cereals.
"Physical examination. A very distressed baby boy. His
underclothes were wet with sweat. Hands and feet swollen,
bluish-red, with fingers held apart and guarded. They showed
a macerated skin covered with ruptured vesicles. His face and
trunk were pale but covered with macerated skin. He cried
constantly. Nasal discharge — throat moderately injected. Mucous
membrane of mouth showed some redness. Teeth, 4 upper, 2
lower with no special reaction in the surrounding gums. Ears
showed dull reflex, neck limber. Lungs clear throughout. Heart
normal. Abdomen level with chest, no tenderness or masses.
Neither liver nor spleen palpable.
"Reflexes — knee jerks hard to obtain. Cremasteric not pres-
ent though scrotum was relaxed. No Kernig. No general
glandular enlargement. Temperature 97°, pulse 100. W.B.C.
18,000. Specimen of urine could not be obtained. Tentative
diagnosis was made of nasopharyngitis.
"He was given atropine, 1/500 q. 4 h. until face began to
flush. Corn starch, drachms 2 ; sod. bicarb., drachm I ; zinc oxide
ointment and petroleum aa oz. I, applied to skin. Camphor, iodine,
menthol aa gr. ^, albolene, drachm I, 4 times a day for nose.
"March 18, 1919. Weight 22 j/^ pounds. Temperature 98°.
For 2 days was much better. Then mother omitted atropine as
face became flushed. Slept well 2 nights, and was not sweating
so much. Feet less painful, also hands. Three days ago (also
third day after last visit) eyes got sensitive to light and were
quite red. Condition of hands and feet about the same as at
first visit. He does not take his food as well. Advise ajRUnuing
Weston : Acrodyma 517
atropine gr. 1/500. Alternating 10 per cent, argyrol with nose
drops.
"March 21, 1919. Weight 23 pounds. Temperature 98°.
Was greatly improved until yesterday morning, when he broke
out with rash again and is now scratching almost as much as at
first. Eyes very sensitive to light. He is drooling extensively,
and around 2 erupting teeth are small areas of necrosed gum.
Hands and feet red, tender, and swollen. He cried all last night,
slept none at all except when mother was rubbing his hands.
Advise continuing nose mixture and atropine, potassium chlorate
mouth wash 4 times a day. Codeine sulphate gr. 1, water 1 oz.
10 drops (1/50) every 4 hours.
"March 29, 1919. Weight 21 pounds, 15 ounces. Temperature
100°. Necrotic area around teeth slightly larger; gums red and
swollen. Does not sweat so much. Hands and feet are not so
swollen. He sleeps better. He scratches more than last week.
Advise omitting codeine, otherwise same.
"April 4, 1919. Temperature 99°. Weight 21 pounds, 11
ounces. Seems better in every way. Hands and feet somewhat
better than last visit. Mouth better. Eyes remain sensitive.
Lungs, heart, abdomen, joints normal. He is droopy and wants
to be held all the time.
"April 8, 1919. Weight 22 pounds, 1 ounce. Temperature
98°. Distinctly improved. Skin and body are dry. Hands and
feet slightly reddened. Notices more. Mouth shows some im-
provement.
"April 16, 1919. Hands and feet warm and dry. Body moist,
but much better. Eyes better. Hands and feet not painful.
Sleeps well.
"May 12, 1919. Weight 21 pounds, 1 ounce. Temperature
98°. Sweating less all the time. Eyes are better, much brighter.
Takes his milk well but declines cereals and toast, and will not
take carrots and spinach. Two bowel movements daily. Sleeps
well. Medicine gradually reduced since last time, not taking
any atropine now. Hands and feet a bit clammy ; some rash
on body, scratching some. Superficial glandular enlargement not
axillary, inguinal, occipital or epitrochlear. Gums healed about
teeth. W. B. C. 18,000. Advise malt, cod liver oil, phosphorus,
teaspoonful t.i.d.
"June 9, 1919. Weight 21 pounds, 15 ounces. Has been pick-
518 Weston : Acrodynia
ing up, doing fine, appetite good. Bowels constipated. Sleeps
well, scratches sometimes, hands and feet do not hurt, eyes sen-
sitive to light. Now taking 1 quart of milk, crackers, toast,
spinach, carrots, meat juice, orange juice, cream of wheat, etc.
Superficial glands about same. No liver, no spleen.
"July 25, 1919. Weight 23 pounds, 7 ounces. Temperature
98.6°. Has been walking last 2 weeks. Eats well, sleeps well.
Hands and feet seem normal now.
"October 5, 1919. Age 16 months. Weight 27 pounds, 7
ounces. Temperature 98.6. Has had a cold last 10 days. Not
much fever, if any. Both ears have been discharging for the
last 2 days. Has been fine up to 10 days ago. Eating everything,
looking fine, eyes normal. No rash, no sweating, hands and feet
O. K. Both ears discharging; nasal discharge. Lungs, heart,
and abdomen O. K. No glandular enlargement. Looks fine again.
Advise irrigation of ears twice daily, nose mixture."
What knowledge we possess of acrodynia is derived chiefly
from the accounts of the Paris epidemic, which was first ob-
served in June, 1828, and lasted until the middle of the winter
of 1829-1830. A number of authors state that this was the first
epidemic of this disease to occur in France. Previous to the
discovery of acrodynia in France, several German writers, not-
ably Schwenkfeld, Wolf, F. Hofifman, and Muller described,
under various names, krampsucht, kornstaupe, kriebelkrankheit,
morbus cerealis, morbus spasmodicus malignus, epidemicus malig-
nus, etc., an epidemic convulsive disease, the descriptions resem-
bling almost identically the Paris epidemic as described by Dance,
Chomel, Cayol, P. Montault, Valliex, and others. Therefore we
feel reasonably sure that while the German authors felt that they
were describing an unusual and peculiar form of pellagra, in
the light of subsequent study we are justified in feeling that the
disease was acrodynia.
In 1837 Dr. Pingault, in an address before the Society of ■
Medicine of Poitiers, reported several cases of "podalgia." The
symptoms which he described as manifested by these patients
are almost identical with those of many of the cases reported in
the Paris epidemic.
Montault, writing about 1829 or 1830, quotes Francois as
having recognized the same disease (Paris epidemic) in the
Weston: Acrodynia 519
West Indies among the negroes, who Hved in houses in low and
damp places.
There is an article in "The Indian Gazette" of August 2,
1880, by Surgeon-Major B. Evers describing a disease in which
the chief manifestation is intense burning of the feet. He calls
it "ignipedites" and says this disease is quite common in India.
Dr. W. J. Cole, of Blairsville, Indiana, published in the St.
Louis (Mo.) Medical and Surgical Journal of April 5, 1880,
3 cases of intense burning of the hands as having occurred in
his practice during the last 3 years. Having read the reports
of the Paris epidemic, he pronounced them acrodynia. His re-
port is very brief. He speaks of using tobacco poultices, morphia,
etc., but concludes that the trouble was self limited as they recov-
ered in due time.
In 1888, Dr. Henry Strachn, senior medical officer, reported
510 cases of "malarial multiple neuritis" observed in the King-
ston (Jamaica) Public Hospital, full notes having been taken
on 121 of these cases. The patients complained of numbness and
burning heat in the palms and soles, often accompanied by cramps,
worse at night and in wet weather. Impaired vision and hearing
were noted, and a feeling of constriction around the lower part
of the chest. An eczematous condition appeared on the tops of
the eyelids, the angles of the mouth, and the mucocutaneous
margins of the nostrils, the lips were usually red and the palms
hot to the touch and hyperemic. Later, motor pains of the upper
and lower extremities occurred. Pain was constant, especially
in the feet. Emaciation developed with the progress of the
disease. Pigmentation of the palms, soles and lips appeared;
respiration is impaired and death may ensue from paralysis
of the respiratory muscles. Death is rare, recovery being the
rule.
The subjective symptoms are dimness of vision, impaired
hearing, numbness and cramps of the extremities, girdle pains,
joint pains, etc. The objective symptoms include trophic changes,
monoplegias, altered gait, knee jerk was absent in over one-half,
exaggerated or subnormal in 23 per cent., normal in rest, cutan-
eous reflexes varied greatly, sensations were blunted or impaired,
soreness of the mucocutaneous line of junction, wasting of the
muscles. Soreness of the mucocutaneous borders, i. e. eyelids,
lips, etc., was almost the first symptom. Wasting and contraction
520 Weston : Acrodynia
of the muscles was very marked in extreme cases, the "claw"
hand and foot being prominent features. The ophthalmoscope
revealed some retinal hyperemia rarely amounting to optic neu-
ritis, but pigmentation of the fundus was observed. Pigmenta-
tion of the brain and cord was the only feature observed post-
mortem. (Pellagra by Marie).
Dr. F. M. Sandwith of London in a letter to Dr. J. W. Bab-
cock makes these interesting comments on Dr. Strachn's cases :
"It is impossible to tell what disease Strachn is describing; cer-
tainly not pellagra or beri beri or malarial neuritis. Is it possible
that his disease is post dysenteric neuritis, of which there is a
good deal in the West Indies? The points against pellagra are:
multiple neuritis, numbness and cramps in the hands and feet,
dimness of sight, tightness around waist, burning in palms and
soles, tenderness over ulnar nerve, patient kept awake at night
rubbing feet and legs, atrophy of muscles producing claw hand,
facial palsy, deafness, scotoma, patients mostly get well, desqua-
mation of palms and soles, skin eruption confined to mucocu-
taneous orifices, palms and soles. Acrodynia might also be con-
sidered. (Pellagra by Marie.) Sir Patrick Manson does not
agree with Strachn's diagnosis either, but does not suggest one."
Practically all the observers who have written accounts of the
Paris epidemic lay stress on the fact that cases coming from
different localities or even from different sections of Paris pre-
sented somewhat different symptoms, and it was a common obser-
vation that in certain barracks a particular manifestation might
be very pronounced in all the cases there, while the same symptom
might be altogether absent in another barrack where the disease
prevailed with equal severity. This observation is especially
applicable to the extent and character of the skin manifestations.
Generally speaking, the first symptoms noticed were numbness,
tingling and itching of the hands and feet. Montault observes
that all the patients he saw had pains of a lancinating nature
and so intense a burning that they wished to immerse their feet
in cold water. Often these sensations were confined to the soles
and hands, but this was by no means a constant observation.
Other writers observe that many of the Paris cases suffered
from an insupportable tingling which they compare to the sensa-
tion one experiences in the hand on compressing the ulnar nerve.
Valliex writes : "Alteration of feeling and touch were also
Weston: Acrodynia 521
observed. Some patients could not touch the softest body without
feeling a painful sensation as if they were touching something
rough; others when walking on a hard surface felt that they
were walking on something soft. In many of the cases complete
paralysis of sensation were lost in the hands and feet for a time."
The same author states that severe cramps were usual, while
in others mere muscular twitchings or muscle spasm was ob-
served. The consensus of opinion among these observers was
that the pains were greater at night and in wet weather.
Another interesting observation to which Valliex calls atten-
tion is that the different alterations of motility, such as contrac-
tion, cramps, paralysis, were far from manifesting themselves
separately. On the contrary, he says, they often succeed one
another in the same patient.
Prof. August Hirsch, who has the advantage of a most ex-
tensive bibliography, in discussing the symptoms makes this in-
teresting statement: "In cases of a severe type, paroxysmal
seizures of cramp, or evidences of paresis of the extremities,
will occur in the subsequent process ; the limbs are kept con-
tinually bent in a state of tonic spasm, or there is an inability to
grasp or hold objects or to walk straight. If these nervous at-
tacks should have persisted for sometime, the affected limbs
waste, and there occurs edema of the thighs and legs, and some-
times even general anasarca." Great irritability and obstinate
insomnia were present in most of the cases. Wasting of the
muscles of the hands and feet was not unusual. Erythema of
the hands and feet was sometimes confined to the palmar and
plantar surfaces ; in other cases the erythema was confined only
to the lower extremities.
These lesions were sometimes vesicular, sometimes papular, in
others pustular ; finally there was a desquamation of more or
less long duration and which renewed itself more or less fre-
quently. Sometimes these lesions appeared in different parts of
the body. Chomel mentions a case in which the entire epidermis
of the breast became detached.
There was marked discoloration of the affected parts, usually
the surface was red, at other times there was a distinct brownish
or black discoloration of the skin. There was irritation and
discoloration of mucus surfaces. Local sweats of the extremities
was the rule, however, general sweats were often observed.
522 Weston .- Acrodynia
Redness of the conjunctivae with lachrimation and sensitive-
ness to light were often observed. Sometimes a pricking sensa-
tion was felt about the eyes, at other times there existed a sensa-
tion as if a foreign body was in the eyes, again there was a sen-
sation about the eyes that was described by the patients as the
same as was felt in the hands and feet. Local or general edema
was usual. Often this swelling was confined to the extremities.
There was no pitting upon pressure.
The digestive symptoms varied from a simple loss of appetite
and epigastric discomfort to nausea, vomiting, diarrhea with
bloody stools. In other patients, constipation was the rule. There
was usually a slight temperature ; in some cases none, but in
cases where the digestive symptoms became very severe the
temperature became high.
Etiology. — Like pellagra the predominance of opinion seems
to be that acrodynia is a food deficiency disease, yet this hypo-
thesis is difficult to reconcile with the history of the epidemics.
We have seen that during the Paris epidemic certain barracks
were entirely free from the disease, while others, the rations
being the same in kind and variety in all, the crowding and hy-
gienic conditions the same, were filled with patients suffering from
this disease. To such an, extent was this true that several bar-
racks had to be evacuated.
Treatment. — The disease is self-limited, therefore treatment
should be directed towards making the patient comfortable and
sustaining his strength by giving a well balanced diet.
Calamine lotion is recommended to allay the intense irritation
of the hands and feet. If the sweating is very severe, use small
doses of atropine. In some cases, where insomnia is very obsti-
nate and cannot be controlled by hydrotherapy, small doses of
morphia will have to be given.
I wish to acknowledge my thanks to Mr. Martin of the Sur-
geon General's Library, to Mr. Samuel Harper, and especially
to Dr. J. W. Babcock for many helpful suggestions and the gen-
erous use of his library.
A CLINICAL CLASSIFICATION OF THE DIARRHEAS
OF INFANCY AND CHILDHOOD.
By Lawrence T. Royster, M.D.
Norfolk, Va.
The one time attitude of the medical profession, as well as
the laity, toward the diarrheas of infancy and childhood furnishes
one of the most striking examples of superstition and fatalism
in the history of medicine, since they have been accepted without
question as necessary accompaniments of the second summer
and teething. There is nothing especially new or original in
the classification here presented as a whole, but it is used in
order that we may better appreciate the proper relation which
exists between the simple, or digestive types and the infectious
group, the clinical manifestation of which, as seen on the Middle
Atlantic Coast, I wish to emphasize.
Diarrheas of the simple digestive or non-infectious type may
occur in either nursing infants, or those artificially fed ; in very
young infants, or in children of several years of age. They may
come on gradually or suddenly, end as abruptly as they appeared,
or drag on to a state of marked chronicity.
For convenience the diarrheas of early life may be classified
as follows :
(A) Nervous Diarrhea
1. Sudden overheating.
2. Sudden chilling.
3. Excitement or fear.
4. Improper or indigestible food.
(B) Food Injury (acute)
L Overloading the digestive tract, particularly the
stomach, with proper food.
2. The accidental administration of an excess of
one or more food elements in a bottle baby's
formula (fat, carbohydrate or proteid).
(C) Food Injury (chronic)
1. The habitual administration of too large quan-
tities of one of the normal and proper food
elements.
2. Mixtures too strong in all elements.
(D) Fermental Diarrhea
523
524 Royster: A Clinical Classification of Diarrheas
(E) Infectious Diarrhea due to:
1. the dysentery group of organisms,
2. the gas bacillus,
3. other organisms. (Clinically, group E may be
divided into 4 types — to be described later.)
Nervous Diarrhea. 1 and 2, sudden changes in temperature,
whether of heat or cold, by acting on the sympathetic nervous
system often cause an increase in peristalsis, thus producing an
increased number of more or less normal stools. If the peristaltic
movement is sufficiently prolonged, there may be an irritation
of the lining mucous membrane of the intestines to an extent
sufficient to produce a watery discharge, or even the appearance
of mucus in the stools. Also, because of the extension of the
peristaltic wave to the duodenum, the gall bladder may be emptied,
the bile, which is a powerful cathartic, causing excessive purga-
tion. A reversal of the peristaltic wave, by reaching the stomach,
may produce vomiting also. This may in turn extend to the
duodenum, in which case the bile is vomited instead of passing
downward. Too long exposure to extremes of temperature, rather
than abrupt changes, may produce the same results. Such in-
stances are a child being allowed to play for too long a time
in the hot sunshine, or an infant being chilled on an automobile
ride. Cold feet in infancy are a potent influence in the produc-
tion of colic, which is often a modification of the above condition.
3. Excitement, either through too violent play, or too much
rocking, jumping or other handling will produce the same effect.
This is often the cause of intractable colic and "indigestion" with
pain. Fear is a too well recognized cause of diarrhea to call for
discussion. Generally these conditions are not accompanied by
fever.
4. Whether or not "improper food," i.e. articles generally
recognized as "indigestible," cause digestive disturbances, vomit-
ing and diarrhea, is a disputed point by authorities. In a number
of cases, however, the eating of certain articles of food, with
their subsequent appearance in the vomitus or bowel discharges,
certainly lends weight to the positive side of the argument. This
class may be accompanied by moderate or even severe fever.
Food Injuries {acute). 1. As a rule this type of diarrhea
occurs in older children who have been allowed to over-eat,
especially at a party. Vomiting is more apt to occur than is
Rovster: a Clinical Classification of Diarrheas 525
diarrhea, but both are often associated, but not infrequently
diarrhea occurs alone. There may be an absence of fever or
a sharp elevation. Convulsions may occur. In this type, the char-
acter of the food may be quite correct, the injury occurring merely
as a result of an unbalance between the normal digestive power
and the strain put upon it.
2. This type occurs with a bottle baby when a mistake has
been made in the proportion of the elements which make up the
formula. Such mistakes may be made by the physician in writing
his directions, or by the attendant who compounds the formula.
Any of the principal elements — fat, carbohydrate or proteid —
may be at fault. This diarrhea may be accompanied by vomiting.
Food Injuries (chrofiic). It must be remembered that an
infant which has an apparent or actual inherent intolerance for one
of the food elements, or, which acquires an intolerance for one
of the food elements, will eventually acquire an intolerance for
all others, if the elemental proportion is not regulated in time.
1. By giving an infant an amount of any one of the main
food elements — fat, sugar or proteid — in excess of its capacity
for that element, over a prolonged period, a diarrhea which may
be intractable is often established. There may be vomiting with-
out diarrhea, or accompanying the diarrhea, but most often a
diarrhea alone is established. The character of the discharge
depends on the element in excess,
2. A generally too strong mixture of milk, beyond the nor-
mal requirements of age and weight, over even a short period of
time, is a frequent cause of diarrhea.
Fermental Diarrhea. A sharply defined distinction, between
diarrhea from "simple indigestion," fermental diarrhea, and in-
fectious diarrhea, is often difficult to make, because the activity
of the so-called normal intestinal flora may become so altered
by various influences as to act in almost any manner common to
bacterial growth, and yet clinically fermental diarrhea is a more
or less definite entity. The saprophytic bacteria are the ones com-
monly active in this type of diarrhea. The characteristics are
watery, greenish, yellow stools, irritating to the skin, caused by
fermentation of either carbohydrate or fat. Curds are usually
absent, but mucus is quite common.
Infectious Diarrhea {enterocolitis — ileocolitis.) Under this
caption is generally included a group of intestinal disturbances
526 Royster: A Clinical Classification of Diarrheas
manifested by diarrhea and other symptoms, which have for a
long time been variously designated as "summer diarrhea," "sum-
mer complaint," "cholera infantum" and the like. With a fatalistic
resignation they have been accepted as a natural incidence of
teething, second summer, catching cold on measles and almost
numberless other conditions. More recent investigations have
served to prove that they are of infectious origin, and are caused
by 3 main groups of microorganisms :
1. The dysentery group. 2. The gas bacillus. 3. Other
organisms.
The clinical manifestations are practically the same for all
3 groups. The dietary treatment, at least, differs materially. That
for 1 and 3 is the same. That for 2 quite the opposite. I have
never seen group 2 in the vicinity of Norfolk, Va., until the
present summer.
Infectious diarrhea or ileocolitis is usually seen during the
summer months, hence its name "summer diarrhea." This how-
ever is not the only time of its appearance. It may occur as an
accompaniment or sequel of measles, influenza or any other disease
of proved or assumed bacterial origin. It is rare in the nursing
infant. There are 4 more or less distinct clinical types seen on
the Middle Atlantic Coast.
Type 1. This remarkable type differs so radically from our
usual conception of diarrhea as to merit special consideration.
The children are taken suddenly and violently ill. Very high tem-
perature is the rule, and marked prostration often within an
hour. They make us think of the "heat stroke" theory of Meinert.
The skin is hot and flushed, but followed very rapidly by a cold,
clammy perspiration. During this stage, these patients are obsti-
nately constipated, an initial purgative rarely producing evacua-
tion. An enema is necessary at once, and this empties the lower
bowel. This is often difficult of accomplishment, giving one the
impression of an impaction with a hard bolus. When the lower
bowel is emptied the initial movement is immediately followed by
mucus, pus and blood. All of this may result in the course of a
very few hours. Vomiting is the exception, but may be violent. I
have never seen this type except during a spell of exceedingly
hot weather. The majority of these cases die in 1 t^ 3 days,
only the mildest cases surviving. The temperature may drop
Royster: a Clinical Classification of Diarrheas 527
rapidly to subnormal or, if the end comes quickly, may remain
elevated to the time of death.
1 am unable to account for this symptomatology. The few
autopsies I have performed show the same pathology as that of
typical ileocolitis. The changes could hardly take place in the
short time between the first symptom and the appearance of blood,
mucus and pus in the stool ; and yet these pathologic changes were
present even in a case which died within a few hours of the onset
of the disease. Whether or not such changes take place before
the apparent onset and cause no symptoms, I am not able to say.
Type 2. In this type the onset is gradual, with loose yellow
stools which increase in frequency until 48 to 72 hours, when
mucus appears. The yellow color slowly changes to green, and
finally after 4 or 5 days blood and pus occur. There is rarely
any vomiting. The temperature, which is usually not high,
reaches its height about the time of the appearance of blood and
pus, gradually declining until it becomes normal on the seventh
to the tenth day. This type is apt to drag to a long convalescence,
usually without temperature, except in cases of complicating
pyuria, which is common.
Type 3. This type shows diarrhea from the start, and usually
mucus, pus and blood in rapid succession within 36 hours. This
type rarely has vomiting as an accompaniment, and the tempera-
ture is usually not high. As a rule the pus and blood disappear
by the end of a week, but mucus diarrhea often continues for a
prolonged period, eventually resulting in marked loss of fluid,
which is very difficult to combat.
Type 4. In this type the green stool of watery consistency
is the predominating symptom. Green mucus appears early,
and has the appearance of chopped spinach. The number of
stools varies from 3 to 4 per day to 20 or 30. The loss of fluid
is rapid and exhausting, the patient emaciating with perceptible
rapidity. Vomiting may not occur at all, but when it does, may
be so violent that when the combination of vomiting and diarrhea
is severe gives the typical picture drawn by the older writers of
"cholera infantum." The duration of this type if not markedly
choleriform runs a course of from 2 to 3 weeks.
The above 4 groups, as described, relate to the diarrheas as
seen during the summer months. In the vicinity of Norfolk
there is usually a warm spell of weather during the first 2 weeks
528 Royster: A Clinical Classification of Diarrheas
of May, at which time a number of cases occur. This is fol-
lowed by 2 weeks of cool, and often rainy weather. During
this period there is an almost complete cessation of cases of
diarrhea. About June 1 the steady warm weather of summer sets
in, and all through June and the first 2 weeks of July the largest
incidence occurs. The worst of the outbreak is over by the
middle of July as a rule, though of course a limited number of
cases continues to occur for the duration of warm weather.
Occasionally during the early fall, if an unusually warm spell
of weather occurs, there is another outbreak. Such an outbreak
occurred last fall, the severest I have seen at that time of the
year. There were comparatively few fatalities during that out-
break.
As has already been stated, ileocolitis or dysentery may compli-
cate or follow any of the infectious diseases. In 1916, in an article
entitled "Grip in Children," I called attention to a gastrointestinal
form of grip. This form has been specially prevalent during the
past winter in Norfolk. Whether it is actually of influenzal origin
I am not prepared to say, but it is always accompanied by an
inflamed pharynx which sometimes exists for several days before
the onset of the dysentery.
During the present summer, an effort was made at the King's
Daughters Visiting Nurses Clinic to ascertain what relation ex-
ists between the onset of "summer diarrhea" and the temperature
and relative humidity ; in addition a number of stools were cul-
tured to ascertain the bacteriology of the cases. The findings
of these observations are presented for what they are worth.
Heat and Humidity. The warm weather this summer was
exceptionally late in its onset, not being well established until
the 12th of June, about 2 or 3 weeks later than usual. The in-
'"idence of diarrhea was correspondingly late in its appearance.
The mean of the observations of the local weather bureau
was taken as the only practical record. The temperature was
averaged each day from the highest and the iQwest recorded.
The relative humidity was observed at 8 A. M. and 8 P. M. and
an average taken. Both of these were obviously misleading on
many of the days, since some days there was a sudden drop in
the temperature, due to thunderstorms or change in the direction
or force of the wind, which would so change the average as to
make the mean represent a day much cooler than actually existed
Royster: a Clinical Classification of Diarrheas 529
when both the heat and humidity have remained much higher
during the greater portion of the day and suddenly dropped very
low, thus bringing the average down considerably. The appended
chart shows the daily mean curve of the heat and humidity for
the period just preceding the onset of diarrhea disturbances and
extends to the time when the incidence was established. There
appears generally to be a compensatory relation between these
curves. There arc however, several brief exceptions to these
general observations. During the period represented on the
chart, the weather was quite cool until May 31, and then began
to rise steadily, reaching a pinnacle on June 3. It then gradually
declined until June 9 and rose rapidly again for 3 days until
June 12. From then on, with an occasional drop, it remained
normal summer temperature.
The incidence of cases exactly follows these curves. In stating
the incidence, the best history of the mother as to the date of
onset of symptoms — usually fever and restlessness, not diarrhea
— is taken as the date of the onset and not the date of the visit
to the clinic. The 'first record of the case was a single case of
May 29, another with onset of May 31. From this date the num-
ber increased very rapidly and reached a pinnacle on June 4. The
number gradually dechned to June 10 and rapidly rose again to
June 13. From then on, the usual number of cases presented.
By following the chart, it will be observed that the height of the
incidence was recorded the day after the height of the temper-
ature.
The marked dififcrence between the incidence of "summer
diarrhea" in the East and especially on the East Coast (more
prevalent on the Atlantic than on the Pacific) and the plateau
regions between the Mississippi and the Rockies must have an
explanation which at some future time will be forthcoming.
Heat alone, as a predisposing cause, can hardly account for the
incidence since the temperature of the plateau regions reaches
a uniformly higher degree than east of the Mississippi. The rela-
tive humidity, however, is extremely low in the East, while at
Norfolk, Virginia, it averages approximately 75 per cent., while
a number of days it attains a much higher level. The question
of radiation naturally suggests itself, hence the appended chart.
While the curves of the chart prove nothing definitely, it is cer-
tainly evident that radiation is greater at a temperature of 100°
530 Royster: A Clinical Classification of Diarrheas
Chart shows the daily mean curve of the heat and humidity for the period just
preceding the onset of diarrhea disturbances and extends to the time when
the incidence was established. •
Royster: a Clinical Classification of Diarrheas 531
to 120° (as in the West), accompanied by a relative humidity of
10 per cent., than at Norfolk, with a temperature of 90° and a
humidity of 85 per cent.
Bacteriology. The bacteriology of the cases studied differs
so little from the findings of other and more competent observers
that only brief mention will be made.
The three main groups of organisms found were the dysentery
group, the gas bacillus (the first time I have found the gas bacil-
lus infection in this city) and the colon bacillus. The colon bacillus
was usually found with either the gas or the dysentery infections,
though in several instances the colon bacillus failed to grow. In
several other instances only the colon bacillus was recovered from
cultures and it would appear that in some cases the colon bacillus
outgrew the other organisms and remained in very much larger
numbers than are usually found. It was noted clinically that in
such instances treatment was difficult and convalescence long
drawn out. As stated, this is the first season during which I have
found gas bacillus infections in this locality. About 16 per cent,
of the cases studied were of this type. These all occurred among
the first few cases.
Clinical Types. The type of diarrhea during the present sea-
son has been noticeably mild. Comparatively few fatal cases
have occurred. During this season the most frequent observa-
tion has been that eilhcr the green spinach-like stools or tho^ e
containing mucus, blood or pus have appeared almost uniformly
on third day of the illness. There have been, however, a small
number which strongly suggest type 1 in my classifications,
though rarely so severe. In these cases blood, mucus and pus
showed itself within a few hours of the onset accompanied with
high temperature and prostration. Most of these cases recovered
but several died with marked symptoms of acidosis on the fifth
day. I have also seen during this summer two cases of true
cholera infantum type.
r wish to extend my thanks to Mr. H. P. Parker, Bacteriolo-
gist for the City of Norfolk, for his valuable aid.
209 Taylor Building, Norfolk, Virginia.
MENINGITIS, CAUSED BY LEAD POISONING, IN A
CHILD OF NINETEEN MONTHS.*
By Robert A. Strong, M.D.
Clinical Professor of Pediatrics, Sch ul of Medicine, Tulane University of Louisiana,
New Orleans.
Lead poisoning, so far as I have been able to find in pediatric
literature, does not seem to be common in children. ' Especially
is this true wherein meningitis, clearly due to the lead, was the
predominating clinical manifestation. Thomas and Blackfan\
in reporting a case from the Harriet Lane Home of Johns Hop-
kins Hospital, which was almost identical with the one that I
wish to record, reviewed the literature very thoroughly and
reached the same conclusion.
The most important symptoms of lead poisoning are colic,
"lead palsy" and "lead encephalopathy" in order of frequency
as named. The latter broad term has been intended to designate
the long known effects of lead on the central nervous system.
In certain fatal cases of lead encephalopathy, anatomic changes
have been noted in the meninges together with an increase of the
fluid in the ventricles or in the subarachnoid space. Thomas and
Blackfan, however, in collecting their reports found that only
the French observers who have always been interested in
poisoning by this metal, had thoroughly studied its effects on the
brain and its coverings and insist that there is a special form
of meningitis due to lead. The observations which were made
in this case seem to confirm this belief, and the source of the
lead being the same as in the case of Thomas and Blackfan,
together with the fact that this source is common to most children,
supports their conclusions that it frequently may be the unsus-
pected source of what we have chosen to call serous meningitis.
The case was a boy 19 months old admitted to Richard Mil-
liken Memorial Hospital for Children of Charity Hospital on
October 5, 1919, for a persistent vomiting and a diarrhea of
a mild type. His temperature on admission was 99°. About 10
days before, the child had been seen to bite paint from the rail
of the bed, and he began vomiting his food a short while there-
after. He was given castor oil by the parents and after a few
days was very much better, but the day before he was admitted
*From the Department of Pediatrics, School of Medicine of Tulane University
of Louisiana.
532
Strong: Meningitis Caused by Lead Poisoning. 533
diarrhea and vomiting started again and he was given another
dose of oil.
The child was born at full term at a normal labor and was
said to be normal in weight and development at birth. The
father is living and well ; the mother, previously well, is a patient
in the Charity Hospital for an acute appendix. Miscarriages,
lues and tuberculosis, or known exposure to latter was denied.
The child had been breast fed for about 3y^ months, then given
condensed milk, cereals and broths to the end of the first year,
when he had been fed "everything." Previous to admission the
child had been healthy, and teething; growth and development
had been normal. The mother later stated that he had a fall from
the bed a week before admission. There was a small contusion
over the left eye which had already almost disappeared and
there was nothing to indicate that this fall was of any con-
sequence.
Physical exammation revealed little except that the tonsils
were hypertrophied. The vomiting was quite persistent. The
stools, 4 or 5 a day, were green in color and contained much
mucus and curds. The temperature, during the first 10 days
after admission, did not at any time exceed 100°. All food was
withheld for the first 48 hours. The stomach was washed and
the colon irrigated. Rhubarb and magnesia were given as a
cathartic. The vomiting was quite persistent for about a week
and at the time was considered more than that which ordinarily
accompanies an intestinal disturbance of this type. The lead
paint was considered as an etiological factor, but at this stage
no signs other than the vomiting could be discovered that
would warrant the conclusion that the case was one of lead poi-
soning. At the end of about 10 days, the child had improved
very much and had responded to ordinary dietetic management.
Under ordinary circumstances, the child would have been dis-
charged at this stage, but, on account of the fact that the mother
was still in the hospital and the child could not be properly
cared for at home, he was kept. During the next 2 weeks he
continued to improve and was up and around.
One morning the nurse on the ward discovered him biting
on the painted rail of the bed, and an examination revealed
the fact that he had bitten oflf some of the paint from the bed.
His stomach was washed and he was given a cathartic. The
534 Strong : Meningitis Caused by Lead Poisoning
bed was draped with sheets so that every painted portion that
he could get to was covered. For the next 24 hours he did not
seem to be any worse for having taken the paint the second
time, but at the end of this time he vomited his food and the
persistent vomiting and moderate diarrhea returned. These
symptoms continued for a week and that the lead was the cause
of the trouble now seemed to be the most logical belief. This
was confirmed on or about the eighth day when stippled red
cells (Grawitz's granules) were demonstrated. Almost at the
same time a blue lead line was observed on the gums near the
upper incisors.
On the tenth day, after the recrudescence of the vomiting, dis-
tinct meningeal symptoms appeared. The head was retracted
and the extremities were extended and rigid. Kernig's sign was
negative. Brudzinski's neck sign was positive. Brudzinski's
contralateral reflex was negative. Macewen's sign was negative,
although there was a difiference of opinion among several who
saw the case which frequently occurs in eliciting this sign. The
child's appearance was distinctly toxic. A ptosis of the left
upper lid was occasionally present, and the child was comatose
the greater part of the time. There was variable pupillary reflex
and occasional strabismus of the left eye inward. There was no
nystagmus. The respiration was markedly irregular as to depth
and time (Biot's breathing), later becoming a Cheyne-Stokes'
type. The temperature did not go above a 100° except just before
death, when it rose rapidly to 103° — so called terminal rise.
Three spinal punctures were made with the following results :
1
2
3
Pressure
Slightly in-
creased
Normal
Normal
Amount
10 c.c.
8 c.c
5 c.c.
Appearance
Clear
Clear
Clear
Cytology
Less than 10,
Less than 10,
Less than 20
mostly
mostly
mostly
polynuclear
polynuclear
polynuclear
Bacteriology
Sterile
Sterile
Sterile
Albumin
+
+
+
Globulin
+
+
+
Fehling
+
. +
+
Strong: Meningitis Caused by Lead Poisoning 535
Animal
Negative
No test
No test
Wassermann
Negative
No test
No test
inoculation
Chemistry
Negative to
No test
No test
lead
The urine was negative to lead as well as other abnormalities.
Opthalmological examination: discs pale and vessels normal.
Blood, other than Grawitz's granules, showed only a mild anemia.
There was no leucocytosis. Convulsions were few and milder
than would be expected. The child showed little improvement,
even after punctures were made and died on the twelfth day
after meningeal symptoms appeared. Permission for autopsy
w^as refused by parents.
The fluid findings were those of a serous meningitis. The
Grawitz granules, lead line and the knowledge that the child
had ingested lead paint on 2 occasions, which in each instance
was followed by symptoms, establishes a chronic lead poisoning.
The well recognized fact that lead is capable of affecting the
central nervous system and the absence of any infection justifies
the conclusion that the meningitis was due to the lead poisoning.
Levinson^, in a recent paper dealing with the qualitative and
quantitative changes in the cerebrospinal fluid in various diseases,
found that whenever there is a retention of chemical substances
in the blood, there is an increase of the same substances in the
cerebrospinal fluid. In nephritis, for instance, where there is a
retention of chlorides in the blood, there was found a correspond-
ing increase in the amount of chloride in the cerebrospinal fluid.
In uremia, where there is a retention of urea in the blood, the
same phenomenon was noted in the fluid and in diabetes, where
the blood sugar is increased in amount, there was also observed
a marked increase in the sugar content of the spinal fluid over
the normal amount usually present.
This would seem to indicate that the lead should be present
in the cerebrospinal fluid in lead poisoning but the negative
finding would seem to be more in accord with the belief of most
observers that under normal conditions very few substances pass
from the blood into the cerebrospinal fluid. Quoting Levinson^ :
"This resistance of the meninges to the entrance of a foreign sub-
stance is held to be due to the impermeability of the meninges,
although^ if we accept the view that the cerebrospinal fluid is
536 Strong : Meningitis Caused by Lead Poisoning
secreted by the chorioid plexus we should speak rather of the
impermeability of the chorioid plexus."
Various experiments, too numerous to mention, have been
made to demonstrate this property of the chorioid but perhaps
those of Dandy and Blackfan*, in the last paper on their study
of internal hydrocephalus, will serve best to illustrate. As a part
of this study they included the oral, intravenous and subcutaneous
administration of various substances to determine their presence
or absence in the cerebrospinal fluid. These observations were
made in animals and patients and they used methylene blue,
indigocarmin, phenolsulphonephthalein, potassium iodid, strych-
nin, morphine, trypan blue, hexamethylenamin and sodium salicy-
late and were only able to recover the latter two in the spinal fluid.
Hexamethylenamin has also been shown to be present in the fluid
after oral administration by others and its ability to pass through
the chorioid was what led to its use in poliomyelitis.
This permeability of the chorioid, however, seems to be in-
fluenced by disease and certain chemical substances. For example,
Mestrezat^ found that when sodium nitrate is administered to
a normal individual before spinal puncture is made, the fluid
shows very little or no nitrate, while in cases of meningitis, the
drug is present in large quantities. That certain chemical sub-
stances may exert a like influence would seem to be indicated
by the observation of Ducro", who noted that injections of
methyl violet are followed by the appearance of the contents of
the blood plasma in the cerebrospinal fluid and in the same pro-
portions found in the blood. He also found that in a jaundice
that bile readily passes into the fluid following methyl violet
injections. His belief is that the methyl violet paralyzes the
secretory chorioidal epithelium and the result is a temporarily
inactive membrane. After several hours the efifects of the methyl
violet wears away and the normal impermeability of the chorioid is
restored.
The foregoing observations have a bearing on the case
presented, only in so far as the passage of the lead into the spinal
fluid is concerned but conclusions can only be reached by experi-
mental work with lead. The passage of the lead into the fluid,
however, is not necessary to produce the symptoms in this case
which, perhaps, may be better designated as meningism, a term
suggested by Dupre'^ in 1895, this term being now applied to
Strong: Meningitis Caused by Lead Poisoning 537
cases that show symptoms of meningeal irritation in which the
fluid is sterile, contains no cell increase and a normal globulin
content. The only variance in this case would be the increase
in globulin and that it was not relieved by puncture.
The pathogenesis of meningism has been suggested by Levin-
son to probably be due to mechanical action of the causative agent,
which in this instance was the lead. The cerebrospinal fluid is
greatly influenced by the blood pressure in the cranium and any
irritation reaching the brain by the general circulation, as in
pneumonia for instance or through adjacent structures, such as
in otitis media, will accelerate the circulation of the blood in the
cranium, thus raising the cranial blood pressure and also pro-
ducing an increase in the cerebrospinal pressure. Whether there
is only an increase in the cerebrospinal pressure or an actual
increase in the fluid cannot be stated with certainty as long as
the mode of origin of the cerebrospinal fluid is not known.
The conclusion that lead should be considered as a possible
etiological factor in unexplained cases of serous meningitis or
meningism seems to be justified.
Suite 1222, Maison Blanche.
REFERENCES
1. Thomas and Blackfan: Am. Jour. Dis. of Child., 1914, viii, 377.
2. I,evinson, A.: Qualitative and Quantitative Changes in the Cerebrospinal Fluid
of Various Diseases and their Significance. Am. Jour. Dis. of Child., 18:
568 (Dec.) 1919.
3. Levinson, A.: Cerebrospinal Fluid in Health and Disease, St. Louis, C. V. Mosby
Co., 1919, p. 38.
4. Dandy, Walter E., and Blackfan, Kenneth O.: Internal Hydrocephalus. An
Experimental and Pathological Study. 8:428 (Dec.) 1914.
5. Cited by Levinson (See Ref. 3), p. 39.
6. Cited by Dandy and Blackfan (See Ref. 4), p. 429.
7. Dupre: Le meningisme, Congres francais de medecine, 1:411, 1893.
Familial Cirrhosis of the Liver (Edinburgh Medical Jour-
nal, Feb., 1916, p. 90). — Byron Bramwell records 4 cases of acute
fatal cirrhosis of the liver in the same family, the patients being
respectively nine, ten, fourteen and fourteen years of age. All
the cases presented the same general symptoms — rise in tem-
perature, jaundice and ascites. Death took place in the course
of three or four weeks. It was possible to exclude alcohol and
syphilis. It is suggested that it is closely related to Wilson's
progressive degeneration of the lenticular nucleus. — British Jour-
nal of Diseases of Children.
FOCAL HEMORRHAGIC ENCEPHALITIS.*
REPORT OF A CASE WITH TRANSFUSION.
By Albert Smedes Root, M.D.,
Raleigh, N. C.
Much has been written within the past 2 years upon a disease
to which the various names "encephalitis lethargica," "influenzal
encephalitis," "epidemic encephalitis," "epidemic somnolence,"
etc., have been applied. None of these terms seem appropriate.
In case of "encephalitis lethargica," as Bassoe^ points out, it is
the patient and not the disease to which "lethargica" refers.
"Influenzal encephalitis" suggests an etiology which has not yet
been proven. "Epidemic encephalitis" and "epidemic somnolence"
are not definitely applicable, for the malady may not prove at all
times to be epidemic in its occurrence.
Of those cases which have come to necropsy, the pathology
is constant, consisting of small hemorrhagic foci in the midbrain,
hence the term "focal hemorrhagic encephalitis" seems a more
correct one than any of those which have been mentioned. The
etiology of focal hemorrhagic encephalitis has not been definitely
determined. Its coincident occurrence with influenza, in both
past and present epidemics, has led most writers upon the subject
to accept a definite relationship between the 2 diseases, if separate
diseases they be. The general consensus of opinion is, that focal
hemorrhagic encephalitis is either a form of influenza specifically
affecting the brain, or that the toxins resulting from influenza
produce the lesions at a time subsequent to the acute attack, or
that an organism or virus different from that of influenza is the
causative agent.
In the latter case, it is pointed out, many of these patients
have recently suffered from influenza so that their resistance is
lowered, consequently they are rendered more susceptible to the
organism or virus causing encephalitis. This would explain the
coincident occurrence of the 2 diseases.
The preliminary report of Loewe and Strauss- indicates that
the disease is caused by a filterable organism resembling that de-
scribed by Flexner and Noguchi in poliomyelitis. These they ob-
served, when smears from the mucous membrane of the naso-
*Read before the Pediatric Section of the North Carolina Medical Society, held
in Charlotte, N. C, April 21, 1920.
538
Root : Focal Hemorrhagic Encephalitis 539
pharynx of fatal cases were stained with Giemsa's solution. The
authors were able to transmit the disease to monkeys and rabbits
by inoculating them with Berkfeld filtrates of nasopharyngeal
washings.
Von Wiesner^, of Venice, announced that he isolated a globoid
diplococcus from a case of encephalitis and reproduced the disease
in a monkey by inoculating the animal subdurally with nervous
tissue from a fatal case.
Cleland and Campbell claim they have successfully conveyed
the virus of the disease to the sheep, the calf and the horse.
Mcintosh*, of London, inoculated a monkey with material
from fatal cases which died with the symptoms of focal hemor-
rhagic encephalitis.
Flexner and other investigators have failed to find an or-
ganism in the cerebrospinal fluid or in the brain, nor have they
obtained any definite results from inoculating monkeys with prep-
arations of emulsified brain and cord substance from individuals
dying from the disease.
Flexner^, in the Journal of the American Medical Associa-
tion, March 27, 1920, writes as follows: "It is still too soon to
say whether or not we are now at the threshold of the clearing up,
by way of animal experiment, of the etiology and mode of com-
munication of this menacing disease, as was accomplished so re-
cently, and also by animal experiment, in the case of poliomyelitis.
It is to be sincerely hoped that we are. But at this moment, and
while waiting for the ultimate and convincing experimental re-
sults, one need entertain no doubt of the infectious and com-
municable nature of lethargic encephalitis."
The pathology of focal hemorrhagic encephalitis is more or less
constant. The lesions consist chiefly of perivascular hemor-
rhages and infiltration of the walls of small vessels with lym-
phocytes and plasma cells, occurring for the most part in the mid-
brain, the pons, peduncles, the basal nuclei, the aqueduct of Syl-
vius, the floor of the fourth ventricle and the optic thalamus.
Less frequently the medulla and the white substance of the spinal
cord are afifected. There is but little necrosis or tissue destruc-
tion.
Of the cases reported by Neal", Tucker', Bassoe^, Heiman",
Crookshank^°, and Barker, Cross and Irwin", a total of 138,' 86
540 Root: Focal Hemorrhagic Encephalitis
were males and 52 females. The ages were between 3 months
and 55 years.
Symptoms. — Many of the cases of focal hemorrhagic ence-
phalitis reported have not been preceded by an attack of influenza,
although a larger number have been, an average duration of 2
weeks intervening between influenza and the onset of encephalitis.
The latter is manifested by a progressively increasing lethargy
and asthenia, frequently associated with cranial nerve palsies.
This triad of symptoms was first observed by French and English
writers. The palsies, however, are present in not more than 25
per cent, of the cases. Slight fever is present, 100 to 102° F, and
constipation is the rule. Headache and diplopia are frequent
symptoms in older children. The patella reflexes may be in-
creased or diminished, more frequently the latter. Rigidity of the
body and muscular tremors have been noted in a number of cases.
Signs of meningeal irritation, however, are usually lacking (Brud-
zmski's and Kernig's). Vomiting frequently occurs in the early
stage. While usually gradual, the onset may be sudden, being
ushered in by a convulsion, Slight optic neuritis may be present,
— but not choked disk. The most characteristic symptom is a
disturbance of general consciousness. There is first noticed men-
tal apathy and drowsiness which becomes day by day more pro-
nounced until a state of coma is reached from which the patient
can be aroused but into which he soon falls again. The immo-
bility of features gives a peculiarly expressionless face. This
comatose state may last for several days, weeks, or months, when
the patient either gradually improves until entirely recovered, or
recovers physically but is left mentally defective, or death takes
place.
The muscles paralyzed are more frequently those enervated by
branches of the 7th and 3d cranial nerves, resulting in facial palsy
or ptosis and ophthalmoplegia, external or internal (pontine and
bulbar nuclei). These palsies usually clear up entirely within 2
or 3 months' time, if the patient survives.
Laboratory Findings. — There is present a moderate leucocy-
tosis. Blood cultures are negative. The cerebrospinal fluid is
clear and under slight, sometimes considerable pressure. The cell
count is, as a rule, low in cases seen late, 5 to 25, but higher in
those seen at the beginning of the disease, sometimes reaching
Root: Focal Hemorrhagic Encephalitis 541
100. The cells are largely mononuclears. Albumin and globulin
are increased, and reduction in Fehling's is normal.
Barker, Cross and Irwin^-, attaching much importance to the
examination of the cerebrospinal fluid, make this statement : "In
our experience, a cell count in the cerebrospinal fluid of from 10
to 100 small mononuclears along with a positive globulin reaction
with negative Wassermann and negative bacteriological smears
and cultures is, at the time of an epidemic of encephalitis, strong
corroborative evidence of the existence of the disease in a patient
in whom the process is for any other reason suspected to exist."
Prognosis. — The mortality according to the English Govern-
ment Report is about 20 per cent., and this figure seems also to
express fairly accurately the mortality in this country from the
cases thus far reported.
The course of the disease is within wide limits, varying from a
few days to several months. In a majority of cases, the course
is protracted to 5 or 6 weeks or longer.
There is not enough data to form an opinion as to the per-
centage of patients who are left mentally defective. Two of
Heiman's 9 cases in children, whose ages fell between 4 months
and ISyz years, became imbecilic. The treatment of the disease
has been purely symptomatic.
The foregoing is a brief resume of focal hemorrhagic encepha-
litis as described by various authors up to the present time. The
chief object of this paper is to call attention to the striking result
which the writer obtained by transfusing a 15 months-old infant
who was suffering from the disease, and for this reason the case
will be reported somewhat in detail.
Baby A., female. Age 15 months, was seen first August 16,
1919. The other 2 children born to the parents were living and
well. The mother has had no miscarriages. There was no tuber-
culosis in the family, nor any exposure to it. The baby had not
had influenza, nor any other disorder prior to the present one.
She was born at term, labor having been normal, birth weight 8
pounds. She had always been well and strong up to the present
illness, and had developed as the normal baby should. She sat up
without support at 6 months of age, stood alone at 9 months, and
said 2 or 3 words at 13 months. She had been nursed every 3
hours from birth (7 feedings), and recently had been having an
ounce of cows' milk after each nursing.
542 Root : Focal Hemorrhagic Encephalitis
The present illness dated back 4 weeks, at which time the baby
seemed to be sleeping more than usual. No particular concern
was felt over this until the somnolence increased to such a degree
that at the end of a week she only aroused for her nursings and
would immediately lapse into the comatose state. She had re-
mained in this condition up to the present tirrie. There had been
little, if any fever, no tremors or paralyses. She was obstinately
constipated.
Physical Examination. — Weight 16^ pounds; height 3O3/2
inches; circumference of head 18 inches; of the chest 16 inches.
Color very pale and skin waxy in appearance. Muscles flabby.
Patella reflexes not obtained. Anterior fontanelle 2j/2xlj4 c.m.
Eyes : negative, no ocular paralyses. Mouth : tongue heavily
coated, corners of mouth excoriated from drooling of saliva, 6
incisor teeth present. Ear drums : negative. Physical examina-
tion of the throat, thorax, abdomen, liver, spleen, genitals and
extremities, negative. Temperature normal. Blood : red blood
cells, 2,600,000 ; hemoglobin, 35 per cent. ; white blood cells, 5000.
Urine : amber, acid, specific gravity 1010 ; albumin, faint trace ;
sugar, negative ; diacetic acid, negative. Microscopic : 5 or 6
white blood cells per field (low power), no casts.
Lumbar puncture was performed and 3 c.c. of clear fluid re-
moved under normal pressure. It contained 2 to 5 cells. Albumin :
trace. Sugar: trace by Benedict's test.
The baby was observed for 2 days. It was with difficulty that
she could be aroused from the deep stupor. While undergoing a
lumbar puncture, she lay with expressionless face and closed eyes,
the only evidence of pain being shown by slight twisting of the
body. On account of the marked degree of anemia, it was decided
to transfuse her.
On August 19, 1919, 60 c.c. of blood, obtained from the
mother, in 7 c.c. of 2i/2 per cent, citric acid solution was intro-
duced into the superior longitudinal sinus. This blood was pre-
viously tested against that of the infant, and vice versa, for
hemolysis. After transfusion, the lips and finger nails became
pink and she nursed vigorously an hour later.
On August 20, 1919, the day following the transfusion, the
red cell count was 3,000,000; hemoglobin, 43 per cent., and white
blood cells 6,500. When seen this morning, she was sitting up
in bed fingering toys. Her general appearance was very much
Root: Focal Hemorrhagic Encephalitis 543
better. For several hours at a time during the day she was wide
awake, would grasp objects placed into her hand and make
cooing sounds. Her diet was regulated and she was sent home.
On September 1, 1919, twelve days later, she was seen again.
She did not seem drowsy, but evinced little interest in anything.
She did not follow objects or sounds. Her physical condition
was distinctly improved. The mother says she is drowsy at in-
frequent intervals, but does not sleep much more than she did
before she became ill.
September 13, 1919, 12 days later, and 25 days from the time
of transfusion, symptoms, relating to the nervous system, were
noted and had developed rather suddenly on the previous day —
continuous spasmodic twitchings of the muscles of the left side
of the face and right arm. Mouth was held open, and coarse
tremor of tongue present and constant drooling of saliva from
corners of mouth. At frequent intervals guttural sounds were
uttered. The lower extremities were unafifected. The weight
was 17 pounds 2 ounces. Red blood cells 3,000,000, hemoglobin
50 per cent., white blood cells 7,000.
September 22, 1919, tremors of face and arm were less marked.
Dermatitis of face from constant drooling. Baby does not notice
objects or sounds. Hemoglobin, 55 per cent.
October 11, 1919, weight 18 pounds. Physical and mental
condition improved. Tremors less marked. She notices objects,
takes watch in her hand, and reaches for mother. She cannot
stand alone.
October 28, 1919, tremors have entirely disappeared. No
further mental improvement. She sits with mouth open and vacant
expression. Cannot stand alone.
January 8, 1920, physical condition improved, appetite good,
bowels regular. No tremors. No improvement in mental condi-
tion.
Summary. We have an infant of 15 months of age who, for
3 weeks, had been in a state of profound somnolence, with no
evidence of improvement taking place either physically or mental-
ly as time went on. She was tranfused with blood from her
mother (who had not had influenza), and a striking improve-
ment followed almost immediately, so that within a short period
of time she came out of the comatose state into which she had
been for so many days. Her appetite returned, she gained in
544 Root: Focal Hemorrhagic Encephalitis
weight, the blood picture rapidly improved, and the obstinate
constipation was overcome.
All indications at the present time point towards the child's
being mentally defective. Whether or not there will be a restora-
tion of, or improvement in, the mental faculties, it is impossible
to say. It is, however, hard to disassociate the rapid and sudden
betterment in the child's physical condition from the efifects of
the transfusion.
201 A^. Wilmington St.
REFERENCES
1. Bassoe, Peter: Epidemic Encephalitis (nona), Jour. A. M. A., 1919. 72: 677.
2. Loewe and Strauss: Etiology of Epidemic (Lethargic) Encephalitis: Preliminary
note, Jour. A. M. A., 1919. 73: 105o.
3. Von Wiesner, R. : Wien. Klin Wchnschr., 1917. 30:933.
4. Forty-eighth Annual Report of the Local Government Board, 1918-1919. Medical
Supplement, London, 1919, p. 76.
5. Flexner, Simon: Lethargic Encephalitis: History, Pathologic and Clinical Fea-
tures, and Epidemiology in Brief, Jour. A. M. A., 1920. 74: 865.
6. Neal, Josephine B. : Lethargic Encephalitis, Arch. Neurol, and Psych. 1919. 2: 271.
7. Tucker, B. R. : Epidemic Encephalitis Lethargica, or Epidernic Somnolence, or
Epidemic Cerebritis, with Report of Cases and Two Necropsies, Jour. A. M. .\ ,
1919. 72: 1448.
8. Bassoe, P.: Epidemic Encephalitis (nona). Jour. A. M. A., 1919. 72:971.
9. Heiman, H.: Postinfluenzal Encephalitis, Am. Jour. Dis. Ch., 1919. 18:83.
10. Crookshank, F. G.: Brit. Med. Jour., 1918. 2:489.
11. Barker Cross and Irwin: Am. Jour. Med. Scien., 1920. CLIX: 157.
12. Barker, Cross and Irwin: Am. Jour. Med. Scien., 1920. CLIX: 337.
Unusual Localization in Infantile Paralysis (La
Pediatria, 1917, xxv, p. 270). — U. Provinciali describes two cases :
(1) A girl, aged 2^ years, with paralysis and flaccidity of the
whole of the lower trunk with atrophy and abolition of the knee-
jerk. Movement was preserved in toes of right foot and absent
in left. The paralysis extended partly and in a less degree to the
upper limbs. On putting the patient in a sitting posture with the
arms forward there was a right dorsal scoliosis, while in the left
flank a hollow was noticed. During expiration the abdominal
walls on the right side bulged out like a hernia. (2) A girl, aged
2 years, with marked atrophy and paralysis of the right leg, with
equino-varus position of foot and absence of knee-jerk. On cry-
ing a psuedo-hernial protrusion on the right abdominal wall was
seen. — British Journal of Children's Diseases.
THE IMPORTANCE OF LUMBAR PUNCTURE IN INTRA-
CRANIAL HEMORRHAGE OF THE NEW-BORN.
REPORT OF A CASE WITH RECOVERY.*
By J. BUREN SiDBURY, M.D.
Wilmington, N. C.
Intracranial hemorrhage of the new-born is not an uncommon
occurrence. On the contrary, it is much more common than any
of us know, due to difficulties in its recognition in some cases.
At times it is not only very difficult of recognition but even im-
possible to make an absolutely certain diagnosis, antemortem.
It may occur in any type of delivery. The most usual history is
that following a prolonged labor, with or without instruments.
It may occur, however, in the so-called normal labors and not
infrequently does it happen to the premature baby. Two such
cases have occurred in my practice in the last 3 years.
This condition was first properly interpreted by Sarah McNutt^
in 1885. It was brought more into prominence some 25 or 30
years later by Little. That the majority of these cases are born
dead or die soon after birth we do not wonder at. However, there
are a certain number who do survive. Of the total mortality under
1 year of age, 30 per cent, is due to congenital disease, of which
syphilis ranks first and this condition not far behind.
Etiology. The cause of this condition may be divided into 2
general heads. First, spontaneous, or hemorrhage due to a general
condition, as hemorrhage of the new-born. Second, and most
common cause is traumatic. Under this head the most common
causes are : ( 1 ) prolonged, tedious or hard labor, with or without
instruments; (2) precipitate labor with injury of the child's head;
(3) injudicious use of pituitary extract; (4) breech extraction of
the aftercoming head; (5) premature babies have very fragile
blood vessels, which are not strong enough to undergo the amount
of pressure necessary even in a normal delivery, hence their pre-
disposition to this condition.
It is unquestionably true that a large majority of the in-
fantile cerebral paralyses occur either in first born children or in
those who have been born after prolonged, dry, hard labors.-
That prolonged, kard labor is a most important factor in the pro-
*Read before the Pediatric Section of the North Carolina Medical Society,
April, 1920.
545
546 SiDBURY : Lumbar Puncture in Intracranial Hemorrhage
duction of this condition, I think, goes without question. The
early, intelligent application of the forceps will reduce the length
of labor, thereby reducing the length of time the head has to
undergo this pressure. Other things being equal and the mother's
condition good, is it not wiser to cut down the period of labor
and not wait until the mother is exhausted and the fetal heart
is imperceptible before offering help?
Pathology. If we think for a moment how delicate the brain
tissue and the capillaries of the new-born must be, we wonder
why more cases do not occur. The bleeding may occur any place
in the cranial cavity, in the vessels of the dura mater, in the
pia mater, in the arachnoid membranes, in the brain tissue or
ventricles. It may be small and punctate or it may be diffuse
and cover one or both hemispheres, forming a clot of varying
size and thickness. It may even occupy a third or a fourth of
the cranial cavity, in which event it will cause compression of
the brain substance and back-pressure of the venous circulation,
and, in turn, may 'rupture other capillaries. If the clot covers
any other area than the motor area, we may get no symptoms
at the beginning, but later a condition of imbecility or epilepsy may
develop with no other signs. The location more than the amount
is likely to give rise to symptoms. We may have quite a large
hemorrhage in the so-called silent area without giving symptoms
at the ,time of bleeding. A small hemorrhage in the motor area
is more apt to give rise to symptoms. Hemorrhage at the base
of the brain may give rise to symptoms not unlike meningitis, due
to basilar irritation.
How long the blood stays in a fluid state or how long it takes
the blood to clot is not definitely known but we do know that
it does not clot so readily as it does on the outside of the body.
When a lumbar puncture is done on some of these cases, as much
as 2 ounces of fluid blood, which clots readily in the test tube,
has been obtained.
When you get that much pure blood on lumbar puncture I
do not think that it can with fairness be attributed to a con-
taminated puncture. This happened in the one case which I am
reporting with recovery. In this case I obtained 2 ounces of
pure blood on lumbar puncture 1 hour after the first convulsion,
and 5 days after delivery.
Mouno^ reports a series of 40 autopsies on infahts dying
SiDBURY : Lumbar Puncture in Intracranial Hemorrhage 547
within a few days of birth in which he found 10 cases of rupture
of the tentorium and 5 of the falx cerebri. In all of these cases
death was due to hemorrhage following the rupture, though the
diagnosis was made first at the autopsy table. This emphasizes
the frequency of the condition as well as the infrequency of its
recognition.
Green* reports 2 cases diagnosed before autopsy, one dying
on the third day, the other on the seventh, the latter showing a
negative spinal fluid. Both of these cases showed much fluid
blood with small clots on the surface of the hemispheres. Each
of these cases gave a history of nursing well and appearing nor-
mal for 2 and 3 days respectively, at the end of which time "they
refused to nurse, had a feeble cry, developed a peculiar pallor
and facial edema." Neither of these cases had any of the typical
signs of compression.
Thrombosis is not an infrequent finding and in some cases
would seem to be the only explanation of the symptoms shown.
Symptoms. — To have a new-born baby nurse well for 2 or
3 days and then refuse to nurse, become pale and listless with
intermittent periods of crying spells followed by stupor and
perhaps convulsions or twitchings of one or more muscle groups
should make you think of a hemorrhage, and especially so if the
mother had a hard or instrumental delivery. Convulsions fol-
lowing an instrumental delivery should always make one sus-
pect this condition. The following are the signs to bear in
mind : convulsions or twitchings of one or more extremities,
bulging fontanel (not a constant sign), nystagmus, strabismus,
which is more or less constant, increased reflexes, which may
be more marked on one side. Stiff neck and Kernig's sign may
be present if the irritation is confined more to the base of the
brain. The pulse is strong, full and at times slow. The respira-
tions are irregular, they may be superficial and rapid or they
may be slow and deep or may even simulate Cheyne-Stokes'.
While any or all of these signs may be present in any one
case, there are other cases which show none of these signs as
was shown by the 2 autopsy cases reported by Green*. I wish
to emphasize that there is no harder diagnosis in medicine to
make, with certainty, than these cases which show none of the
typical signs. Any obscure illness of the new-born, which can
not be satisfactorily explained any other way, should make us
548 SiDBURY : Lumbar Puncture in Intracranial Hemorrhage
think of hemorrhage or thrombosis, especially if there was a
difficult labor.
It must be borne in mind that all symptoms may be entirely
absent at birth, and, so far as the mother knows, the baby has
been perfectly well until about 8 or 10 months of age. The
mother brings the baby to the office because she does not think
the baby has been developing as a baby of his age should. He
does not sit up, does not grasp objects or show the proper
interest in his surroundings. On physical examination nothing
definite is usually found and the doctor tells the mother to go
home and stop worrying about the child, for he will be all right
or he will "outgrow it." A more careful examination will
probably show that this child has an increased spinal pressure
of 10 or 20 mm. of mercury, not infrequently signs in the eyes,
denoting intracranial pressure, as papillitis or distended and
engorged veins.
There is another or older type which may come to the doctor
about the age of puberty, either a few years older or a few years
younger, because they have "peculiar spells." He may have
epileptic seizures with or without the loss of consciousness, or
he is unmanagaable and incorrigible. These are some of the
latent signs of hemorrhage of the brain in the new-born. Whether
we have symptoms in early infancy depends upon first, the loca-
tion, whether it is in the motor or the silent area and second,
the size of the hemorrhage. I think every one will agree that
there must be cases of birth hemorrhage which do not give any
symptoms and which get entirely well. Freeman^ refers to
a case which had all of the signs of hemorrhage and compres-
sion for which he advised an operation. The parents refused
operation and nothing was done and the child made a complete
recovery. No lumbar puncture was done. This was a fortunate
outcome, which, in my mind, represents a very small percentage
of these cases. The risk of following this as a routine is apparent.
Diagnosis. In every case of suspected intracranial hemorrhage
a lumbar puncture should be done. It will help in 3 ways : ( 1 )
letting olT the spinal fluid will relieve the intracranial pressure
and stop the convulsions, and will make the child more comfort-
able in every way; (2) it may cure the patient; (3) it will be
an aid to diagnosis. If pure blood is obtained by lumbar punc-
ture in amount more than could be explained by "contaminated
SiDBURV : Lumbar Puncture in Intracranial Hemorrhage 549
puncture" or if the blood flows as freely at the end as at the
beginning, we are fair in assuming" that there was free blood
in the spinal canal. The use of the spinal mercurial manometer
will enable one to tell with certainty the exact intracranial pres-
sure. The normal intracranial pressure of an infant is 2 to 5
mm. mercury. The majority of these cases will show an intra-
cranial pressure of from 5 to 25 millimeters of mercury.
The findings in the spinal fluid are not constant. The spinal
fluid may be almost pure blood, and may be as much as 2 ounces
in quantity. There is an admixture of spinal fluid with the blood
and you may get 3 or more ounces in all. The spinal fluid may
show no abnormalities, or it may show only a few red cells
with some broken-down red cells. In some cases one gets an
amber colored spinal fluid with hematin pigments. This I have
seen in 2 cases.
Case Reports. Case 1. E. C. R., age 5 days, male, the result
of the first pregnancy, birth weight 6 lbs., full term, abnormal
delivery. The mother had eclampsia and just before delivery
had 1 or 2 convulsions. The labor was induced and took about
14 hours, was hard and tedious and was terminated by the use
of forceps with difficulty. The mother's condition was so serious
at the last that the life of the child was not considered, for it
seemed that the mother would surely die. At delivery the cord
was around the neck twice and it was with difficulty that the
child was made to breathe. On physical examination the child
was poorly nourished and weak. He had a double cephalhema-
toma with 2 or 3 forceps marks on the head. He had to be
fed with the medicine dropper, for he would not nurse. Nothing
unusual happened until the fifth day after delivery, when at
8 P. M. the child had its first convulsion, which was general and
lasted about 5 minutes. Two other similar convulsions occurred
in the next hour. At 9 P. M. the child showed a bulging fontanel,
a peculiar pallor and a double internal strabismus. His knee
jerks were active and equal, and there was no Kernig's sign
and no stiflf neck. A lumbar puncture was done and 3 c.c. of
fluid was obtained, of which 2 c.c. were pure blood. The spinal
pressure reading was 15 mm. of mercury. The baby had a
very good night, had no more convulsions and nursed the mother
the next morning and continued to nurse her for 10 months.
A lumbar puncture was repeated each day for 4 successive days,
550 SiDBURY : Lumbar Puncture in Intracranial Hemorrhage
at which time the fluid became clear and the pressure normal.
He had an uneventful recovery and at 12 months weighed 22
pounds. His mental and physical development has been normal.
He is now 20 months old and is normal in every way.
Case 2. O. V., aged 3 years 5 months, female, the result of
the fourth' pregnancy, the mother had a miscarriage at 3 months,
2 other children living and well. The child was delivered of
a breech presentation with difficulty in delivering the after-com-
ing head. Mother was in labor from Wednesday 11 A. M. till
Thursday 9 P. M. Twenty-four hours after delivery the baby
began having general convulsions at frequent intervals con-
tinuing for 48 hours, having probably 30 or 40 convulsions in
that time. For the first 8 months of the baby's life, she slept
very little and cried a great deal of the time. The child never
nursed, was fed modified milk with the spoon at first and when
it would take the nipple at 3 weeks of age it was started on
the bottle. The feeding history was not a rational one and may
have accounted for some of the sleeplessness and crying. Physi-
cal examination showed an undernourished and underdeveloped
child, color fairly good, muscles soft and flabby. The child was
unable to sit or stand up, could use her legs and they were
not stiff but made no efifort to use them in walking. Her present
weight is 20 pounds 9 ounces, her birth weight is unknown but
she was an average size baby. Measurements : height 33 inches,
circumference of head 18^^ inches, chest 19 inches, abdomen I73/2
inches, right calf 6 inches, left calf 5}^ inches. She cut her first
tooth at 8 months, has 20 now in good condition. She under-
stands what is said to her but can say only 1 or 2 syllables. Her
blood count and urine were normal. Spinal puncture showed 10
mm. of mercury pressure, while the fluid gave a negative Was-
sermann and a normal cell count. The retinal veins were en-
gorged and distended. There was no choked disc.
Case 3. N. M., male, 3 years, the result of the second preg-
nancy, the first pregnancy resulting in craniotomy of child be-
fore he could be delivered, 2 other living children, well and
healthy. All labors are hard and long with instruments. Chief
complaint is stiffness of the legs and inability to stand alone
or to walk without assistance. He was born at term, birth
weight 9j/2 pounds, nursed his mother 8 months, then fed mixed
diet. He sat up at 7 months, talked at 18 months, cut his first
SiDBURY : Lumbar Puncture in Intracranial Hemorrhage 551
tooth at 8 months, walked first at 18 months, but never very
well, and less well now than he did 6 months ago. Physical
examination shows a well nourished child, good color, muscles
firm with those of the lower extremeties unusually firm. His knee
jerks are very active and equal. Eyes: pupils equal and react to
light and accommodation, the disc is blurred and the veins
distended and tortuous. He has a positive Kernig's sign on
both legs and a very active patella reflex. His gait is that of a
spastic diplegia. Measurements : height 38^ inches, circumfer-
ence of head 20^ inches, chest 22 inches, circumference of
calves and thighs equal, weight 36 pounds. Spinal pressure was
20 mm. mercury, cell count normal, Wassermann negative.
Case 4. M. D., aged 7 days, girl, premature 7 months, result
of the second pregnancy which followed 11 months after the first.
The labor was normal and the baby did very well, nursed well
and had a pink color and cried vigorously. On the fifth day, the
baby refused to nurse, had 1 or 2 slight convulsions, became
quite pale and stupid, but at times would cry out. On examination
the fontanel was tense, there was a double Kernig's sign, no
stiffness of the neck. Lumbar puncture gave an amber fluid
which registered 8 mm. of mercury. On examination there were
some broken down red cells and 20 red blood cells intact, to each
cubic millimeter. The child died the following day ; no autopsy
obtained.
Case 5. J. L. W., aged 17 years, male, result of the first
pregnancy, mother was in labor 3 days, instruments used. At
end of 48 hours the baby began to have convulsions and 3 or 4
convulsions each day for the first month. There are 3 brothers
and 2 sisters living and well. Past history : he had diarrhea his
second summer, has had jaundice twice, no other illnesses. He
has always been an unmanageable child, will not work at one
position more than 2 or 3 days. He has escaped from an insti-
tution for the feeble minded 3 different times. He frequently
goes away from home 3 and 4 weeks at a time, sleeps in the
woods and either begs food or eats barks or roots of shrubs.
When asked why he does this he gives a simple grin and says
because he wants to run away. On physical examination he
looks like a mental defective, his eyes are dull and vacant in
their expression, has a thick skin and coarse dry hair. He is
well nourished and has an unusually large nose. His tempera-
552 SiDBURY : Lumbar Puncture in Intracranial Hemorrhai:^e
ture, pulse and respirations are normal. His blood pressure is
105 systolic and 50 diastolic. His height is 67 inches, weight
111 pounds. His spinal fluid gave a negative cell count and
negative Noguchi reaction, the Wassermann on blood and spinal
fluid was negative and his spinal pressure was 18 mm. of mercury.
His optic disc was pale and the retinal veins were distended and
tortuous.
Treatment. In all cases of suspected birth hemorrhage, a
lumbar puncture should be done for diagnostic as well as for
therapeutic purposes. Repeated daily lumbar punctures, until
the spinal fluid is clear of blood, are indicated in these cases
with the use of the spinal mercurial manometer to register the
intracranial pressure each time. By this means one can de-
termine whether the pressure has been reduced to normal as
well as drain off as much blood as may come by this route.
After having done this, if there are any focal signs, such as
twitching of any group of muscles or eye signs, as papillitis or
marked venous engorgement of the retinal veins, a decompression
operation should be considered and a surgeon called. I feel, how-
ever that it is wiser to call a surgeon with the first symptoms that
he may be better able to advise as to the advisability of operation.
The question of an operation is an important one and if it is
going to be done should be done early, before the clot organizes,
if we expect the best results. Up to 1914, only 17 decompres-
sion operations had been reported for this condition. Of this
number 7 recovered, 4 of these were operated on by Gushing
while 5 others he operated on died.
Aspiration of the subdural space by puncture through the
coronal suture at the lateral angle of the anterior fontanel has
been done by Henschen** with good results. Giles" has reported
1 case cured by aspiration of the subdural space or as he called
it, "decompression cranial puncture."
More recently Dr. William Sharpe", of New York, has op-
erated on a number of these cases and his results are as follows :
Of 27 cases treated by Dr. Sharpe, "9 had a cranial operation,
4 had lumbar puncture drainage, while the others did not have
a definite increase of the intracranial pressure — so 'latent' types —
and recovered life without operation or repeated spinal drain-
age. Five of these cases died, 3 following the operation. Unless
the intracranial pressure is very high in these new-born cases.
SiDBURY : Lumbar Puncture in Intracranial Hemorrhage 553
they should be given the opportunity of recovering Hfe and
the greatest ultimate normality by repeated spinal drainage."
The advisability of an operation in these cases is a difficult
one and will have to be decided on the individual merits of
the case. We know that cases have recovered with only a lumbar
puncture. Up to the present time, 4 cases have been reported
cured by lumbar puncture. Brady'^ reports 3 cases treated this
way, with 2 complete recoveries. In 1916 Green" reported 1
case cured by lumbar puncture, and in the same year Lippman^"
reported another case.
The importance of the early recognition of this condition
can not be emphasized too strongly. In the beginning, if an
operation should be done, it should be done immediately if the
best results are to be obtained. A lumbar puncture should be
done on every case. It will not only relieve symptoms but it
may even cure the patient. The spinal mercurial manometer
will accurately determine the intracranial pressure.
Aside from the medical aspect, it is of economic value to
the State that these little fellows get a square deal at birth.
The world is too full of imbeciles, idiots, spastic diplegias, paraly-
tics, epileptics and other less defectives who are occupying
our institutions as well as are in our best familes, who would
probably have been normal, valuable citizens had they been given
a "square deal" at birth. Might Cesaerean section not be sub-
stituted for high forceps and the length of labor not be cut down
by early intelligent application of the forceps, when the mother's
condition will warrant it?
BIBLIOGRAPHY
1. Green: Boston Med. & Surgical Jr. CLXXII, No. 19, 1914.
2. B. Sach: J. A. M. A. XLVII, 19.
3. Mouno: Archives Mensuelles D'Obstetrique et de Gynecologic, Apr., 1915.
4. Green: Boston Med. & Surgical Jr. CLXX, No. 18.
5. Freeman, Rowland G.: Bost. Med. & Surgical Jr. 174, 947, Jan. 29, 1916.
6. Ilenschen: Vernhandt. deutsch. gesellsch f. Chir., 1912, vol. 41, 271.
7. Giles: Rev. Mens, de gyn. Vol. VII, p. 465-74.
8. Brady, J. M.: J. A. M. A. LXXI, Aug. 3, 1918, p. 347.
9. Green: Bost. Med. & Surgical Jr. 174, 947, Jan. 29, 1916.
10. Lippman: N. Y. Med. Jr. 103, 263, Feb. 5, 1916.
11. Sharpr, William, New Yo"k.
12. Meara & Taylor: Arch. Fed., Nov., 1909.
13. Currier, Andrew F. : Med. News, Aug 3, 1901.
14. Sachs, B.: J. A. M. A., Nov. 10, 1906, p. 1326.
15. Davis, E. P.. W. B. Saunders Co., 1911, 483.
16. Warwick, M.: Am. J. Med. Sc. 158, 95, July, 1919.
17. Vescher. A. L.: Cor. Bl. F. Schweiz Aerste 49:230, Feb. 22. 1919.
THE PROPHYLAXIS OF ILEOCOLITIS*
By J. Ross Snyder, M.D.
Birmingham, Alabama.
There is no specific prophylactic treatment for acute cohtis and
yet I know of no other infectious disease against which intelHgent
measures can be used so satisfactorily. The prophylaxis consists
in keeping every child's resistance above or as near normal as
possible and in feeding the child nothing but clean, well adapted
food ; all of which is much easier said than done. There is a well-
founded dread of the second summer. The explanation for the
greater prevalence of colitis among children between 12 and 24
months of age, rather than among younger infants, lies, not so
much in the fact that children of the former age have been weaned
and are cutting difficult teeth, as in the fact that these children are
crawling and walking. The young infant stays on the bed or in
arms. The older child on foot or on hands and knees, makes ex-
cursions of exploration during which he comes in contact with
many germ-laden objects. The bulk and the shape of many of
these are such that the baby cannot get them into his mouth, but
nothing daunted he tests their palatability by licking them with
his tongue. Ofttimes the object, whether it be a dead fly, a piece
of coal, a tack, an apple core, a ball of hair, rat excrement, or
what not, is of such size as to permit ingestion. A piece of man-
ure cast off by father's boot and the remains of Fido's dinner
appeal to the baby's peculiar appetite as morsels equally delicate
and savory. The foreign body swallowed and then passing along
the sensitive mucosa of the intestinal tract exercises a multiple
function ; at one time it plows, it fertilizes, and it sows the seed ;
and the harvest of colitis is always an abundant one.
A play pen, of dimensions to limit the amount of floor space
over which the baby may crawl but to encompass an area sufficient
to permit exercise, is a good prophylactic device. The floor of the
pen should be covered with a detachable piece of oil cloth, lino-
leum or sheeting. Whatever article is selected for this purpose,
it should be kept scrupulously clean.
Only toys with smooth, easily washable surfaces should be
allowed in the pen. The toys should be of such construction that
no part of them can be detached and swallowed.
*Read at meeting of Medical Association, State of Alabama, April 22, 1920.
554
Snyder : The Prophylaxis of Ileocolitis 555
Notwithstanding popular ideas to the contrary, a baby can
have just as good time playing in cleanliness as he can in filth and
dirt. Far less cruel than to permit the baby to crawl over dirty
floors making promiscuous mouth-gatherings would it be to leash
and muzzle him. Although I have paid my respects to the "paci-
fier" on many previous occasions, I make no apology for again
calling on you to condemn this abominable device. The iniquity
of its use is found not only in its breach of the sanitary code but
of the moral law as well. The thing cannot be kept clean and it
destroys the contour of the baby's mouth. Its immorality is that
it serves neither as a food nor to any other useful purpose. Some-
times it is called a ''fooler," which is more nearly descriptive, but
the most appropriate name is "liar," since it conveys the first lie
from parent to child. The parent, guilty of this first lie, continues
throughout parenthood with the same careless disregard of re-
sponsibiliy. Look around you and see if that isn't so. Clothing
is an important consideration. During the spring and early sum-
mer, we have in this state and in neighboring states some exces-
sively hot days followed by nights that are chilly. Young chil-
dren are exceedingly sensitive to such quick atmospheric changes.
So far from being endangered by quick changes in clothing to
meet these weather changes the baby is protected thereby. If the
days are hot, strip to the thinnest garment ; if the nights are chill,
put on a shirt and a gown of sufficient weight to keep the child
comfortably warm. It does not lie within our power to change the
weather but unless our minds are befuddled by traditions and
superstitions we can exercise common sense enough to adjust the
baby's clothes to atmospheric conditions.
During the summer, if any breeze is stirring, it should be
courted for the baby and the latter should be kept in the shaded
open. Sometimes when the air is still and hot, it is cooler in-
doors than outside. After such a day there is no objection to
the baby sleeping out in the open, provided he can be protected
from mosquitoes and other nocturnal insects. If economic con-
ditions are such as to prevent screening the entire house, the
baby ought to be screened. This can be done at slight cost and
is always a paying investment, as it prevents flies from gaining
access to the baby and the baby's food.
The baby's face and hands should be kept clean. To refresh
him and keep him clean, the baby should be bathed frequently
556 Snyder : The Prophylaxis of Ileocolitis
both inside and outside. If he is teething, shaved ice between
feedings will cool and soothe the gums and furnish additional
water.
Guard the baby against excitement and too much romping.
See to it that he gets his naps at regular intervals and that the
household does not interrupt or disturb his sleep.
After observations made over a period of more than 5 years,
I am convinced that for artificially-fed babies it is safer to use,
during the summer, dry milk rather than pasteurized fresh milk.
The incidence of colitis among children fed on dry milk is con-
siderably less than among children using boiled or raw milk. I
have never seen a case of rickets or scurvy traceable to the use
of dry milk. I heartily commend the eflforts of municipal boards
of health to pasteurize all market milk which does not meet the
requirements of safety. The city government ought to have just
the same right to enforce laws to assure its citizens of a safe
milk supply as it has to enforce laws to keep its water supply safe.
Until such right is granted and exercised, prohibition laws re-
lating to intoxicants should be regarded as another illustration of
the folly of putting "the cart before the horse."
With the very first indication of bowel trouble in summer,
the child should be treated actively. A dose of castor oil should
be given at once and food should be stopped until it can be de-
termined how serious is to be the disturbance. The possibilities
of food contamination and the source thereof should be investi-
gated. The food formula should be readjusted to suit the indi-
cations. If there is evidence of an inflamed condition of the
bowels, a bowel irrigation should be given after the oil acts. In-
struct the nurse or the mother how to irrigate the bowel. It
cannot be done with an infant syringe and a cupful of water.
One or more gallons of saline, as hot as the infant can stand with
comfort, should be used. I do not advise the use of the colon
tube but insert the nozzle of the tube of the fountain syringe
just well within the rectum. The hips of the baby should be ele-
vated. In this way and by using a larger amount of water I
believe the colon will be as nearly reached as when the colon tube
is used. There is danger even in experienced hands of me-
chanically injuring the bowel with a colon tube. By prompt
measures such as these I am convinced that many cases of colitis
can be aborted.
Snyder: The Prophylaxis of Ileocolitis 557
Finally, I believe that acute colitis should be made a report-
able disease. The bowel discharges from a colitis case are as
dangerous as those from a typhoid fever case. Whenever pos-
sible the person who administers water, food and medicine ought
to do only that and nothing more for the patient. Bathing and
changing the soiled diapers should be done by some one who
will not touch the things which are given by mouth. Whoever
handles the patient and takes care of the diapers should be given
explicit directions as to precautions necessary to keep her hands
from being a menace to herself and to others. Soiled diapers
should be kept in a covered pail in antiseptic solution. After
washing they should be thoroughly boiled. I am convinced that
if boards of health would use their influence and legal authority
in efforts to have every case of colitis handled properly, much
cotild be done to limit the occurrence of this dread disease.
'rkL'ATMKNT OK CONGENITAL MEGACOLON TN CnrLDKEN (Re-
vista di Clinica Pediatrica, June, 1920). Magliani describes
Francioni's method of treating this condition by introducing a
long Hexible tube into the rectum. This overcomes the kink that
is the cause of the obstruction. He assumes that the sigmoid
loop is unusually long or for other reason gets kinked or other-
wise occluded. I'y allowing the escape of gases and feces, the
disturbances are corrected and time is given for the anomaly to
be outgrown or compensated. He leaves the tube in place for a
number of hours, up to thirty-six, and reintroduces it at intervals
of four or five days or oftener as symptoms develop. In two
cases reported in detail, an infant 19 days old and a child of nearly
three presented intense tympanites, cyanosis and stupor, but al-
most immediate relief followed the intubation. In each case the
tube seemed to meet with an obstacle past which it had to be
worked. Conditions were apparently permanently corrected in the
infant in a few days, but the treatment was kept up intermittently
for several months in the older child. This intubation should
certainly be given a trial, Magliani adds, before resorting to sur-
gical measures in young children. — Journal A. M. A.
THE DIPHTHERIA CARRIER.
By W, L. FuNKHOusER, M.D.,
Atlanta, Georgia.
Scientific research has added materially to our present conirol
and management of diphtheria epidemics. In our enthusiasm
over our ability to detect susceptibles and their immunization by
toxin-antitoxin, we must not overlook a time-honored procedure
— the detection and cleaning up of individuals harboring virulent
diphtheria bacilli in their nasopharynx and throat.
As an example of a pandemic throat infection among school
children with the diphtheria bacilli, I wish to give the following
report : The writer, at the time, was responsible for the handling
of an epidemic of diphtheria which seemed imminent in a small
Georgia city. There had been no case of diphtheria reported from
April to July 10 of that year. The public schools opened the
first Monday in September. By the latter part of the month, 8
clinical cases of diphtheria were reported in one ward, several
manifesting their first symptom in the school room. All the chil-
dren in this .school were cultured. Examinations of cultures were
made at the laboratories of the State Board of Health. The report
was as follows :
October 9, of 61 cultures, 46 were positive.
October 10, of 47 cultures, 32 were positive.
October 11, of 50 cultures, 30 were positive.
Total, 158 cultures, 108 positive, or 68% positive..
This school was immediately closed. Recommendations were
sent to the city authorities that all carriers be quarantined. This
was attempted but the protest among the parents was great, owing
to the fact that none of the 68 per cent, showed any clinical symp-
toms of diphtheria. Several children, however, whose throats
showed the diphtheria bacilli present came down later with the
disease.
Simultaneously, 4 clinical cases were reported in another ward
with 1 death, the fatal case having attended school 30 hours be-
fore. All children from this school were cultured, then dismisserl
The report of the cultures from this school was as follows :
October 16, of 39 cultures, 28 were positive.
October 17, of 28 cultures, 24 were positive.
558
Funkhouser: The Diphtheria Carrier 559
October 18, of 35 cultures. 28 were positive.
October 19, of 129 cultures, 95 were positive.
Total, 231 cultures, 175 positive or 7S% positive.
This makes a grand total of 389 cultures taken, 283 being
positive and 76 negative; 30 were marked contaminated.
Reports of clinical cases of diphtheria came in rapidly from
other wards, making a total of 26. There being no rigid enforce-
ment of the city ordinance requiring the reporting of contagious
diseases, and the clinical manifestations in most cases being mild,
many therefore possibly overlooked, it was estimated that there
were, no doubt, twice as many cases as had been reported.
All the city schools were closed. There was, naturally, some
public sentiment against the closing of the schools ; a feeling
among many implied, if not expressed, that it was a useless
procedure, especially in view of the fact that the clinical cases
were mild, there being only 1 fatality. The school board assumed
the logical and sensible attitude that a loss of 1 month or even
2 to save 1 life was a justifiable procedure. To ofTset any objec-
tion which might arise as the result of ignorance, so that we could
use persuasion based on enlightenment, rather than force on
ignorance, intensive publicity campaigns were instituted, until
the public accepted with confidence the following recommenda-
tions : '
1. All clinical cases strictly isolated.
2. Two successive negative cultures before clinical case re-
leased.
3. After release, room inhabited by clinical case fumigated
with formaldehyde gas.
4. The doctors to enlighten the public regarding the dangers
of the disease and manner of conveyance.
5. Physicians report all cases of diphtheria, including sus-
picious cases.
6. Carriers to be kept at home ; not to mingle with others.
7. Carriers required 2 successive negative cultures beiore
being allowed to attend school or to mingle in society.
8. Antitoxin administered promptly in all positive or highly
suspicious cases.
9. Attendance of children at Sunday School or any gathering
discouraged.
There were similar outbreaks in other parts of the State, which
560
Funkhouser: The Diphtheria Carrier
so crowded the laboratories of the State Board of Health that
they were unable to give any local assistance, either by sending
a man or by examining more than 50 specimens a day. An ap-
peal was made to the United States Public Health Service and
they sent relief. A laboratory was established and plans were
made to open the school with only those showing negative cul-
tures. Children and teachers were called for culturing at certain
hours, then immediately dismissed. Those found negative were
allowed to return the next day ; those positive were not ad-
mitted until after 2 successive negatives.
On November 6, schools began to be re-opened, having been
closed 19 days. The children's throats showing the diphtheria
bacilli present were re-cultured from time to time until finally,
December 7, all were found negative, no clinical cases having been
reported in the meanwhile. No measures were taken to treat the
throats of the carriers but it was the intention to have the cul-
tures of persistent carriers tested for virulency but they all
cleared so rapidly that this was not necessary. Close daily in-
spection of all throats was made ; on slightest suspicion, a culture
was taken and the child sent home until the next day. None of
these suspicious cases proved to be either diphtheria or carriers.
The result of the first examination of cultures for reopening
school was as follows :
High School,
Grammar School,
Primary Central,
Primary 4th Ward,
Primary 5th Ward,
Primary 6th Ward,
Primary 7th Ward,
Colored 6th Ward,
Colored 7th Ward,
Colored 5th Ward,
Colored 4th Ward,
Teachers white.
Teachers colored.
370 examined,
535 examined,
137 examined,
184 examined,
173 examined,
165 examined,
161 examined,
372 examined,
120 examined,
93 examined,
43 examined,
42 examined,
9 examined.
42 positive or
99 positive or
8 positive or
22 positive or
23 positive or
21 positive or
28 positive or
60 positive or
8 positive or
6 positive or
6 positive or
3 positive or
0 positive or
11.3%
18.5%
5.8%
11.9%
13.2%
12.7%
17.3%
16.1%
6.6%
6.4%
13.9%
7%
0%
Total
2404 examined, 326 positive or 13.5%
FuNKHOUSER : The Diphtheria Carrier 561
Age of school children who were found to be carriers :
Age: 6 7 8 9 10 11 12 13 14 15 16 17 18
Female: 11 16 14 19 14 20 12 13 8 3 2 3 1
Male: 16 10 13 22 24 22 23 21 15 8 5 4 4
Total carriers: 27 26 27 41 38 42 35 34 23 11 7 7 5
Epidemiological data is about as follows: In May, a case
was reported, another in July. No other cases were reported
until after school opened in September ; 6 being the total in this
month, with one death ; in October, 20 cases were reported. Each
case was investigated to ascertain the following facts : Church
or Sunday School attended ; theatre, circus or school attended ;
visiting in homes with sickness, especially sore throat ; or visiting
in other towns or cities. Result showed 16 had attended school
but many had been otherwise exposed ; of these 16, 4 developed
their first symptoms in school.
Pennington, in Philadelphia, found that 10 per cent, of ap-
parently healthy school children had diphtheria bacilli in their
throats, one half of which were non-virulent. The investigation
of the Massachusetts Board of Health estimated that 2 per cent,
of the inhabitants of any city will show diphtheria bacilli in their
throats and 8 to 50 per cent, if exposed to the disease. There are
similar reports from other sources. These findings in diphtheria
complicate the carrier problem, yet Williams' report of the control
of a recent epidemic by searching out the carriers in the school,
families of the patient and all exposed to clinical cases and then
requiring from the known carriers a negative culture before being
released, proves how necessary it is to reckon with carriers.
This evidence seems to substantiate the value of detecting
and excluding from school carriers, when there are clinical cases
of diphtheria in a locality, especially among school children. With
all measures at our command for the control of diphtheria, we
may well bear in mind the words of Rosenau, 'Tt is plain that
the control of diphtheria outbreaks in institutions, camps, on ship-
board, in schools, and in similar places where a number of people
are crowded together, as well as the final control of epidemic out-
breaks in cities and towns, depends eventually upon the recogni-
tion of carriers and their isolation."
SOCIETY REPORT
THE NEW YORK ACADEMY OF MEDICINE-
SECTION ON PEDIATRICS
Stated Meeting, Held March 11, 1920
Dr. Charles Hendee Smith, in the Chair
THE ADVANTAGES OF HOME OVER INSTITUTIONAL CARE
Dr. Miner C. Hill stated that the home care of children had
many advantages over institutional care which were not generally
appreciated. The investigations of Dr. Henry Dwight Chapin of
New York and Dr. Holsclaw and Dr. Rude of San Francisco
showed that institutional care was far from ideal. The latter in-
vestigators found a 50 per cent, mortality in the foundling
asylums of San Francisco. Among the same type of infants
boarded out in private homes under supervision the mortality was
reduced to 12 per cent. Comparing the mortality rate of sick
children in the hospital and sick children treated in the homes
was not fair to the hospitals because they were receiving more
serious cases. Hospital care for surgical conditions and many
medical conditions was, and always would be, essential. But
the writer was of the opinion that a great many medical cases,
now treated in the hospital ward, could be more successfully cared
for in the home. If the child must have hospital care, the shorter
the stay the better for the child. It had been the unhappy ex-
perience of some of them to see the ''boarder baby," well and
robust on admission to an institution, steadily decline under what
was considered ideal institutional care. There was rarely a
sufficient number of nurses to give the constant individual at-
tention an infant required. This was well illustrated by the fact
that when a feeding ward was light the gains in weight were
greater than when the ward was filled to capacity. In the home,
time was always found to give affection as well as routine
physical care and it was not uncommon to see a foster mother
holding a baby on her lap or carrying it about. This change
from the prone position and the exercise unconsciously obtained
562
New York Academy of Medicine — Section on Pediatrics 563
undoubtedly improved the baby's general tone. Admitting the
value and necessity of hospital care, we should bear in mind that
its prolongation was bad for the baby, did not educate the parent
and was expensive. Those who had had the opportunity to
observe results of institutional and home care under the same
supervision were favorably inclined toward the home care. For
instance, the Gramercy Nursery was opened March 1, 1916, as
a temporary shelter for infants whose home care had become im-
possible through the illness or death of the mother. This nursery
had a capacity for 7 babies, was well equipped and efficiently
managed. During the year 1917, fifty-six babies were cared for,
the cost per child i>er day being nearly $3.00, and the average
weekly gain 4 ounces. The mortality was 4 per cent. The work
was worth while, the results were good but the costs were
excessive, owing to a constant overhead expense. After con-
sultation with Dr. Chapin, the nursery was reorganized on a
boarding-out plan sim'ilar to the work of the Speedwell Society.
From October 1, 1917, to October 1, 1918, 115 babies were cared
for on the boarding-out plan at $1.29 per day with an average
weekly gain of 5.15 ounces; that is, in using the boarding out
plan twice as many babies were cared for with a greater weekly
gain at less than half the per capita cost of institutional care. The
greatest difficulty of the boarding-out plan was the finding of
suitable foster homes within a workable area. The Health
Center of the Bowling Green Neighborhood Association had
shown what could be done in the home care of sick children. In-
struction in preparing formulae, giving baths, enemata, ear irriga-
tions, etc., were given the parent by the nurse at the Health Center
and in the home. During acute illness, the case was referred to
the Henry Street Settlement nurse who made 1 or 2 visits daily
as requested, and the Health Center physician or family doctor
visited the home to direct the medical care. With this equipment
it was necessary to send few children to the hospital. A reduc-
tion of the mortality rate for this district from 232 in 1913, to 59
in 1917 was a good index of the practicality of the health center
idea. In neighborhoods where there was no hospital, it would
seem practicable to have a small receiving ward in connection
with a health center. Here each acute case could be observed
for a day or two, during which time the usual laboratory work
could be done, and the baby could then be returned to its home or
564 New York Academy of Medicine — Section on Pediatrics
assigned to a boarding home where the foster mother showed
particular aptitude for caring for the condition from wh.ch the
child was suffering.
PROBLEMS OF BOARDING-OUT WITH AN ATTEMPTED SOLUTION
Dr. Henry Dwight Chapin said the present drift of opinion
was strongly against the collective management of abandoned
infants and little children in institutions. There had been an
extraordinary agreement on this question among those who had
had the widest chance for observation and experiment. The
carefully selected foster home was for the normal child the best
substitute for the natural home. This was the opinion held as
far back as 1909 by a conference on the care of dependent
(hiidren held in Washington. D. C, at the call of President
Roosevelt who \yas much interested in this vital human problem.
Ten years later, an international conference of Red Cross
workers, held at Cannes, gave what could fairly be said to repre-
sent the best world thought on this question as follows: "'Per-
manent institutional care for infants and young children should
be discouraged on account of the almost insuperable difficulties
in maintaining nutrition in infancy under these conditions and
because of the great susceptibility of young children to infection.
Preference should be given to placing such children .n suitable
families. All creches, day nurseries and the like should be under
close medical inspection. The 2 main difficulties of boarding-out
consisted in selecting suitable homes, and in exercising constant
and proper supervision."
Dr. Chapin said that in 1902 he had developed what was known
as the Speedwell System that represented a sustained effort to
regulate and systematize boarding-out so as to place its good
effects at a m.^ximum and its possible bad effects at a minimum.
This had been accomplished by what might be called the unit
system of intensive boarding-out. A unit was a neighborhood
that had been selected after a survey had been made to learn the
general conditions of healthfulness and the number of good homes
that might be available in the locality. There was then in-
augurated a constant oversight especially as to diet and hygiene,
on the part of a salaried physician and nurse who were thoroughly
familiar with this class of cases and knew how to deal with
them. The work was kept up during the whole year and not
New York Academy of Medicine — Section on Pediatrics 565
limited to certain seasons. An important educational work was
carried on among the families taking their children. The simple
machinery that endeavored to really and permanently help the
abandoned and ailing child, at the same time assisted in educating
each community in which it operated in the prevention and cure
.of disease and the care of its own ailing children. This by-
product involved improved social ideals and a higher standard of
living, and might be made a very important feature of this work.
In the successful working out of this plan, the human effort was
the important factor, and the system, in order to attain its greatest
efficiency, called for high grade workers, who could idealize their
efforts, and for good family homes, where the boarded-out child
would be reared under constant and intelligent supervision.
' A unit might include a part or a whole of a village or a ward
in a city. Their exj^erience had shown that it was a mistake to
be too fastidious in selecting homes. If the woman of the house
hold had motherly instincts and fairly healthy children of her
own, and seemed fairly teachable, a certain amount of dirt and
disorder could be overlooked at the start. A porch or back yard
or some open space was essential, as plenty of fresh air was one
of the most important features of this work. The next step was
to select a committee of women, living in or near the locality
selected for the unit, who were familiar with the neighborhood
and the people, and who constituted the local managers of the
undertaking. The records kept of the children were uniform in
all the units and careful histories on a card system showed the
conditions and results of their care. Their experience showed it
to be a mistake to attempt to keep too elaborate and complicated
a system of histories. The object of this work was not research
but helpfulness to the children, and not many data were required
for this purpose.
In comparing the results of institutional care with systematic
boarding-out, it would be found that both mortality and morbidity
were less under the latter plan. The incidence of communicable
disease was much less among boarded-out infants. From Nov.
30, 1918, to Dec. 31, 1919, the one Speedwell unit at Morristown,
N. J., cared for 172 children and among these there were only 2
deaths, and these occurred in infants under 6 months of age. The
unit at Yonkers, X. Y., cared for 84 children with 4 deaths.
After considerable experience they had found that this method
566 New York Academy of Medicine — Section on Pediatrics
was not adapted to handling acute sickness that was better
managed in a hospital. In the earlier years of experiment, all
kinds of cases were sent out to the boarding homes, such as
acute toxic infections, unresolved pneumonia, and, in the
summer months, many babies, who were near death from bowel
disturbances, in the hope that change and fresh air would g^ve.
them a chance. This gave a hospital mortality and the foster
mothers became fatigued and discouraged, and did not possess
the necessary nursing skill or appHances. After the acute disease
had subsided, however, the results in convalescence had been
most satisfactory. It was rarely possible for an infant or a
young child to get well in a hospital. The results in difficult
cases of wasting, or atrophic infants taken from institutions or
tenement houses, had been most encouraging. Finally, the
children had always left their care in good physical and mental
condition, such as would be apt to follow a more or less prolonged
stay in a natural home.
The daily per capita cost for 1919 was $1.23 for the Morris-
town unit and $1.20 for the Yonkers unit. The cost for 1920
would be higher. It was becoming increasingly difficult to secure
good homes for little babies, especially of the atrophic type. They
required constant care night as well as day, and were liable to
die in spite of all that could be done for them. There should be
a sliding scale of prices, paying women who took care of such
cases a much larger sum than was usually allowed. They now
give $18 a month and paid for the best grade milk, but this pay-
ment must be still increased if necessary to hold women on this
important job. If the lives of these little waifs were worth any-
thing, they were worth more than was usually paid to try to save
them. It was to be remembered that in this boarding-out plan
there was no interest on invested capital, no overhead expense in
running a plant, and no remitted taxes to be counted in the cost.
If the large institutions would sell their expensive plants and use
the money in intensive human service, that was in paying doctors
and nurses, with more generous treatment of foster mothers, this
problem would be in the way of solution. A few small plants
could serve as collecting stations, which would be all that would
be necessary from the institutional standpoint when operating
this form of regulated boarding-out. Dr. Chapin said that these
babies are not getting a fair deal. We should try to give them
New Y,ork Academy of Medicine — Section on Pediatrics 567
natural and watchful care in the way they need. They are
brought into the world singly, not in droves, and they suffer in
the crowd.
Dr. Chapin said he would like to see every city develop this
work according to a plan he presented which would consist of
various collecting units in the city that would be in constant
communication with units in the surrounding villages. Thus far
the Speedwell System had developed 3 of these units, one at
Morristown, one at Yonkers and one at New Rochelle.
THE BOARDING-GUT DEPARTMENT OF THE NURSERY AND CHILD's
HOSPITAL.
Miss Edith A. Hooper read this paper (to be published in a
later number of Archives.)
Discussion — Dr. Smith said he hoped he would be pardoned
for speaking at this point in the meeting, but there was one aspect
of this problem which had been touched upon only lightly and
which he wished to bring out before the discussion rather than
after it. This was a matter of temporary care for infants in
emergencies.
Dr. Smith said he did not wish to uphold the institutional
care of infants as opposed to boarding-out in the least degree,
but he thought there was a place for small, well-conducted tem-
porary shelters to meet sudden emergencies or for cases where
the care need to be only very short.
The Manhattanville Day Nursery had been conducting an
experiment in this kind of care for the last 2 years. The man-
agers of this institution had believed for a long time that there
was an urgent need for emergency care, consequently when their
new building was erected, one ward was set aside for day and
night care. Th's ward was especially equipped with glass parti-
tions forming small cubicles for each bed. This separation of the
patients, with careful examination and history of exposure on
admission, had seemed to control the contagious disease problem.
Whooping cough, chickenpox, scarlet fever, diphtheria and in-
fluenza had all been admitted during the incubation period. How-
ever, up to the present time, there had been no development of
secondary cases. Day and night care required more highly
skilled attendance than the ordinary day nursery staff. It had
been found necessary to have a trained nurse for superintendent.
568 New York Academy of Medicine — Section on Pediatrics
and a trained nurse in charge of the night baby room, with 2 or
3 untrained assistants. These cases also require more frequent
visits by an attending physician. In spite of the cost of the
extra equipment and the extra cost of maintenance for this work,
the Manhattanville Day Nursery feels that it is very much worth
while. As a matter of fact, the receipts for the care of these 12
lo 14 babies were nearly one and two-thirds timej the receipts
for the day care of approximately 55 children. While it was not
possible to say that the night babies actually paid for their keep,
they very much more nearly did so than the nursery children
who are supposed to be the main business of the nursery. Bab.es
were taken whose mothers had suddenly become acutely ill or
died. In such cases, boarding-out was very diflficult and temporary
shelter must be found until the family had a chance to look around
and readjust itself. During the mother's absence for confinement
or surgical operation, the temporary shelter also was of value and
the institutional care was not prolonged long enough to do the
child any great harm. It seemed as if there was an obligation
imposed upon the day nurseries to take up this work more gen-
erally. At present there are 31 children on the waiting list for
"emergency" care at the Manhattanville Day Nursery, so the
need was obvious. The hospitals were not equipped, with few
exceptions, to admit well babies. The day nurseries would seem
to be the only agencies to properly step m. Great pressure was
being brought upon them to take up this work more generally.
Hox. John Kingsbury, ex-commissioner of Charities of New-
York City and at present head of the War Relief in Serbia, said
that as he listened to Dr. Chapin's remarks it was with a great deal
of sorrow rather than gladness. He felt sorrow when he thought
that the City of New York had not grasped its great opportunity
to get behind a work of the kind done at Speedwell, and of work
such as was done at the Manhattanville Day Nursery which was
a step towards Speedwell. Dr. Chapin had established the work
at Speedwell and shown what it could do some years ago and
had kept hammering away at it year after year, and yet the city
went on putting more and more money ^nto institutions. If that
money were put into skilled nursing care for children in homes,
thousands, instead of hundreds of children could be saved today.
He believed, however, that this method of caring for children in
homes was coming and that New York would soon wake up to
Neiv York Academy of Medicine — Section on Pediatrics 569
its opportunity. Physicians knew the number of children in
institutions and that the death rate was cruelly and murderously
high. If one wanted to get some idea of what this death rate had
been, he need only read the records of Randall's Island before it
was used as an institution for the feeble-minded. Forty or 50
years ago Randall's Island was a morgue for little babies, the
death rate being 100 per cent. That was decreased when they
began to board babies out. After all we had made great progress
and should not feel discouraged.
Mr. Kingsbury said it might be of interest for the moment
to know something of what was being done for the babies of
Serbia. Serbia was not a country of little babies, but as a people
they were little children Serbia had lost more in the war and
has less today than any of our allies. There was a popular illusion
that Belgium was the greatest sufiferer from the war, but the
truth was that of all the nations in the war, Belgium had suffered
the least with the exception of the United States in both loss of
life and property. Serbia lost one-third of her population and her
boys retreated into the mountains of Albania and many perished.
Serbia was a country of widowed mothers and children ; the babies
had mostly died. Serbia through all her sufferings of a thousand
years had still an unconquered soul. Serbia was going to profit
by taking the stand that it is better to die in beauty than to live
in shame. But she will live. She has written on her statute
books the most progressive child welfare laws. Today they have
elevated the importance of the child to the extent that they have
created a special cabinet office and have a national department
of health. In this country we had a Bureau of Child Welfare
tucked away in one department and a Bureau of Public Health
Service in another department. Serbia wants the experience of
America. They are asking for trained nurses and doctors, and
are going to ask the experienced men and women of this country
to give them the benefit of their experience. They are going to
ask these doctors and nurses to go over there and help translate
into action the legislation which they have enacted. If this was
carried out to even the extent of 50 or 75 per cent, it would
place them in the position of leaders in child welfare and public
health work. Serbia is translating into action what we have held
as ideal. Mr. Kingsbury said his hearers had before this heard him
and heard Mayor Mitchel say that they believed that the home
570 New York Academy of Medicine — Section On Pediatrics
with the mother in it was a better place for children than the best
managed institution in the land, and he was glad to hear that
there was a movernent toward having these plans carried out
They were going to carry out similar plans on the other side of
the water.
Dr. Philip Van Ingen said he did not think many of us
realized what Dr. Chapin had been doing for the last 18 years.
The Speedwell Society, which, at any rate until the last few
years, was Dr. Chapin, for without Dr. Chapin it would not have
existed, had done a splendid work. Dr. Van Ingen said he
had watched the progress of this work, and it had been one of
the most effective factors in dealing with one of the biggest
problems that we faced in regard to dependent children. Mr.
Kingsbury had spoken of the statistics of Randall's Island 40
or 50 years ago, and stated that we had made great progress. It
was true we had. Seven years ago he had had occasion to look
into the mortality of children under 2 years of age in New York
State. During the period studied, there were 28,210 children
cared for by 11 institutions, and the death rate for children under
2 years of age was 422 per 1,000 or almost one half. In New
York City at the same time in one institution the -mortality rate
for children under 1 year of age was 516 per 1,000. That was
what we had done up to 7 years ago. We had already done
a great deal in 1917. One great trouble was that it required
too much red tape to get the children out of the institutions
The child was usually dead before anything could be done, but
at last somebody was trying to meet the emergency. Austria-
Hungary was not a popular country to talk about, but in 1903
they passed a law that every child under 15 years of age was
entitled to care, clothing, food, education and a home. If the
child did not have parents who could give these things it was the
job of the State to see that he got them. By 1910 the system
was developed to such an extent that no matter what the cause,
any child brought to one of the 17 state asylums was admitted.
If it was found that the parents could support the child, they were
compelled to do so and to pay a penalty ; if the parents could not
support the child, the State took care of him. The child was
kept in an institution long enough to see that it was physically
fit, or not acutely ill, and then placed in one of the colonies of
which there were 374 in the country, and in these colonies they
New York Academy of Medicine — Section on Pediatrics 571
had a mortality rate of 200 per 1,000. At a little later date
in our State, we have a mortality rate of 422, and in one insti-
tution in New York City a mortality rate of 517 per 1,000.
Many of these children under state care in Hungary were
illegitimate, and as was well known the death rate among this
class of children was high, so that had really accomplished
something. The one thing that had stood in the way of our work
in this country was that we did not know what other people were
doing. We established a great many excellent things and when
they were fairly started we found that other countries had been
doing the same things for many years. That applied to maternity
centers and to baby welfare work, etc. We did not know what
others were doing; we simply tried to thresh a thing out for
ourselves without learning first of the experience of others. As
an example of the poor management that had been noted. Dr.
Van Ingen recalled an instance that occurred when Mr. Kings-
bury was Commissioner of Charities, and which Mr. Kingsbury
had told. A woman with 6 dependent children went to the De-
partment of Charities to get relief. They said they would give
her some help, so they took away 4 of her children and gave
her 4 children from an institution to board.
Miss Rogers, of the Henry Street Settlement, stated that the
Henry Street Nursing Service had always emphasized home care
for children, and while the nursing service exemplified the care
of sick children rather than of dependent children, they would
be most enthusiastic over one of Dr. Chapin's institutions in
their neighborhood. The visiting nurse had for a long time stood
for a long felt need in the community ; today she stood to a
greater extent than formerly for the educational and social factor
in the community which was a very large factor. The training
schools for nurses had contributed so far much more toward
enlarging the opportunities for nursing by giving them a worth-
while service in pediatrics. They felt that in any nursing service
the nurse must have a large understanding of children and in
field work she might develop that understanding in a complete
way. The nurse had to do much as the social worker did in
entering a home. She had to adapt the necessary care of the
child to the environment of the child and this was considerable
of a problem. One encountered so many difficulties and there
were many natural guardians who did not recognize their re-
572 New York Academy of Medicine — Section on Pediatrics
sponsibilities. In meeting and solving these problems much could
be done by the visiting physician and nurse. They could insist
on certain requirements.
In speaking from the standpoint of the Henry Street Nursing
Service, it seemed necessary to give a few figures relative to
the care of the sick which showed what could be done under
seemingly adverse circumstances in the care of children and in
the way of preventative measures. Pneumonia, gastrointestinal
conditions and many communicable diseases were successfully
cared for in the home as well as much maternity work. Statistics
showed that about 90 per cent, of all sickness was cared for in
the home. There were 4,683 maternity cases cared for by the
Henry Street Settlement with 4,348 living births, where the
mothers were under prenatal care and supervision ; the infant
death rate per 1,000 was 9.8 for nearly 5,000 cases. Among
1,000, in whom the care and supervision was only postnatal, the
mortality was 14.2 per cent., the city death rate for infants
under 1 month being 37 i>er 1,000. The miscarriages and
abortions under prenatal care were 6.8 per thousand. The num-
ber where there was no prenatal care was 35.7 per 1,000,
and the number of still births under prenatal care only 21 per
thousand. Where there was postnatal care only, the number of
deaths per 1,000 births was 34.5. The figures for feeding cases
were much more difficult to give because there were so many
affiliated agencies doing this work, but those for pneumonia were
more interesting. The figures for 1918 and 1919 were not given
because of the influenza epidemic, but those for 1916 were fairly
representative for any year. The number bi pneumonia cases
cared for in 1916 was almost 4,000, with a mortality of 8.67 per
cent. Out of this number 1,564 were Italians, with a mortality
of 181 or 11.6 per cent.; 1,221 were Hebrews, with a mortality of
38, or 3.1 per cent., giving an interesting contrast as regards
nationalities. They found a marked difiference among the various
nationalities in studying the feeding cases. One found many
cases of rachitis if he went into the Italian districts. In 1916 and
1917 the average death rate from pneumonia in the age group
under 5 years was 8 per cent., while during the influenza epidemic
it was 16 per cent., twice the usual rate for pneumonia.
The visiting nurse needed to do so much more than merely
to observe the sick when she entered a home. She had to
New York Academy of Medicine — Section on Pediatrics 573
recognize the family group and the social responsibilities. Fre-
quently social conditions underlying the illness and the social
condition was a much bigger problem than the actual illness.
Frequently these conditions had to be considered in cooperation
with affiliated agencies. The dependent child or the one that
needed supervisory care they met with every day, and they
wished they might have larger and better facilities today in
meeting that need.
Miss Tiieis, of the State Charities Aid Association, said their
work was largely that of placing children in permanent homes.
Their experience, she stated, bore out what Dr. Chapin, Dr. Hill
and Miss Hooper had said as to the better general development
of children in homes. In regard to the death rate in homes,
their children were mostly in free homes, and they had not had a
single death in 1916. In 1918 and 1919 there were 6, 1 due to
pneumonia, 1 boy was killed and 4 died of influenza. A great
deal had been said with reference to the physical improvement
of the children in these homes, but a word might be said with
reference to the child's own point of view. Miss Theis said
she had personal oversight of 2,000 children, placed in temporary
boarding homes in preparation for permanent homes. Almost
without exception these children wished to remain in the homes.
I have asked the stafif of these homes how many children wished
to go back into institutions and they said they had known of only
6 children who wished to return. That was most convincing that
the children did not wish to go back to institutions, yet the
homes in which they were living were by no means ideal. Their
one terror was the fear of being sent back to an institution, and
this was used, unwisely she felt, by some persons as an aid to
discipline. The Nursery and Child's Hospital furnished them
the largest number of children. One of the advantages of the
boarding-out system was its elasticity, inasmuch as the size of
the organization could be increased or decreased as the need
required.
Miss Arnold, of the Babies' Welfare Association, said that
speaking for all the social workers she could say that they were
looking for the day when the Speedwell idea would be generally
adopted. The agencies now doing that work had long waiting
lists of children who should receive that care. There was also a
demand among parents for boarding homes for children. They
574 New York Academy of Medicine — Section on Pediatrics
had had 1,990 parents seeking homes for children for whom they
wished to pay. There were 2,000 homes Hcensed by the Board of
Health. A duplicate list of these homes was given to the Babies'
Welfare Association so that they could know where they could
find homes that would provide care for their children. Their
mformation, however, was somewhat limited, as they could
not get out and make investigations, but through Dr. Baker, of
the Bureau of Child Hygiene, they received the duplicate reports
from the Board of Health. The nurses also came and told them
of specially good homes for babies and older children. If a father
or mother came with a baby under 2 years of age, they put the
matter on a business basis. They demanded of the woman who
took the child that she should take it to a milk station. They
then telephoned to the milk station nearest the home and had the
milk station see that the babies were duly enrolled. In the Bronx
the supervising nurse had a system whereby the visiting nurses
advised her when there was a demand for more foster homes.
There was more of a demand for foster homes than there were
homes. Dr. Smith spoke of the 6 babies brought to the Alan-
hattanville Day Nursery in 1 day. There was always a demand
for homes for young babies, and they had offered special induce-
ments in order to find homes for a limited number of babies, and
they could not find homes even at $10.00 a week. There was a
wonderful field for that kind of work. Where the mothers had
died the fathers were very anxious that their babies should have
home care. Sometimes fathers come and ask that their babies
be placed in an institution, and we explain to them the advan-
tages of home care and find a home for the baby. Later if some-
thing happens that it is necessary to make a change, these same
fathers will come and tell us just what they have been told some
time before in regard to the advantages of home care. The
Babies' Welfare Association had 156 homes, about which it had
special data for parents. She thought Mr. Kingsbury would be
interested to know that a large majority of their 1,990 babies
came from the Department of Public Charities.
Dr. Sidney V. Haas said he wished to say a word in favor
of institutions, though, of course, everyone familiar with this
question knew that even in a poor home a baby was better off
than in the average, or, perhaps, in any institution, and no one
deserved greater credit for trying to force this fact on the public
New York Academy of Medicine — Section on Pediatrics 575
than Dr. Chapin. But after 18 years of effort the resuhs showed
housing for only a small group of children. All who had spoken
could mention only a few thousand boarding homes. Mr. Kings-
bury several years ago said there were several hundred thousand
children requiring such homes. What were they going to do with
the children in the interval until a boarding-out system was built
up and sufficient homes secured ? There was at least 1 institution
in the city the statistics of which were quite different from those
they had heard this evening. This is the Home for Hebrew In-
fants. There they had had a death rate between 1915 and 1919
of from 3 to 7 per cent. They had the death rate of 7 per cent,
in 1917, when they had an epidemic of measles. The year of
the influenza epidemic they had a 6 per cent, death rate. In
normal years the death rate was about 3 per cent., and they
housed about 400 children under 5 years of age. These children
did not look white and marantic. As a matter of fact, they com-
pared favorably with children in private homes. They often
received children in deplorable condition and after having them
for a time showed just such results as Dr. Chapin had shown they
were getting at Speedwell. Some of these cases were received
from boarding homes. This did not mean that in boarding the
children out they were not doing good work ; it only showed
the difficulties of the problem and what a great field under present
conditions would have to be covered. If it could be undertaken
by the Government it might be made possible.
It might also be of interest to know the cost of caring for
these children in the Hebrew Orphan Asylum. The cost of
caring for the infants was $7.30 per capita per week, about what
Dr. Chapin's babies cost. In 1918 the cost was $8.12 per week,
which was less than Dr. Chapin's estimate for that year.
It might also be of interest to know that since May, 1916, they
had been using the Schick test, except in a small group which
was used as a control — no case of diptheria occurred except in
this group. Diphtheria was practically eliminated from this in-
stitution. While they were attempting to obtain proper homes
and to build up a practical Speedwell System, institutions could
be improved and by the adoption of the cubicle system the children
could be kept free from contagious diseases. Many of the chil-
dren at the Home for Hebrew Infants were the ruddiest, finest
youngsters, so he thought that while they were waiting for Dr.
576 New York Academy of Medicine — Section on Pediatrics
Chapin's system to develop, they should not lose sight of the
many things that could be done by improving institutions.
Rectal Feeding (Journal A. M. A., May 18, 1918). E. E.
Conwall calls attention to certain facts and principles to be taken
into consideration in rectal feeding. First, he says, proof is lack-
ing that the colon possesses adequate digestive capacity, hence all
food introduced this way should be thoroughly predigested, if not
already in forms suitable for immediate absorption by the colonic
mucosa. It is necessary to think of the protein ration in terms of
amino-acids and of particular forms of these, because the proteins
of foodstuffs split up into different groups of amino-acids, and
the body not only requires a definite variety but requires them in
special proportions. Articles of food whose protein contains po-
tentially all the amino-acids the body needs in approximately ideal
proportions are meat, milk and eggs. Meat and eggs are undesir-
able because of their tendency to putrefy. Milk is free from this
disadvantage to a great extent, and it is obvious that the milk
should be fresh and unboiled to save its enzymes and vitamins,
and should also be skimmed to free it of considerable fat. Glu-
cose in solution supplies carbohydrate in a perfectly available form.
Salts are also necessary, and those of milk approximate the body
requirements, and desirable salts can be introduced to a limited
extent by fruit juices, which add in the form of levulose a carbo-
hydrate, which seems to be capable of absorption to a limited
extent. Lactose, the carbohydrate of milk, is apparently not avail-
able for fuel, but its lactic acid fermentation makes it useful in
preventing putrefaction. Other salts, especially those of sodium
and calcium, are required if rectal feeding is to be long continued.
The essentially alkaline character of the diet must be kept up, to
prevent acidosis, a chemical menace to life as great as the bacterial
one. The vitamins, needed by the body to utilize its food are of
two general classes, the water soluble and the fat soluble. The
former can be supplied by milk, cereal decoctions and fruit juices,
and the latter by milk. Two prescriptions, or sets of prescriptions
with their possible modifications, for rectal feeding, covering the
above pririciples are given by the author. The enemas should be
given warm, lOOF. and slowly, the patient's buttocks should be
elevated, and he should lie on his right side for an hour after the
injections. — Journal A. M. A.
Archives of Pediatrics
OCTOBER, 1920
HAROLD RUCKMAN MIXSELL. A.B.. M.D.. Editor
CHARLES ALBERT LANG. M.B., M.R.C.S., Associate Editor
COLLABORATORS :
L. Emmett Holt, M.D New York Fritz B. Talbot, M.D Boston
W. P. NoRTHRUP, M.D New York Maynard Ladd, M.D Boston
Augustus CaillS, M.D New York Charles Hunter Dunn, M.D. .. .Boston
Henry D. Chapin, M.D New York Henry I. Bowditch. M.D Boston
Francis Huber, M.D New York Richard M. Smith, M.D Boston
Henry Koplik, M.D New York L. R. De Buys, M.D New Orleans
Rowland G. Freeman, M.D. ...New York Robert A. Strong, M.D....New Orleans
Walter Lester Carr, M.D... New York S. S. Adams, M.D Washington
C. G. Kerley, M.D New York B. K. Rachford, M.D Cincinnati
L. E. La FfiTRA, M.D New York Henry J. Gerstenberger, M.D. .Cleveland
Royal Storrs Haynes, M.D... New York Borden S. Veeder, M.D St. Louis
Oscar M. Schloss, M.D New York William P. Lucas, M.D... San Francisco
Herbeht B. Wilcox, M.D New York R. Langley Porter, M.D..San Francisco
Charles Herrman. M.D New York E. C. Fleischner, M.D San Francisco
Edwin E. Graham, M.D Philadelphia Frederick W. Schlutz, M.D.Minneapolis
}. P. Crozer Griffith, M.D.Philadelphia Julius P. Sedgwick, M.D. . .Minneapolis
. C. Gittings, M.D Philadelphia Edmund Cautley, M.D London
A. Graeme Mitchell, M.D.. Philadelphia G. A. Sutherland, M.D London
Charles A. Fife, M.D Philadelphia J. D. Rolleston, M.D London
H. C. Carpenter, M.D -..Philadelphia J. W. Ballantyne, M.D Edinburgh
Henry F. Helmholz, M.D Chicago Tames Carmichael. M.D Edinburgh
L A. Abt, M.D Chicago John Thomson. M.D Edinburgh
A. D. Blackader, M.D Montreal G. A. Wright, M.D Manchester
PUBLISHED MONTHLY BY E. B. TREAT 4 CO.. 45 EAST 17tH STREET. NEW YOBK.
ORIGINAL COMMUNICATIONS
SOME PECULIARITIES IN THE SYMPTOMATOLOGY
OF CHILDHOOD.
By Herbert B. Wilcox, M.D,,
New York.
In our text books on pediatrics prominent space is given to
consideration of the peculiarities of disease as observed in child-
hood. Although these variations as occurring between young
and older subjects are discussed quite in detail from the stand-
points of etiology, pathology, symptomatology, diagnosis and
prognosis, apparently little effort is made to offer an explanation
for them. This paper will concern itself with some of the
peculiarities shown by children in the expression of disease both
subjectively and objectively and the reasons for them,
577
578 Wilcox : Symptomatology of Childhood
It is evident that the greatest contrast occurs in infancy and
the early years of childhood, and that such difiference is less
noticeable with the approach to adult state. When mention has
been made of the great susceptibility of the infant to unaccustomed
external stimuli, the instability of control of all bodily functions
due to incomplete development of the central nervous system, and
the influence of rapid growth on such functions, one is struck
by the difficulty of preparing the subject for presentation, because
of the fact that much of the detailed material seems too obvious
to bear lengthy discussion.
In 1915, an article appearing in the Lancet Clinic, in which
certain general observations were made on the indications of
disease in children, was reviewed at length in Progressive Medi-
cine, partly as follows : "In the absence of an evident cause of
illness, fever during the first week of life may be assumed to be
of the inanition type. Severe prostrating fever, beginning in the
second week of life, may, in the absence of marked intestinal dis-
turbance or other evident cause, be considered due to sepsis. In
children over 1 month or under 2 years of age, intestinal toxemia
is the commonest cause of fever. If the temperature falls antl
remains low under catharsis and starvation for 24 hours, the
diagnosis is confirmed. If fever continues for 3 or 4 days, otitis
media should be thought of, even in the absence of aural or
mastoid symptoms. A sustained high temperature of 103° or
104° in infants should always be treated as a lobar pneumonia
until a definite diagnosis can be made. In a child over 3 years
of age, free from signs of pneumonia, continuous fever should
lead to a tentative diagnosis of typhoid. A remitting fever,
persisting day after day without apparent cause, should always
arouse a suspicion of pyelitis and lead to an examination of the
urine."
As the original article was intended to lay down general rules
only the attitude of the reviewer is interesting in that it seems
to indicate his readiness to accept these general considerations
without reference to the fact that although children may differ
in the expression of their ills, the same methods of investigation
are applicable to them, and that the logical interpretation of their
symptoms k:ads as directly to diagnosis as is the case in adult
life. This is quoted then by way of introduction, because it seems
Wilcox : Symptomatology of Childhood 579
to indicate the usefulness of a review of some of the differential
points in the diagnosis of children's disease.
In general, the whole subject of the incidence of disease at
different ages, and the variations of bodily reaction to it and to
all stimuli from without rests upon the immunity peculiar in
the infant to certain types of affections, his susceptibility to others,
and his general lack of adaptability.
The infant's inherited immunity protects him for his first year
from certain forms of infection. Most of the acute infectious
diseases are rare at this period. About this time, however, he
comes to the point where he must acquire by experience the im-
munity and adaptability which will, when complete, place him in
the adult category.
It is during, and because of, this process of acquirement that
the child exhibits the greatest variations in disease expression.
For instance, the 2 extremes of the development of one form of
bodily defense are shown in the action of immature as opposed to
adult tissue to foreign cellular invasion.
Cancer cells can be readily grown upon the membranes of
the egg. A cancer plant, however, in a full grown fowl is promptly
destroyed by phagocytic action of that adult animal. If these
cancer cells are planted on the membranes of an egg mixed with
embryonic spleen tissue, they will live upon this spleen tissue,
destroy it, and flourish. If on the other hand, the same plant is
mixed with the spleen pulp from an adult fowl, the cancer cells
are themselves promptly destroyed.
As a general proposition, the immaturity referred to and the
instability of governing centers, to be mentioned later, may explain
all the idiosyncrasies shown by sick children, but there are some
peculiarities in childhood which admit of more definite and
detailed physiological or pathological explanation. It is with
such a group of symptoms that this article concerns itself.
Temperature, pulse and respiration occupy a most prominent
place in all bedside records. Children show some interesting
peculiarities in these respects. A distinct elevation in the tem-
perature curve of the adult chart usually connotes change of im-
portance and often gravity. On the other hand, a temperature
of 104°, observed in a 5 days old infant, frequently associated
with extreme irritability and prostration, is as often produced by
lack of 'fluids or food, as by any serious bodily lesion. Obviously
580 Wilcox : Symptomatology of Childhood
pyrexia, due to dehydration, is common to both adults and chil-
dren. However, elevation of temperature follows hunger or with-
drawal of fluid in children much more promptly and to a greater
,degree than is ever seen in adults, often accompanies mild dis-
orders, giving no evidence of disease, and, if given undue con-
sideration, will greatly exaggerate the clinical picture. Con-
versely, a temperature which in the adult will result in evident
discomfort, will in the child often be tolerated without discomfort,
and be overlooked unless revealed by the clinical thermometer.
Lusk has shown that the temperature of a fasting adult is normal
until the end of his fasting period, when it may be subnormal, but
that it is never elevated. Why should a child have fever when
the adult does not? This may be accounted for on the ground
that the capacity for heat production in the infant is greater than
in the adult, both actually and relatively — actually, because infant
metabolism is 3 times greater than the adult; relatively, because
heat production varies directly with surface area, so that the
smaller the body, the relatively greater the amount of heat pro-
duced. It may be said, in reply to this theory of heat production,
that diminished heat loss, not increased heat production, is the
true cause of pyrexia.
On this hypothesis the important factors become not metabolic
activity, surface area and bulk, but conduction, radiation and
evaporation, the 3 methods of heat elimination. As the body
temperature rises, elimination by conduction, radiation and
evaporation increases. The elasticity of the 2 former is not great,
being controlled as it is by many physical conditions, such as
atmospheric changes and clothing. Therefore, whatever heat
cannot be taken care of by conduction and radiation must be
eliminated by evaporation, and it is this factor, evaporation, that
is both most affected in fever, and the least well developed in the
child.
Obviously, in the rnatter of radiation and conduction, the baby
is at a great disadvantage ; he is banded, shirted, diapered, dressed
and blanketed to a state of such perfect insulation that he can
neither profit much by conduction, nor utilize his surface area
for radiation. But aside from such material handicaps, develop-
mentally he is embarassed, because of the late acquirement of
the ability to accommodate, without reaction in body temperature,
to changes both thermal and humid by calling into selective
Wilcox: Symptomatology of Childhood 581
action either his mechanical or chemical means of temperature
control. Evaporation of perspiration is the expression of this
chemical means of temperature control.
In addition to these fevers produced by intrinsic causes, lov/
water and food, and these are somewhat synonymous in terms
of infancy, we must consider pyrexias resultant upon extrinsic
causes, such as temperature, clothing, artificial heat and humid-
ity. The adult animal is not affected by elevation in tempera-
ture or humidity unless the latter reach a point above 87° satura-
tion. On the other hand, infants respond to such external in-
fluences promptly and at times alarmingly. Accurate control
of incubator atmosphere, if this apparatus is used, is an absolute
necessity as the baby's temperature will promptly follow any
change in that of the incubator.
In young and old alike, inanition fevers occur when loss of
fluid has reached the point of causing loss of body weight. The
degree of pyrexia varies inversely with the body weight. Balcar,.
Sansum, and Woodyatt, in their work on "Fever and the Water
Reserve of the Body," have shown the relation between low
available fluids and pyrexia. They do not prove that reduced
body fluids are either the sole, or the inevitably contributing
cause of inanition fever. On the contrary, it is well known that
the blood serum shows not increased, but rather decreased con-
centration in most acute infections of childhood. An exception
to this is the finding of markedly concentrated blood serum m
intestinal intoxications.
As Finkelstein had previously noted pyrexia in infants given
high sugars by mouth, so these investigators found fever result-
ing from the increased diuresis carried to a point of loss of re-
serve body fluid produced by administration of sugar solutions
intravenously in dogs. In both cases the water available foi-
evaporation is removed and thus the chemical temperature con-
trol embarrassed. In these experiments again, the degree ot
temperature produced is found to vary inversely with the body
weight. In fevers resulting also from increased affinity of body
cells for water, due to their occasionally augmented salt content,
water elimination by the lungs and skin is reduced, again affecting
the chemical control of temperature by evaporation, and again
attacking the weak point in the infant. The conclusion is that
when the normal water reserve is reduced, fevers result because
582 Wilcox: Symptomatology of Childhood
of the lack of water available for evaporation at the normal body
temperature. But it is emphasized that in the adult such pyrexia
will result only when through preceding cause the body fluid
has become reduced to a minimum.
Pyrexia is not immediate. It is a fact that the reserve body
fluids in infancy are low, and easily depleted, and that the ability
to selectively control temperature is a late development. The
whole well-being" of the child is bound up in an adequate intake
and available reserve supply of water. When pyrexia is caused
or aggravated by low fluids, then the child responds more prompt-
ly. From these considerations comes an explanation of the
prompt, and, at times, excessive pyrexia in infants resulting from
reduction of fluids. These, then, are some of the factors playing
a part in the causation of this temperature variation in childhood.
The Heart and Circulation. — There is a gradual reduction
in the size of the heart in relation to that of the body from birth
to maturity. Exactly corresponding to this is the reduction of
the heart's rate and the speed with which the circuit of the arterio-
venous system is completed. While systolic blood pressure
relatively corresponds to that in the adult, the diastolic is dis-
proportionately lower.
During the first 4 years the heart's position in the chest is
nearly horizontal, with the apex outside the nipple line in the 4th
space. From the 4th to the 9th year the apex moves inward
and downward to its adult location. In dilatation or hypertrophy
the apex beat is displaced more often upward and outward than
downward and outward as in adult life. Perhaps the most strik-
ing thing about the heart in the child is the great recuperative
power shown by it.
For 4 years there was maintained a country convalescent ward
in connection with the Bellevue Children's Service, and so an
opportunity offered of making a comparative study of this re-
cuperative power of a group of cardiac cases, 77 in number, and
114 children suffering from a variety of other serious illnesses.
These children, cardiac and non-cardiac, were all severe cases,
picked out, not because they had reached the usual period of trans-
fer to convalescent homes, but rather because they seemed so
sick as to demand something in addition to the routine ward
care, if they were to recover at all. Fifteen per cent, less of the
cardiacs than the non-cardiacs were discharged as cured, that
Wilcox : Symptomatology of Childhood 583
is, relieved of all obvious evidences of their disease. Thirteen
per cent, more of the cardiacs than the non-cardiacs showed
marked improvement in general on their discharge. The average
gain in weight was practically the same for both groups. In
other, words, our cardiacs responded about as readily to treat-
ment as did the average run of cases. This experience empha-
sizes the great recuperative power that these young patients may
evidence, when a proper environment can be provided to meet the
needs of the anemia, which is such an important factor in relation
to the nourishment of the heart wall itself. The ultimate differ-
ence in the proportion of cardiac and non-cardiac cases, who had
made satisfactory improvement, was only 2 per cent. The sub-
sequent course of these children was followed in some instances
for 1, and in others 2 or 3 years, and the majority showed their
improvement to be permanent.
Both cardiac and vasomotor centers in childhood are in a
state of most unstable equilibrium; irregularities of action may
result on influences in no way related to the cardiovascular sys-
tem. Thus during active digestion errant impulses from esopha-
geal, gastric and intestinal branches of the vagus, wandering to
the cardiac branches of that nerve, probably account' for as much
embarrassment of action as does direct pressure on the heart
from a distended stomach or intestine. Alarming evidences of
circulatory failure often accompany insignificant and transient
disease due to stimuli subminimal to the adult, but active in
these younger subjects. The presence of a roaring harsh mur-
mur over the precordium frequently appears as an evidence of
acute conus dilatation attendant upon very slight bodily dis-
turbance, and until its subsidence with the falling temperature,
often leaves one in grave doubt as to whether the heart has re-
ceived actual injury or not.
A red throat, and high fever, accompanied by such a mur-
mur less often mean acute endocardial infection than simple
change in the outline of the heart wall at its weakest point, due
to vaso-depression. It is not uncommon to find a sturdy infant
of 8 to 12 months, pallid, clammy, almost pulseless, with dilated
pupils, and every evidence of profound collapse, due to nothing
more than the disturbance of vasomotor balance, dependent upon
a period of vomiting and refusal of fluids. The accidental heart
murmurs heard in connection with rapid temperature rises, and
584 Wilcox: Symptontatology of Childhood
in conditions of vaso-depression are not always easy of diagnosis
from those produced by actual endocardial lesions. They are
jiot confined to the base, but are often loudest at the apex, and
transmitted in varying degree to resemble those arising from
damaged valves. In quality too they may differ from the usual
soft blow of the so-called hemic murmur. They are as quick in
development as fleeting and sudden in disappearance. It is there-
fore not unusual that physical signs which on first examination
point to primary cardiac failure or disease, should on second
examination prove purely secondary in importance, and functional
in character.
Dullness and bronchial voice and breathing, that is, the classi-
cal evidence of lung consolidation at the left base, are commonly
present in childhood as evidence of enlargement of the heart,
or of pericardial effusion. Such signs were observed in a boy of
7, who presented in addition to his cardiac disease, a healed
tuberculous hip. On first examination the diagnosis of tubercu-
lous consolidation of the left lower lobe, with probable cavita-
tion, was made, but with the reduction of the cardiac dilatation
and effusion, the lung findings became normal, having evidently
been due entirely to pressure from the enlarged heart. Similar
signs of pulmonary compression were observed over the right,
middle and upper lobes anteriorly in a recent case, suffering from
dilatation and pericardial effusion. Apparently a change in di-
rection of pressure exerted on the lung by the distended pericar-
dium was followed by corresponding change in location of the
evidence of pulmonary pressure. These signs persisted with
the cardiac enlargement, and disappeared only when the heart
and pericardium had returned nearly to their normal state. Such
evidences of lung compression from pericardial effusion are not
uncommonly seen in adults, but the signs are less intense than
when observed in children, and are usually over a lower lobe.
This is the first time that they have been noted by us as occurring
in the anterior portions of the lung. In these 2 cases the striking
physical signs were not referable to the primary heart condition
as much as to the pulmonary lesion secondary to it. Such physical
signs are frequent and pronounced in heart disease in childhood,
and are difficult of explanation except by analogy. Similarly,
dullness or dull tympany and sharp bronchial breathing and voice
are found over pleuritic effusion in childhood, when that
Wilcox : Symptomatology of Childhood 585
effusion is in sufficient quantity to exert pressure on the adjacent
lung and produce tension in the thin chest wall. These physical
signs are striking in contrast to the usual evidence of pleuritic
effusion in the adult, and are in causation comparable to the
results of cardiac enlargement under discussion.
The Blood. — The interpretation of evidence obtained from
examination of the blood in childhood differs little from that in
adults. The leukocyte count is a little higher in the former, nor-
mally ranging from 10 to 12,000. As is true of temperature
variations, so the range of variation in white cell count is likely
to be greater than in adults from the same cause. This is par-
ticularly true of the leukopenia accompanying depleted, lowered
resistance. In addition to the relative polynuclear increase, ob-
served in starvation in adults, there is an absolute increase in
the white cells in children in this condition. The observations
of Mitchell have recently demonstrated that in bottle fed infants
there may be a slight leukocyte increase immediately following
ingestion of food, but that in 3^ an hour to 2 hours after feeding,
there is, in the majority of instances, a distinct leukopenia. The
explanation of this apparent contradiction of the previously ac-
cepted digestive leukocytosis is that there is probably a diminu-
tion of the white cells in the superficial circulation due in part to
the activity of the digestive organs, and in part to the chilling ot
the surface of that part from which the blood is taken, rather
than an actual reduction of the white blood cells. Up to the fifth
year there is normally a predominance of lymphocytes over poly-
nuclears, the normal adult ratio of 70 to 30 being reversed.
The hemoglobin content of the blood is highest at birth, being
20 to 24 grams per 100 c.c. ; minimum at 5 months, 10 to 14 grams
per 100 c.c; at 2 years, 11 to 13 grams per 100 c.c, and gradu-
ally rising to the adult normal of 18 grams to the 100 c.c. at 16
years. As all hemoglobinometers are calibrated to this adult
standard, an allowance for age is necessary if one is to avoid
classifying as anemic many children whose blood is actually noj--
mal. A direct reading of 60 per cent, hemoglobin in a child oft
2 years corrected would indicate the true hemoglobin as nearer
90 per cent, than 60 per cent., whereas uncorrected, would er-
roneously indicate a moderate anemia.
Since 1914 the superior longitudinal sinus has been more and
more constantly employed as a site for obtaining blood for ex-
586 Wilcox : Symptomatology of Childhood
amination or for intravenous medication. The sinus may be more
easily reached through the anterior fontanel than the small super-
ficial vein through the skin and abundant subcutaneous fat, and
with less discomfort to the patient. There has been no report
of injury following this procedure, and in several instances au-
topsy on cases previously subjected to it have shown no damage
to the brain or extravasation of blood, even when, through too
deep penetration of the needle both walls of the sinus have been
transfixed. This procedure may be followed up to the time of
complete bony closure of the fontanel.
Lungs. — Certain structural differences peculiar to youth af-
fect the physical signs of the chest, such as the thin elastic chest
wall, and the relatively larger space occupied by the bronchial
tree. Breathing is louder, expiration more nearly equal to in-
spiration, and make an impression more approaching broncho-
vesicular in quality in children than in adults, giving rise to the
term "puerile breathing." Such differences in percussion and
auscultation as are peculiar to certain areas of the chest due to
physiological causes, become correspondingly exaggerated.
Relative dullness is normal to the right apex because of the ar-
rangement of the underlying bronchus ; the same is true over the
right lower lobe, because of the underlying liver. In both region?
the difference is greater in children, for the reasons given above.
The intensified breath sounds, normally heard at the right apex
anteriorly in the adult, are so much more marked in children as
to make this a difficult area in which to interpret uncertain phy-
sical signs. Doubt as to the existence of a lesion at the right
apex often times may be cleared up by comparison of the physical
signs here and in the axilla, as in the latter location the physi-
ological conditions affecting the signs anteriorly do not obtain,
while a pathological lesion of the apex of the lung should produce
much the same symptoms in the axilla, anteriorly or posteriorly.
Because of the delicacy of the alveoli, emphysema occurs often in
children, develops very rapidly, and may be only of short duration.
Regularity of the respiratory rhythm is usually not well developed
until after the second year.
Illustrating the above points and the errors in diagnosis possi-
ble in the interpretation of physical signs of the chest in children
is the case of a child of 18 months, sick for 3 days with cough,
temperature 101° to 103°, following a head cold. The child was
Wilcox : Symptomatology of Childhood 587
restless and constantly crying hard ; his respirations were 35, and
markedly irregular; percussion was hyperresonant throughout,
except for the right apex anteriorly where the resonance was dis-
tinctly impaired, the breathing high pitched, exaggerated with a
slightly bronchovesicular element. The diagnosis made was early
bronchopneumonia involving the right upper lobe. As both
breathing and voice were normal in the apex of the axilla, it
seemed possible that the irregularity of respiration was simply
that of age, the signs at the right apex physiological rather than
pathological, the hyperresonance due to long crying, and that
another cause must be sought to explain the condition. Aside
from the cold in the head there had been no symptoms suggesting
involvement of the middle ear, but routine examination demon-
strated a bulging right drum, incision of which promptly ter-
minated all symptoms. From the adult standpoint the physical
signs justified a tentative diagnosis of pneumonia; the error lay
in failure to allow for the influence of the child's age on these
physical signs.
Regarding the evidences of involvement of the middle ear in
children, the only one of any importance is the presence on in-
spection of changes in the ear drum. This inspection should, of
course, be a part of every routine examination. Although the
external auditory canal is small, the drum is relatively large in
children. It does not lie at right angles to the line of vision as in
adults, but faces sharply downward and forward. So it is possi-
ble to mistake this normal position for a bulging or displaced
drum, especially if there is dulling of the surface epithelium due
to congestion. An early and common sign of mastoid involve-
ment is the drooping of the posterior and superior wall of the
auditory canal, just external to the attachment of the membrana
tympani. This is more to be depended upon than mastoid ten-
derness, because objective evidence is more definite than sub-
jective in children, and localization of pain uncertain. This sign
is peculiar to children, because the thinness of the bony plate
separating the antrum from the external auditory canal allows of
prompt edema and swelling of the periosteum overlying it. Simi-
larly the frequency with which subperiosteal post-auricular ab-
scess is found in children seems to be due, up to the end of the
first year, to a somewhat analagous condition, the open Ravinian
segment, which constitutes the posterior third of the bony tym-
588 Wilcox: Symptomatology of Childhood
panic ring, through which pus from the middle ear may easily
find its way, and during the second year to the patency of the
squamomastoidal suture, which, passing through the antrum wall
and across the post-auricular surface of the temporal bone, pro-
vides an easy route for the extension of infection.
More attention is being paid now than formerly to the over-
growth of lymphoid tissue at the base of the tongue. In children
this is almost as often a cause of susceptibility to infection in the
upper respiratory tract, embarrassed breathing, and particularly
of persistent cough, as are the faucial tonsils and adenoids
themselves.
The diagnosis of acidosis is so commonly made solely on the
presence of acetone , bodies in the urine, that some reference to
this symptom is necessary. These bodies are normally present
in the urine of infants to the amount of 1 to 7 milligrams per kilo
of body weight. They may occur in sick children in much larger
quantity, but are usually of no particular significance, because it
requires their presence in considerable excess to impoverish the
alkali reserve of the body fluids to the point of producing true
acidosis. So their increased production or decreased oxidation in
children is often of no clinical importance. There are several
explanations of this early and marked urinary symptom in chil-
dren, which may be noted without danger of going too deeply into
a most complicated part of body chemistry.
On slight provocation children turn promptly to the oxidation
of stored fats, and if this fat metabolism or oxidation is faulty,
production of acetone bodies results. Such metabolism may be
faulty because of the lack of sufficient carbohydrates to provide
for complete oxidation of the fats. The evidences of this error
in oxidation are hastened and enhanced in conditions of circu-
latory depression through the capillary dilatation commonly pro-
duced by bacterial toxemias or intestinal intoxications, as a result
of which the active circulating blood volume is reduced with
resultant suboxidation of all the tissues. It is interesting in con-
nection with this theory of the reduced oxidizing power of the
blood to note that acetone is present many times more frequently
as an accompaniment of respiratory disease than in aflfections of
other types. Partial starvation may occur in many obscure in-
fections with all its promptly appearing train of secondary symp-
Wilcox : Symptotnatology of Childhood 589
toms, so that acetonuria often receives unwarranted attention,
while the actual cause of the illness goes undetected.
Reflexes. — In addition to lesions of the pyramidal tracts
commonly causing changes in the superficial reflexes, the pyra-
midal tract in the child is subject to functional affections on ac-
count of its imperfect development, incomplete myelinization, and
low cortical control. Kernig's sign, almost universally present
in normal man, is for this reason of small significance as a fine
test. The child, however, is less sensitive to this stretching of
the posterior nerve roots, and the dural protrusions which follow
them from the cord, and his muscles are less stiff. He sucks his
toe almost as comfortably as his thumb. Kernig's sign is there-
fore important when present as evidence of meningeal irritation.
Conversely Babinski's sign is normal to children until locomotion
becomes established, and is of questionable value during the first
years of life.
Convulsions. — Convulsion is a symptom common to many
of the ills of childhood. Because of the imperfect development
of the central nervous system as a whole, efferent and afferent
tracts alike, convulsions are less common during the first 4 months
than during the remainder of the first 2 years. This coincides
with the infrequency with which tetany is observed and the low
electrical irritability of normal children during this period.
Convulsions become more common when the motor neurons
with their efferent tracts, and the lower centers, such as the
splanchnics, are further matured, but are as yet ungoverned by
the still later developing nervous mechanism of coordination and
control. Thus it is that a brain lesion, occurring in the first month,
may not at once give symptoms referable to the central nervous
system, and later only such symptoms as are indirect and easily
referable to other secondary causes; for instance, evidences of
disturbed digestion. In connection with these facts one condition
in particular is to be emphasized ; that is, the frequency of cere-
bral hemorrhage occurring at birth or soon after, causing no brain
symptoms at that time, and later such symptoms as are more
indicative of toxic intestinal absorption than cortical lesion.
Cerebral lesion and intestinal toxemia may with equal frequency
be the cause of convulsive seizures. Thus a history of spasm in
the early stages of a period of nutritional disorder should bring
up the question as to whether it refers to an early obscure cerebral
590 Wilcox : Symptomatology of Childhood
lesion, such as birth hemorrhage, or is merely a part of the evi-
dence of intestinal toxemia.
A child of 6 months, weighing the same as at birth, with a
history of moderate convulsive attacks occurring shortly after
a change from nursing to artificial feeding at one month, and who
from this time on has shown no symptoms other than the general
one of asthenia and malnutrition, is usually looked upon as a
purely nutritional problem, with the convulsions digestive in
origin. Many such, after weeks of fruitless effort to find a suc-
cessful dietetic scheme, terminate fatally without symptoms definite
enough either to guide us in our dietetic measures, or explain the
severity of the condition. Such is the history of an actual case,
and if uncommon at all, it is only so in that autopsy was obtain-
able to make certain the diagnosis of cerebral hemorrhage, prob-
ably occurring at birth.
Case Report. — A 4th child, the others normal, no miscar-
riages, labor easy and normal.- The child was normal at birth, and
weighed 7 pounds, 6 ounces.
She nursed entirely for 4 weeks, and at the end of that time
was put on part feedings of dry milk. Three days later
an attack of twitching occurred on the right side. On the fol-
lowing morning twitching was observed on the left side. This
lasted for some little time, becoming more pronounced in the
middle of the day, and almost continuous throughout the after-
noon. These attacks of twitching recurred off and on for 2 days,
during which time there was constipation, vomiting and later
diarrhea.
During the next 4 months, various formulae were tried with
varying success. At 7 months of age, she weighed 8 pounds.
Physical examination at this time revealed a small, badly nour-
ished child, with general hypertonus and rather marked rigidity
of the neck. The skull development was good and the an-
terior fontanel was open 2x2 cm. The posterior fontanel
was closed. All the reflexes were exaggerated, no tache, and
there was marked retraction of the head. The epitrochlears on
both sides were markedly enlarged, but there was no other glan-
dular enlargement. The baby had all the distinctive muscular
rigidities of undernourishment, without anything definitely refer-
able to the central nervous system. She was taking the food
well, but was not gaining in strength or weight. On July 25
Wilcox : Symptomatology of Childhood 591
she was admitted to the New York Nursery and Child's Hospital
in a state of collapse, and died almost immediately after ad-
mission.
Autopsy Findings. — Body is that of a white female child
7 months old, markedly emaciated, rigor mortis passed off. The
abdomen is scaphoid. Eyes and cheeks are sunken in. Fontanel
depressed. The cornea are clear. Median section — panniculus —
presents markedly atrophied fat. The peritoneum has lost some
of its luster — somewhat dry and presents a diffuse engorgement
of vessels. The abdominal cavity contains about 15 c.c. of serous
fluid with a large amount of flaked fibrin. This engorgement is
only present in the peritoneum and does not extend into the
underlying tissues. Intestines are distended with gas.
Brain — 500 grams. Rather pale and on serial sections pre-
sents bi-lateral organized old hemorrhages. These lie about two-
thirds back of the frontal lobes. They lie embedded in the corpus
striatum for the most part, involving the caudate nuclei surround-
ing the internal capsules, but not involving them to any extent.
They measure 1 by 1 3^2 cm. and are extremely firm in consist-
ency. They are a light rusty color, streamed with white fibrous
strands. There is no evidence of any injury or any thrombosis
of the striate branches of the middle cerebral vessels. The old
masses are undoubtedly organized hemorrhages of long standing.
Heart — 15 grams. Extremely pale, firm and of a glassy ap-
pearance. Otherwise negative.
Lungs — Together 80 grams. Present hypostatic congestion
and several subpleural extravasations.
Liver — 100 grams. Dark brown color. Extremely firm and of
a dry leathery consistency.
Spleen — 8 grams. Dark red. Firm, dry, leathery consistency.
Thymus — Atrophy.
Pancreas — Negative.
Stomach and Intestines — Extremely thin. Present marked
atrophy of mucous lining.
Kidneys — 15 grams. Negative.
Anatomical Diagnosis — Old organized bi-lateral cerebral
hemorrhage of the corpora striata; hypostatic congestion of
lungs; dehydration of viscera and early inflammation of peri-
toneum.
592 Wilcox: Symptomatology of Childhood
This is illustrative of a large group of so-called unsatisfactory
feeding cases in which the question is whether the malnutrition
and asthenia are of central or digestive origin. The answer in
these cases is not found in an analysis of the spinal fluid, nor in the
observation of the digestive condition, but only in the ultimate find-
ing of definite evidence of brain injury, which has occurred si-
lently, but has gone on to distutja the entire physical balance,
without definite clinical symptoms.
jp East 7f)th Street.
Hereditary Syphilis Cause of Membranous Perienteritis
(Surgery, Gynecology and Obstetrics, August, 1920). Hereditary
syphilis is regarded by Castex and del Valle as being a very fre-
quent cause — perhaps the most frequent — of membranous perien-
teritis and analogous conditions. Its pathogenesis is complex as
several factors operate, which in chronological order are : defects
of conformation in the intestinal walls because of the faulty en-,
docrine function which presides over and governs their develop-
ment. These malformations on the one hand, and the abnormal
function of the nervous system (sympathetic and autonomous),
owing to the endocrine deficiencies, produce defects in the gastro-
intestinal statics and dynamics. As a consequence of the latter
we have intestinal stasis which brings on chronic inflammation of
the colon. From the wall of the colon the inflammation spreads
to the surrounding serous membrane, aggravating the existing
congenital lesions. The primary cause of all this is hereditary
syphilitic infection, generally in the form of a late manifestation.
These patients, first of all, should be given mixed antisyphilitic
treatment with mercury chiefly. The surgical treatment is not
to be abandoned, but is to be restricted to cases in which definite
indications, confirmed by clinical and radiologic diagnoses, point
to mechanical alterations of importance (kinks, adhesions, etc.) ;
or to coexisting inflammatory lesions of adjacent organs : ovaries,
tubes, appendix, gallbladder, duodenum, and stomach. Surgical
treatment should consist in separating membranes and in molding
and mobilizing the peritoneum, together with careful peritoniza-
tion and removal of the adjacent affected organs. — Journal A.
M.A.
REPORT OF A CASE OF DIAPHRAGMATIC HERNIA.
By John E. Greiwe, M.D.,
Cincinnati.
It seems desirable to present this case not only because of
the rarity of the condition, but especially because of the evidently
unique etiologic factor.
A. v., a girl 5^^ years old, was brought to me by Dr. R. Lee
Bird, of Latonia, Kentucky. The history of her present illness,
in a sense, preceded her birth, inasmuch as the mother, at the
time of delivery and' immediately thereafter, was seriously ill
from whooping cough. The child, despite severe paroxysms of
cough on the part of the mother, was carried to term, and is
said to have weighed 4 pounds when born. It may be added
that, besides the mother, 2 other children in the family had
pertussis at the same time.
Immediately after birth the child was seized with severe at-
tacks of coughing which continued to the fifth year. From the
very beginning, vomiting was a pronounced feature, occurring
at various times and bearing no special relationship to the char-
acter of the food or to the time of feeding. In fact, a liquid
diet had been almost exclusively adopted, since even the most
readily digested foods — milk, Mellin's, broths, etc. — were not
completely retained for any considerable length of time. Solids
were not given because even water was rejected by the stomach.
The child was physically depressed and evidently retained just
enough food barely to sustain life. At the age of 5>4 years the
weight was 28 pounds. Constipation was a marked feature.
Effort and excitement invariably brought on an attack of vom-
iting; a few days before the first consultation the vomited mate-
rial had what the parents described as a fecal odor.
The physical examination revealed a child exceedingly thin,
pale, poorly nourished, with badly developed musculature and
practically no subcutaneous fat. The excursions of the chest
were fair, with dullness amounting to flatness on percussion over
the lower portion of the right chest. This area of dullness
shifted with the position of the patient. The apex of the heart,
on auscultation, was found to the left of the sternum about mid-
way between the left margin of the sternum and the mid-clavicu-
593
594 Greiwe: Case of Diaphragmatic Hernia
lar line in the fourth interspace on the left side. Over the lower
portion of the chest, the heart tones were very clear and without
murmurs. The respiratory sounds were good, except over the
lower portion of the right chest. On the day before operation,
gurgling was present over the lower part of the left chest. The
abdomen was flat and the abdominal walls were practically with-
out fat tissue. The urine showed neither albumin, sugar, casts
nor acetone.
The history of the case would lead one to suspect a partial
obstruction at the pylorus. The X-ray examinations, however,
which were made by Dr. J. R. Cooper, revealed the fact that the
stomach was not in the abdominal cavity, but well within the
left side of the thorax. The pylorus and the antrum were below
the diaphragm, and the diaphragm was causing the obstruction.
With the X-ray (Plate I), the diaphragm could be seen on
the right side; fluid was found in small amount in the right
pleural sac, and the heart was somewhat tilted from its normal
position to the right. On subsequent examinations it was noticed
that the position of the heart varied with the fullness of the
stomach. A curious feature was the condition of the diaphragm
on the left side. Here no well-defined line could be noticed and
it was a question in the first examination whether or not there
was a partial absence of the diaphragm on the left side. There
was also some question as to whether or not the colon, because
of its high position, might not be within the left thoracic cavity.
Further X-ray examination (Plate II), however, more particu-
larly stereoscopic pictures, revealed the presence of the left side
of the diaphragm, as well as the colon within the abdominal
cavity.
Briefly, then, w-e were dealing with a case of diaphragmatic
hernia, with a history of severe paroxysmal cough (whooping
cough), which developed immediately after birth.
Hernia, with stomach, colon and parts of the small intestine
within the thorax, while not common, nevertheless has been the
subject of surgical procedures. Congenital absence of the dia-
phragm is a known pathological condition. Hernias, the result
of injuries by falling, by blows upon the abdomen, stab wounds
of the diaphragm, etc., are very often seen; hernias, developing
years after a stab wound, have been recorded, but so far as I
am able to ascertain, there is no case on record in which, so
Greiwe : Case of Diaphragmatic Hernia
595
Plate I — Koentgenogram taken at first examination. The stomach in a horizontal
position, occupying Tower portion of thorax. The pylorus, covering two-thirds of
heart shadow, is above the diaphragm on the right side. On the left, the diaphragm
cannot be made out. This picture suggests an absence of the left half of the
diapnragm.
596
Greiwe: Case of Diaphragmatic Hernia
Plate II — Taken 1 hour after Plate I. The stomach has changed its position. The
pyloric end is directed' downward, in the manner of a protrusion through an orifice, — -
evidently the pylorus passing through the hernial opening in the mid-line of the
diaphragm into the abdomen. The shadow above the diaphragm on the right is due
to fluid in the right pleural sac. A very small amount of barium has passed into
the intestines and is in the lower left iliac region.
Greiwe: Case of Diaphragmatic Hernia 597
Plate III — Taken 6 months after operation. The stomach is wholly within th^
abdomen and the diaphragm is apparent on both the right and left sides.
598 Greiwe : Case of Diaphragmatic Hernia
early in life, hernia has developed as the result of damage to
the diaphragm, due to violent attacks of coughing. It is, of
course, not possible to say that the rupture of the diaphragm
occurred immediately after the first paroxysms. The coughing
persisted for the first 5 years, but the vomiting continued up to
the time of the opera4:ion.
The operation was successfully done by the abdominal route
by Dr. Otto Seibert, who has submitted the following transcript
of his procedure :
"Operative Procedure, Augusta V., April 12, ipi8. — Median
incision, extending from the ensiform to just above the umbil-
icus. Careful exploration confirmed pre-operative diagnosis.
The entire stomach was found in the post-mediastinum behind
the heart. There were no adhesions of the stomach to the ring.
There was an opening in the diaphragm from 2 to 2^ inches in
diameter, appearing to be the esophageal opening much enlarged.
The stomach was withdrawn from the chest cavity with diffi-
culty, as with each inspiration the negative pressure pulled it
back through the opening in the diaphragm. Not until after
firmly securing the stomach with stomach clamps was I able to
pass sutures to closje the diaphragmatic opening. Three heavy
chromic gut sutures were passed through the margin and tifd
so as almost entirely to close the opening, leaving just enough
room for the esophagus to pass. The anterior stomach wall was
fixed to the abdominal wall by means of 2 chromic gut sutures
passed through the serous coat of the stomach and through the
peritoneal and muscular layers of the abdominal wall. The
abdomen was closed in the usual manner. About the seventh
day after operation the entire abdominal incision fell open from
end to end. This necessitated a second complete closure. Con-
valescence thereafter was uneventful. The patient began imme-
diately to take nourishment in moderate quantities and, before
leaving the hospital, was enjoying practically a full diet. In
reporting a case of this kind before the Cincinnati Academy of
Medicine, 2 years ago, I suggested that, if occasion again pre-
sented itself, I should use the reverse Trendelenburg position to
make the field more accessible, and thus facilitate the operation.
In this case I tried this position, but the child took the anesthetic
so poorly that we had to place her back in the prone position."
The patient's weight increased satisfactorily within 6 months
Greiwe: Case of Diaphragmatic Hernia 599
after the operation, her weight at this time being 43 pounds.
She is attending school, is bright and happy, retains her food
and is perfectly well. X-ray (Plate III), taken 6 months after
the operation, shows the stomach in the abdominal cavity and
the rent in the diaphragm closed.
In conclusion, it may be added that we were dealing, not
with a hernia resulting from a congenital diaphragmatic defect,
usually inoperable because of its size, but with a diaphragmatic
hernia of the stomach, caused by the rupture of the diaphragm
during the paroxysms of whooping cough.
The X-ray examinations were made by Dr. J. R. Cooper,
who has kindly furnished the photographs and supplied the
legends.
i8oi Union Central Buildins:.
Injections of Patient's Own Milk to Stimulate Secre-
tion (Zentralblatt fiir Gynakologie. June 5, 1920). Meyer re-
ports the results of the injection of the woman's own milk in
twenty women after childbirth. In two cases no effect was
noted ; in six cases the effect was weakly positive ; twice it was
impossible to decide whether the increased milk flow was due to
the injections or to other causes, but in sixteen cases, or 61.5 per
cent., in from twelve to thirty-six hours after the subcutaneous
injection of from 1.5 to 3 c.c. of the woman's milk a distinct
increase of the milk secretion was noted, but as a rule the increase
lasted only a few days, when the flow fell off again. The effect
in most cases followed so soon after the injection that doubts as
to the causal connection seem unwarranted. Sometimes the pa-
tients were not informed as to the nature of the injections, and
in many cases the increased amount of milk following the injec-
tion was more than dbuble that of the preceding day. Lonne
reports two cases among others in which the injections several
weeks after childbirth seemed to afford the needed stimulus for
the deficient secretion, the women thereafter having abundance
of milk. — Journal A. M. A. ,
LAMBOTTE-HANDLEY DRAINAGE IN A CASE OF
CHYLOUS ASCITES (Second Report)
By Francis Huber, M.D.
Consulting Physician to Gouverneur Hospital; Consulting Pediatrician to The
Jewish Hospital of Brooklyn; Chief of Pediatrics, Beth Moses Hospital of Brooklyn;
Attending Physician to The Broad Street Hospital, New York.
In the Journal of the A.M. A., (November 8, 1919, page 1427)
an abstract is given of an article on "Autodrainage of Ascites &c.,"
taken from the Correspondenz-Blatt fuer Schweizer Aerzte,
September 11, 1919. The author. Dr. Schirmer, reports the later
outcome of the case of ascites in which Tavel, in 1910, drained the
fluid into the subcutaneous tissues 'of the abdominal wall, using a
glass spool to keep the opening patent. No other case of the kind,
of such long continued success, is on record. The ascites was
of the "premenstrual type," the patient a girl 13 years of age. The
fluid thus drained into the connective tissue was readily absorbed
in the beginning, later, however, large water cushions formed
in the groins, sagging down and overlapping the thighs. The
operation caused a marked improvement in the general health ;
in time the benefits were counterbalanced by the discomfort and
deformity caused by these irregular and large collections of fluid
in the abdominal walls. Subsequently they became encysted and
as no further absorption took place, grew larger and more tense
necessitating repeated tapping at longer or shorter intervals.*
The spool, which had become loose, had fortunately escaped into
one of the pouches and had been removed several years ago.
The "water bags" were finally removed by Henschel in 1918. The
operation, difficult and tedious on account of the matting together
of the structures by newly formed dense fibrous tissue, revealed
a large aperture about the size of a 50 cent piece in the thickened
peritoneum at the site where the glass spool had been inserted
originally. There was free communication between the peritoneal
cavity and the multiple, irregular, extensive, and freely inter-
communicating cyst-like pouches lined with a thick smooth
glistening serous membrane resembling peritoneum. The peri-
toneal opening (resembling the neck of an umbilical hernia) was
then closed and the necessary tedious surgical measures to resect
*The two illustrations in the original article show the ?5«^ent and character of the
deformity and the cosmetic success after operation,
600
Huber: Chylous Ascites 601
the numerous sacs were carried out successfully. Though the
deformity was relieved, the ascites persisted, in spite of all that
had been done, medically and surgically.
The above reported experience induces me to give the subse-
quent history of a case of "acute chylous ascites" treated by auto-
drainage with strands of silk. The case is reported in detail in
the "American Journal of Diseases of Children," July, 1914. It,
brief, the history is as follows : Male, age 8 years, has never
been out of New York, parents Russian Polish. With the ex-
ception of measles at 4, and pneumonia at 5^, he enjoyed fair
health up to within 2 weeks prior to his admission toi the hospital
on December 15, 1913. Though afflicted with a severe nasal
discharge, he nevertheless attended school, feeling sick generally.
Two days before, while undressing, the father noticed the swelling
of the abdomen and genitals. No fever, headache, urinary dis-
turbance or general depression noticed.
On admission marked edema of penis, slight edema of the
upper part of both thighs, abdominal walls and back, none about
the ankles or feet. The abdomen was greatly distended with
fluid. Urine, blood, von Pirquet and Wassermann negative. The
general condition was fair, appetite "simply enormous," bowels
regular.
As there was no improvement under medical treatment, the
abdomen was tapped and over 3,000 c.c. of a slightly turbid, milky
fluid were removed. Considerable oozing occurred through the
puncture and continued for several days. Eleven days later, 2000
c.c. were drawn oflf. The fluid recurring so quickly, more radical
measures were indicated and after consultation with my surgical
colleague. Dr. Henry M. Silver, an exploratory laparotomy was
decided upon ; first, to ascertain the cause* and, secondly, to drain
the "peritoneal pond" into the subcutaneous tissues of the upper
thighs and the anterior abdominal wall, thereby conserving a
fluid rich in proteins, salts and the other characteristic constituents
of the body fluids. The exploratory laparotomy was carried
out by Dr. Silver a few days later. The abdomen was opened
. *The indefinite history, and a painstaking consideration of the points brought out
in the physical examination of the patient, failed to throw any light upon the etiology.
No history of trauma was elicited, the blood did npt reveal any filaria, nor did the boy
present any evidence of tubercular glands, Hodgkin's Disease or a possible malignant
affection. The rapid onset of the ascites and the equally rapid recurrence of the
milky fluid after tapping, the large prominent veins over the abaomen, the local edema
of the back, abdomen and genitals, pointed to some intraabdominal condition inter-
fering with the chylous circulation.
602 Huber: Chylous Ascites
and explored through a 3 inch incision downwards, beginning
about the level and a little to the right of the umbilicus. Con-
siderable fluid escaped and more than 1500 c.c. were drawn off by
a suction apparatus. The small intestines were pale and distended
with gas. The lacteals, not only in the intestines but in the
mesentery, were greatly distended and were prominent, flexuous
in their course, constricted in places, and presenting a beaded or
varicose appearance. The constrictions on the intestines were
so tight in spots, that the lacteals would disappear only to reappear
in the mesentery. Isolated lymphatic glands, much enlarged, were
present, small near the gut, growing larger and more numerous
towards the mesentery roots. Some were the size of a small
hickory nut, soft, elastic and of a yellowish color. No tubercular
peritonitis or other abnormality, as far as could be made out
through the 3 inch incision, was discernible. The child's condi-
tion not being very good, it was not deemed advisable to remove
a gland for a more careful study. There was evidently, though
not discovered, some obstruction higher up in the lymphatic cir-
culation, consequently some simple, rapidly carried out form of
drainage, was indicated. The Lambotte-Handley plan was
adopted. Six strands of No. 7 white silk, 4 inches long, were
caught in the grasp of a narrow blade dressing forceps, carried
into the abdomen and thrust through the peritoneum to the outer
side of the femoral vessels, into the cellular tissue of the thigh,
only half inch of the silk remaining within the peritoneal cavity.
This was repeated on the opposite side. At the upper angle of the
wound, a similar procedure was adopted, the silk being intro-
duced into the tissues above the umbilicus, the lower half inch
projecting into the peritoneal cavity. Great care was observed
to allow only a little of the silk to project, for carefully conducted
experiments have shown that long strands may cause intestinal
obstruction by forming attachments to the omentum or other
intra-abdominal structures.
The convalescence was rapid and uneventful. At the end of a
week, upon the removal of the dressings, the wound had healed
completely without any edema or infiltration about the edges.
Some edema persisted in the upper portion of the right thigh,
very little in the left and none over the upper abdomen. He
was discharged in fine condition, every trace of edema gone, the
latter part of March. The appetite, which prior to operation, had
Huber: Chylous Ascites 603
been "enormous" became normal. Five months later a careful
examination failed to show any abnormality, the abdomen was
lax, no mass or thickening" anywhere over the areas where the
silk had been introduced.
The patient has continued to enjoy good health since and at
the present time (March, 1920), more than 6 years after the
operation, is a bright, active, well developed lad, height, 4 feet.
1 1 inches ; weight, 97 yj pounds.
I have seen but one other instance about 18 years ago. In
this case the ascites was but a part of the general water-logged
state. The boy had, in addition, large glandular swellings in the
neck. The urine contained albumin and casts in abundance.
Upon tapping the abdomen, a large quantity of a lactescent fluid
was removed. The ascites reappearing quickly, he was tapped
several times. In the hope of relieving the pressure, the group of
glands about the neck were removed. In spite of the radical
work, they recurred within a few months. Decapsulation of both
kidneys failed to give more than temporary relief. The sub-
sequent outcome is not known as the boy was taken home and
passed from observation. Longcope (Osier's Modern Medicine),
discussing Hodgkin's Disease, says, "with enlargement of the
bronchial and mediastinal glands, effusion into the pleural sacs
occurs in a certain number of instances. This is usually seen
only late in the disease. The fluid is most often serous, although
chylous fluids are mentioned. Edsall has described in one case a
curious type of milky, albuminous effusion into the pleura which
at first sight appeared to be chylous in character."
Remarks. Schirmer's contribution is of extreme interest and
will repay a careful perusal. It teaches the danger of using a
glass drain, which loosening up and becoming displaced, does
not become encysted, but must be removed as a foreign body.
We find that the immediate results were satisfactory. That is to
say (we may justly infer) as long as the fluid escaped slowly into
the connective tissues through the lumen of the glass drain.
Unfortunately, as subsequent events proved, the drain gradually
became loose and the peritoneal opening proportionally increased
in size, thus allowing more fluid to enter the tissues than could
be disposed of by the absorbents. In consequence of which, a
proliferation of the connective tissue occurred, resulting in an
irregular walling off of the extruded fluid in the abdominal wall.
604 Huber: Chylous Ascites
Furthermore, the original cause of the ascites was still active. A
close inspection of the open abdomen by Henschel failed to reveal
the exact nature of the process.
The ultimate failure in Tavel's case is readily explained. Too
much fluid under pressure escaped through too large an opening
into the tissues . . . more than could be taken care of by
the lymphatics. Handley says, "if the absorptive power of the
tissues are normal, and the amount of the fluid led into them is
not excessive the appearance of edema is not to be expected."
Schirmer, upon a careful consideration of the subject, is of
the belief that the conditions for absorption in the retroperitoneal
and lumbar regions are more promising, pointing out further, that
the fluid might find its way from here down into the legs, thus
providing a larger area for absorption. He favors the use of
"calf aorta" hardened in formaldehyde for drainage as the drain
would heal in situ, become organized without being obstructed
and, moreover, would not act as a foreign body.
In the opinion of the writer, the increased difficulties of the
posterior operation, the disadvantages of a large aperture in the
peritoneum and the possible dangers of a hernia, are practical
points that must be kept in mind. The anterior operation using
sterile silk as drains, is relatively simple and easy of execution.
The Lambotte-Handley method allows the fluid to enter the
tissues slowly and continuously, permitting ready absorption. The
tissues are not flooded with excessive amounts under too great
a vis-a-tergo. We may compare the action to that of the "'Murphy
Drip," slow delivery and ready absorption. The final results in
our case, notwithstanding the rapid recurrence of the fluid after
the 2 tappings prior to the radical operation, were not only grati-
fying but were permanent. The plan is not adapted to all cases of
ascites. Those due to malignant disease, or inoperable tumors,
renal aflfections, heart troubles, or rapidly progressing hepatic
disorders, cases in which the fluid recurs quickly after tapping, are
not benefitted by the procedure.
In conclusion, a word as to the final changes taking place in
the silk drain, is in order. McDill's experiments (using -iilk
strands as drains upon animals) show the short intraabdominal
ends enveloped with a densely organized membrane outside the
silk and a general infiltration of the meshes by cells, single, in
bundles and in septa. Although the angle of the silk with the
Huber: Chylous Ascites 605
peritoneum is plainly marked, showing an actual ectropium of
the serous membrane along side the silk, the latter really acts as a
silk connective tissue plug. This angle is the place at which
McDill claims, an intraperitoneal fluid must find its exit by
pressure and gravity to the subcutaneous lymph spaces, along the
outside of and not within the body of the silk.
Addenda
In the early part of May, 1920, the patient presented himself
for examination. For some weeks he had experienced a sense of
weight in his legs, and became easily tired, though he did not
appear to suffer in his general health. The left leg was more
swollen than the right, and an undue fullness was observed in
either inguinal region. There was a slight amount of fluid in the
left tunica vaginalis, no ascites, Wassermann negative, nothing
abnormal in the blood or urine. No valvular trouble present.
A careful x-ray examination of the chest and abdomen, made
by Dr. Savage at the Broad St. Hospital, failed to reveal anything
abnormal in the lungs. No enlarged bronchial, mediastinal, or
retroperitoneal glands could be detected. The cervical, axillary
and inguinal glands were moderately enlarged (not suggestive
however of Hodgkin's Disease).
Under rest, tonics and gentle massage of the lower extremities,
some improvement took place. At present, October 10, 1920, the
hydrocele has disappeared, the edema of the right leg is very
much less, there is still considerable edema of the left leg and
thigh. The fullness in the inguinal region is still present.
The new recurrence of the ascites justifies the inference that
the drains are still efifective. As there is no evidence of any lesion
in the heart or kidneys, profound anemia or other cause to explain
the rather solid edema, the fault must lie in the absorbents. The
subject has been very carefully studied by Henschen (see original
article).
The case is still under observation. Should the edema con-
tinue rebellious to treatment, or the patient be greatly inconven-
ienced, further surgical methods may be resorted to, as incision
or excision of large strips of the fascia lata, to favor absorption
of the fluids by the deeper lymphatics.
209 E. \7th Street.
AN UNUSUAL. INSTANCE OF MULTIPLE
INFECTIONS.*
By Archibald L. Hoyne, M.D.,
Chicago.
A report of this case is made for 2 reasons: first, because of
the exceptional combination of circumstances relating to it; sec-
ond, on account of the manner in which it emphasizes the neces-
sity for caution in admitting- patients to a contagious disease
hospital if crossed infections are to be avoided.
Before setting forth the report, it should be stated that the
Municipal Contagious Disease Hospital of Chicago is built ac-
cording to the cubicle system. This is the true cubicle system
with glass partitions 7 feet high and the same air circulating
over the heads of all patients. I have said true cubicle system,
because of the frequency with which this term is applied to hos-
pitals wherein the construction allows for isolation in small wards
or individual rooms with 4 complete walls extending to the
ceiling.
Cases of measles or chickenpox are not received in our
cubicles, but are isolated on the top floor of the building in sep-
arate rooms. The purpose for this is two-fold: (1) we are con-
fident that measles and chickenpox, in contrast to such diseases,
as scarlet fever and diphtheria, are air borne to some extent at
least; (2) measles may be carried by a draught from one end
of a ward to another, and the tendency of the infecting organism
is always to travel upward in a building. Instances of the latter
have been witnessed at the Cook County Hospital, where the
infection passed up a ventilating shaft from a child sufifering
with measles on one floor to attack a susceptible in the room im-
mediately above. Even where there was no direct connecting
link, as in the case of the ventilating flue, it has been noted that
the disease traveled from a patient on one floor to a child occu-
pying the room directly over it. The only explanation for such
instances, several of which have been studied, was, since they
occurred at a period of the year when windows were open, that
the infection passed out of the window on one floor and in the
window on the upper floor.
With the foregoing explanation it will now be apparent from
Read before the Chicago Pediatric Society, January 13, 1920.
606
Hoyne: Multiple Infections 607
the following account of this case how many possibilities there
were for crossed infections in the hospital had not extreme care
been exercised when the patient was admitted.
Report of Case.— At 7 P. M., March 3, 1919, R. C, an ex-
ceptionally robust white boy, 7 years of age, was sent to the
Municipal Hospital with a diagnosis of laryngeal diphtheria and
request for intubation. The history accompanying the child
stated he had been ill 5 days. Also that he had suffered from
no previous disease at any time. No diphtheria antioxin had
been given.
When received at the hospital the patient had a temperature
of 105° F., pulse 128, respirations 30. He appeared to be ex-
tremely ill, was delirious and very croupy. The conjunctivae
were congested; the cervical glands were swollen The tonsils
were enlarged and the mucous surfaces very much inflamed, but
no diphtheritic membrane was seen. The tongue was heavily
coated, papillae prominent, and the history read "strawberry
tongue." The skin was hot but normal in appearance, except
for the face, which looked flushed.
The diagnosis on admission was laryngeal diphtheria and
scarlet fever (onset). Intubation was not considered necessary
at this time, though the possibility of its being indicated later was
considered, and on this account the child was isolated on the
first floor, where provision for all intubated cases is made.
The patient was given 30,000 units of diphtheria antitoxin.
Cultures were taken from nose and throat. Ihe urine analysis
was negative. No blood count was made.
At 9 o'clock the following morning the patient's condition
showed little change. The temperature was 104° F., one degree
less than on admission, pulse 128, and respirations 32. The eyes
were considerably congested, and, in view of the fact that the
temperature was so high and cough so marked, it seemed more
than probable that this was a case of measles in the prodromal
stage. (A report on the culture had not been received at this
time.) A very careful inspection of the mucous membranes of
the mouth failed to disclose any Koplik spots, however, and so
measles was excluded from the diagnosis.
The cough was distinctly of a laryngeal type, and there was
slight retraction of the supra-clavicular spaces. A diagnosis of
laryngeal diphtheria was then adhered to, and, at the completion
608 Hoyne: Multiple Infections
of the examination, the report of a positive culture was received,
which sustained the conchtsion. No false membrane could be
detected, though a laryngoscope was not used.
The skin seemed to be normal in appearance, except the face,
which was still somewhat flushed. There was no real circumoral
pallor, nor any rash on other portions of the body. Scarlet fever
onset was suspected, but positive diagnosis not determined. On
a very thorough examination, however, one solitary vesicle was
disclosed on the left foot just below the external malleolus. This
lesion was so absolutely typical of chickenpox that a diagnosis
of that disease was then made. Accordingly the patient (14
hours after admission) was ordered transferred to the top floor
for isolation as a case of diphtheria and chickenpox. Since there
was already a patient with diphtheria and chickenpox isolated
on that floor, it was suggested, for the sake of economy in space,
that this child be placed in the same room. Nevertheless such an
arrangement was not deemed advisable, so the patient was isol-
ated separately.
At 7 P. M., March 4, just 24 hours after admission, the
patient broke out with a typical measles eruption, and at 8 P. M.
the temperature, which had been rising again in the afternoon,
had declined to 103° F. The following morning, at 8 o'clock,
temperature was 102° F., the coryza was marked and the typical
maculo-papular eruption was scattered over the entire body.
On the afternoon of March 5, the third day in the hospital,
temperature rose to 103° F., pulse 140, respirations 30, and a
finely papular rash, with a subcuticular flush, made its appear-
ance. This rash covered the entire body, involving the areas
of normal skin which the scattered and blotchy eruption of
measles had missed. The exanthem seemed to be unmistakably
scarlet fever and appeared just 49 hours from time of admission.
During the next two days — March 6 and 7 — the rashes were
seen to be fading and there was much improvement in the boy's
condition. The cough, however, continued.
On March 8, at 8 A. M., the temperature was 98.6° F., pulse
92, respirations 26. At 4 o'clock in the afternoon of this day
temperature rose to 100.4° F. and a papulo-vesicular eruption
appeared in groups over the chest and back, this being the fifth
day since the one lone vesicle was observed on the left foot.
The lesions continued to appear in crops for the next 2 days
Hoyne: Multiple Infections 609
until the eruption was profuse over the trunk, face and extremi-
ties. The temperature rose to 102° F. on March 11 — the third
day of the general outbreaking with chickenpox and the ninth
day since entering hospital. From this time on the temperature
declined, never again exceeding 99°. F. during the patient's stay.
The child made a complete recovery without any complica-
tions other than those noted. There was no diphtheritic paral-
ysis, no bronchopneumonia, no nephritis or otitis media, and no
abscesses nor other infections.
The patient was in the hospital 35 days, being discharged on
April 8, when desquamation was complete and 2 negative cultures
on consecutive days had been obtained.
A summary of this case shows a number of erroneous de-
ductions which led, however, to favorable action :
1. March 3, evening, patient sent to hospital for intubation.
2. Admitted as laryngeal diphtheria and scarlet fever (on-
set), (a) No intubation done, (b) Not placed with other
diphtheria and scarlet fever patients having this double infection,
(c) Isolated on first floor, owing to laryngeal condition.
3. March 4, morning: (a) Laryngeal diphtheria confirmed,
(b) Measles considered but "excluded" on absence of Kop.lik
spots, (c) Scarlet fever (onset) questioned, (d) Chickenpox
diagnosed — one vesicle on foot, (e) Transferred to 4th floor
as diphtheria and chickenpox. (f) Not isolated with another
case of diphtheria and chickenpox. Isolation separate.
4. March 4, evening : Measles eruption appeared. March 5,
evening: Scarlet fever eruption developed. March 8, evening:
Chickenpox (profuse) eruption.
It will be observed from the foregoing that none of the dis-
eases was contracted in the hospital. It may also be stated that
no crossed infections resulted from this case, owing to the care
with which it was handled.
^5 East Washington St.
BUTTER FAT AND THE CHILD'S WEIGHT.*
By J, H. Larson,
SECRETARY OF THE NEW YORK MILK COMMITTEE.
The data presented here consists of the graphic presentation
of the weights of 10 children selected from a group of resident
children at an orphans' cottage home at Rochester, N. Y. The
records were obtained during the recent survey of the Rochester
milk supply under the direction of Dr. Charles E. North. The
weights shown were recorded at 6-month intervals during 2^
years previous to the end of 1918. The weights of 3 of the chil-
dren were incomplete for this entire period, due either to the fact
that they were discharged before the end of 1918, or had not been
admitted by the end of 1916. It should be explained that though
the cottages have a population of about 30 children, the reason
for so few out of the entire group being shown is that there is
constant shifting in the population through discharges and ad-
missions, and also that weight records were not taken from the
histories of any children who had been under medical treatment
or for whom had been prescribed medicines or emulsions of any
kind. In other words, the data presented is limited to those chil-
dren who were sufficiently normal as to health and general phy-
sical condition to be considered as not needing medical super-
vision.
TABLE SHOWING THE WEIGHT PER CHILD FOR 5 SIX-MONTH PERIODS
ENDING DECEMBER 31, 1918.
AGE WEIGHT
12/31/16 12/31/16 7/1/17 12/30/17 6/29/18 12/27/18
1. Boy 13 8/12 70.75 77. S 88. 84.75 91.25
2. Boy 14 9/12 90. 94. 102. 100.5
3. Boy 8 9/12 56. 58.5 54.25 60.25
4. Girl 9 52.75 52.75 56.25 55. 62.5
5. Boy 11 3/12 54.75 54.5 60. 57.5 65.5
6. Girl 10 3/12 63. 67.5 73.75 71. 82.
7. Boy 11 2/12 70.75 77.25 79.75 78.50 82.25
8. Girl 16 6/12 72. 70.25 75.
9. Girl 14 9/12 99.50 104.25 116.5 123. 132.
10. Boy 1110/12 66. 67.5 71.25 66.25 77.37
From this table it is observed that there was a gain in weight
for each 6 months with the exception of the fourth 6-month
period; in other words, the period between January 1 and June
30, 1918. Though he had made no effort to tabulate the weights.
•Presented before the Section on Pediatrics, New York Academy of Medicine,
December 11, 1919.
610
Larson: Butter Fat and the Child's Weight 611
the superintendent intimated to the writer that the data might
show some interest as to weight variation during the above-
mentioned 6-month period. His explanation was that out of a
desire of himself and his governing board to comply with the
request of the Federal Government for food conservation, par-
ticularly animal fats, during the first 6 months of 1918 oleomar-
garine was substituted for butter in the diet of the children and
the workers at this orphans' home. From the graph showing
the individual weight of each child at 6-month intervals, it is
seen that 9 of these 10 children lost weight during the oleomar-
garine period. One girl, who, by the way, is physically super-
normal, that is, considerably above her weight and height for the
theoretical weight and height for a girl of her age, did not lose
weight during that period. It is interesting to note that her
progress was slightly retarded as compared with her gain during
the previous and succeeding butter periods.
The graph showing the total weights of 7 children, whose
records were complete for the 2^/^ years, shows that at the end
of the last 6 months of 1916 they weighed 477^^ pounds. Six
months later they weighed 501^ pounds, a gain of 23^ pounds.
At the end of the next 6 months period, that ending June 30, 1917.
this group of 7 weighed 545^ pounds, a gain of 44^4 pounds
over the previous 6-month period. At the end of June, 1918,
which is also the end of the oleomargarine period, the group
weighed 536 pounds, showing a loss in weight of 9^ pounds.
At this point oleomargarine was excluded from the diet and the
feeding of butter again resumed. The weights taken at the end of
December, 1918, again the end of a 6-months period, the group
weighed 592.87 pounds, or a gain of 56.87 pounds over the oleo-
margarine 6 months period preceding. The superintendent of
the home is authority for the statement that the oleomargarine
fed during the first 6 months of 1918 contained no butter fat and
this statement is corroborated by the manufacturer of the product.
The graph tells its own story regarding the weights of these
7 children more eloquently than words can do. Interpreting
this, it seems to indicate that the gain in weight during the last
6 months shown, and during which butter constituted a part of
the diet, the children not only experienced a normal gain but also
went one better and made up the loss in weight they had suffered
during the previous 6 months or the oleomargarine period. In
612 I. ARSON : Butter Fat and the Child's Weight
^^"—'•'^
io.sem:ewqcht
/
X
Z BOYM-'Sa:
i m'&m:is
i QRLl^ 72.
.X
7 B0Yi0iTa75
i GIRL9' 63.
|:BoyiD*:5^,7^
y
,/
X
./
ATE \^i{-\(> Till J2S
Larson : Butter Fat and the Child's Weight 613
DATE I2-3H4 7-M7 l2-30i7 ^-aSIS I227-I8
T0TALWEICHT^7i5o 501^5 5^jJ9 53^ 592.87
CrOUPOFSEVENKORMALCHILDREN WHOSE RECORDS WERE
COMPLETE FOR FIVE SIXMOMTHS PERIODS.
614 Larson : Butter Fat and the Child's Weight
other words, if we chart a curve along the tops of the columns for
the 4 butter periods, we have a progressive increase in weight dur-
ing the 2y2 years, on which the influence of the oleomargarine
period is insignificant.
An Experimental and Clinical Therapeutic Study of
Whooping-Cough (Bulletin of Johns Hopkins Hospital, July,
1920). David I. Macht made a study of about 115 cases of
whooping-cough, the majority being children ranging in ages
from a few weeks to fourteen years. All other medication was
discontinued and the patients were given a 20 per cent, solution
of benzyl-benzoate by month. The dosage varied from 5 to 40
drops in water, three or four times a day and oftener, depending
upon the age of the patient and the severity of the disease. If
the simple alcoholic solution of benzyl-benzoate was found to be
too distasteful to the young patients it was flavored with a few
drops of benzaldehyde and the medicine was administered in
sugar water or milk. About 90 per cent, of all the patients
showed more or less beneficial effects ; about 50 per cent, ex-
hibited marked improvement in the symptoms. The therapeutic
effects of benzyl-benzoate were not of a curative character but
were of a distinctly palliative nature. The findings are summar-
ized in the following conclusions : 1 . The administration of
benzyl-benzoate solution alone, and still better, in combination
with small doses of benzaldehyde, exerts a beneficial palliative
effect on the violence and number of whooping-cough paroxysms.
2. The mode of action of the drug in such cases has been inves-
tigated experimentally (discussed by the writer in the text).
3. In view of the low toxicity of benzyl-benzoate and benzal-
dehyde, and the considerable number of successful therapeutic
results obtained with them, their further trial in the symptomatic
treatment of paroxysmal cough and especially of whooping-cough
is deemed advisable. — Medical Record.
SOCIETY REPORTS
THE NEW YORK ACADEMY OF MEDICINE.
SECTION ON PEDIATRICS.
Stated Meeting, Held April 8, 1920.
Charles Hendee Smith, M.D., in the Chair.
DIRECT LARYNGOSCOPY IN CHILDREN.
Dr. Henry Lowndes Lynah read this paper. (To appear
in a later number of Archives.)
nephrolithiasis in a GIRL OF THREE YEARS.
Dr. Miner C. Hill and Dr. A. R. Stevens reported this
case, the report being presented by Dr. Stevens, who stated that
the patient was a little girl 3 years of age last November. She
had been perfectly well until 2 years of age and had had none of
the diseases of childhood: In the fall of 1918 her parents thought
she was not quite up to the mark and called in a pediatrist of
this city. He found nothing out of the way except pus and
bacilli in the urine. He treated the patient with alkalies for a
period of time. The result of this treatment they did not know ;
but the following spring, last June, she came under Dr. Hill's
care. He found a very healthy looking child, but discovered
a good deal of pus and bacilli in the urine. For about 2 months
he treated her with alkalies and then with acid sodium phosphate
and urotropin. These remedies seemed to make no impression
on the condition. Dr. Hill then called in Dr. Stevens. As the
little girl was apparently quite well otherwise, they had deferred
investigation until last fall. At that time a radiograph was taken
and they were surprised to find numerous calculi in the left
kidney. The right kidney at first showed a suspicious shadow,
but no stones were found on further examination. Early in
January, a double ureteral catheterization was done under gas
and oxygen. Both ureters were catheterized with No. 5 catheters,
using a cystoscope of French 18 caliber, and specimens were
obtained from both kidneys. An intravenous injection of phenol-
615
616 Ne1&) York Academy of Medicine — Section on Pediatrics
phthalein was given to test the relative function of the kidneys.
A wax-tipped catheter was passed up to the right kidney and
there was no scratch on the catheter. The right kidney, from the
tests made, seemed to be normal. From the left kidney pus
and gram negative bacilli were obtained. The urea from the
right kidney was 1.2 per cent, and from the left 0.4 per cent.
There was about three times as much phthalein from the right
as from the left kidney. Inasmuch as there was pus in the left
kidney and not in the right, it was deemed advisable to do a
nephrectomy. There were 6 or 8 stones present, and even if
one removed all of these stones and left an infected kidney there
would be danger of the opposite healthy kidney becoming in-
fected. Dr. Holt and Dr. Blake, in consultation, agreed that a
nephrectomy was indicated.
On January 25, a nephrectomy was done and Dr. Stevens
removed a pyonephrotic kidney. The largest stone and one smaller
one were left in the specimen. Practically all the calyces were
occupied with granular masses composed of one-half phosphates
and one-half uric acid. On the fourth day following the opera-
tion, the urine was clear and free from -pus and bacilli, and has
remained so since.
Dr. Stevens said we did not hear much about surgical condi-
tions in the kidneys of children, and both Dr. Blake and Dr. Holt
said they had not seen a case just like this one. Of 320 cases
of kidney stones in children (one-half of these were autopsies),
140 were found in children under 1 year of age and only 26 in
children from 1 to 6 months old. When renal calculi are present
in babies, the supposition is that the babies usually died.
They wished particularly to call to mind the fact that surgical
conditions occurred in the urinary tract in children oftener than
we thought ; and to suggest that if, after 2 or 3 months treatment
by ordinary methods, pus could not be made to disappear from
the urine, it was well to have these cases further investigated to
more carefully locate the source of the pus.
THE SUBOXIDATION SYNDROME IN CHILDHOOD.
Dr. Chares Gilmore Kerley and Dr. Louis Berman pre-
sented this paper. They stated that the condition which they had
designated as the "suboxidation syndrome" was found with few
exceptions in the offspring of the well-to-do. The forebears of
New York Academy of Medicine — Section on Pediatrics 617
children presenting this syndrome were usually those who had
lived indoor occupational lives for 2 or more generations — those
who had been occupied with intellectual pursuits and not with
manual labor. The child with the suboxidation syndrome was one
whose physical functions were habitually below normal. There was
a lowered capacity for endurance and his emotional control was
defective. As a rule the child was precocious and mentally over-
active. There was a tendency to erythema, mild eczema, perspi-
ration was scant, low temperatures were keenly felt. A moderate
anemia was present in most cases. A frequently encountered fea-
ture was a tendency to febrile rhinitis and bronchitis. It was rare
to find a patient of this type who had not had tonsils and adenoids
removed with little or no benefit. Another feature of this syndrome
was a tendency to recurrent vomiting. Not all cases showed the
identical train of acute manifestations but in one respect they
were very similar ; they had a defective metabolism for the hydro-
carbons, particularly for cows' milk fat in the amount that they
had accustomed themselves during the last few decades to give
children.
A series of illustrative cases was cited showing that the note-
worthy feature in nearly every case had been the improvement
in appetite and the marked gain in weight as soon as the fats and
sugars, which had been given above the capacity of the patient,
had been removed from the diet. An examination of the urine
in a certain percentage of these cases showed a slight but con-
stant acetonuria on an ordinary diet, and those subject to attacks
of vomiting showed marked acetonuria during the attack. A
study of the blood in these cases had shown a hyperglycemia
varying from 130 mg. of glucose per 100 c.c. of blood as the
lowest, to 280 mg. per 100 c.c. as the highest, in a series of 67
cases, the average being 163. The blood sugar of 93 children
not belonging to this group was examined and found to vary
between 80 and 125, averaging 105. The method used to determine
blood sugar was an adaptation of Benedict's modified picric
acid and picrate method to finger blood along the lines followed
by Epstein in applying the original picric acid method.
Discussion. — Dr. Herman Schwarz, referring to the clinical
side of this question, said he had seen a great many cases with the
syndrome Dr. Kerley described, who had eaten very little sugar.
Quite a number of cases coming under his observation had not
618 New York Academy of Medicine — Section on Pediatrics
responded to reducing- the sugar as such. Personally he did not
see how it could relieve the condition simply to withhold sugar,
if the children were having bread and cereal, though there might
be an easier absorbability of sugar. When Epstein brought out the
modification of the Benedict method of estimating blood sugar,
the speaker made a g^reat many examinations, especially in cases
where there seemed to be intolerance to sugar as shown by in-
creased number of movements. Here he found the blood sugar
in the early morning before breakfast perfectly normal. In cases
of eczema and so-called exudative diathesis, blood sugar was
not regularly increased. He had plotted out the blood sugar curves
and could not see any difference in the reaction of the blood sugar
in these children to those in normal cases.
Dr. Henry Dwight Chapin said that in the paper by Dr.
Meyer and himself, recently published ift the American Journal
of Diseases of Children, it was shown that a number of cases
showed hyperglycemia with very little or no glycosuria. In the
line which Dr. Kerley had studied much might be learned fiom
examinations of the blood. One point that Dr. Kerley mentioned
might be given more emphasis, namely, that many tonsils and
adenoids had been removed that need not have been removed
on the assumption that the troubles of which the child was com-
plaining were due to that source, when, in fact, they were quite
often caused by faults in metabolism or in feeding. He was
very glad Dr. Kerley had brought that point out.
Dr. Berman said that in reference to Dr. Chapin's remarks,
they were interested to see the figures of Dr. Chapin and Meyer,
published in the American Journal of Diseases of Children,
showing a hyperglycemia in children suffering from recurrent
vomiting. They were published when Dr. Kerley and he had
practically completed their studies, and they confirmed and were
in accord with their own results. However, they were practically
all obtained in institutional children. It should be emphasized
that their studies were made in private patients, under the con-
ditions of everyday life. Institutional life meant a definite and
abrupt change in the regime of the child which must reflect itself
in its metabolism. The 2 sets of results were, therefore, not
strictly comparable.
The same comment applied to what Dr. Schwarz had said
regarding his work on the blood sugar in cases of sugar intol-
New York Academy of Medicine — Section on Pediatrics 619
erance. Besides, sugar intolerance and the suboxidation syndrome
were not necessarily synonymous. Then he employed Epstein's
method, whereas they had used, on the advice of Dr. Benedict,
a finger blood modification of Benedict's revised picric acid and
picrate method. The figures they obtained with their controls in
92 cases of the most varied conditions, varying between 80 and 125
mg. per 100 c.c. were absolutely comparable with those obtained
when one used larger quantities of blood. The only other criti-
cism possible of their results was their relation to mealtime. These
determinations were made in the afternoon, at least 2j/2 hours,
and in most cases 4 or 5 hours after lunch, which, as far as
carbohydrate was concerned, was the lightest meal of the day
for these children. In view of these facts Dr. Schwarz's results
could not be compared with theirs.
A question had been asked about the relation of the caloric
values of the children's diets to the suboxidation syndrome. They
had not gone into the question of the exact caloric values of the
diets, but it was obvious from the dietetic schedules that the chil-
dren were being calorically overfed on the foods of the highest
caloric value — milk, milk fat and cane sugar.
It might be interesting to go into the evidence that justified
the use of the term "suboxidation syndrome." The earliest
metabolic study of recurrent vomiting, the typical symptoms of
the syndrome, was made by Holt sometime in the nineties. He
showed that at the height of the attack there was an increase
of some 200 to 400 per cent, in the amount of uric acid excreted,
corresponding to that found in the crises of gout. Then Rachforrl
of Cincinnati showed a marked increase in the paraxanthin and
hekroxanthin bodies of the urine in the attack, and he had put
down this as well as the increase in uric acid to a break in the
chain of oxidation of the nucleic acid molecule. Then Howland
and Richards redirected attention to the importance of the sub-
oxidation of the carbohydrate molecule by their finding of lactic
acid in the urine at the height of the attack, later confirmed by
Underbill and Steele — lactic acid having been definitely estab-
lished by Lusk as a product of the break in the chain of oxida-
tion of glucose in the organism. They also showed in experimental
animals, poisoned by cyanide and chloroform, which interfered
with body oxidation in general, that with general symptoms of
intoxication, including vomiting, there occurred in the urine lactic
620 New York Academy of Medicine — Section on Pediatrics
acid, and an increased neutral sulphur, that was to say oxidized
sulphur. Finally, Sedgwick of Minneapolis, and Mellanby of
London showed that at the height of the attack an increased
creatinuria, creatin and creatinin metabolism did not belong to
the realm of certainties, and definitely demonstrated conclusions,
but that there was a relation between an increased creatinuria
and interference with the course of carbohydrate metabolism
many investigators agreed. All the evidence pointed to a sub-
oxidation occurring at least paroxysmally in these children. Their
work showing the existence in them of a hyperglycemia, when
apparently well, proved that there was in them a continuous
disturbance of metabolism, which went on to crisis. The fact
that in between attacks there was a hyperglycemia, was interest-
ing as pointing possibly to the biological value of the attack as
an attempt to get rid of suboxidation products. A synthesis of
all these findings had been attempted in the term "suboxidation
syndrome."
FROZEN MILK.
Dr. Harold Ruckman Mixsell presented this paper. (See
Archives of Pediatrics, May, 1920, p. 270.)
Discussion. — Dr. Herbert B. Wilcox said that some years
ago he became interested in a report by Dr. Talbot of Boston on
the apparent eflfecl of frozen milk and very shortly afterward
another report came from Burlington, Vt., on the same sub-
ject. Dr. Talbot's report was on 20 or 30 cases and the other
writer reported 11 cases. They spoke of the effect of frozen milk
as being constitutionally depressing rather than as producing a
definite type of intestinal lesion.
At Bellevue they had a number of cases of gastrointestinal
disturbance and in investigating the cause found that the milk
they had been getting had been frozen in the cans. There were
46 children affected, varying in age from a few weeks to several
months. All but 7 were, before taking this frozen milk, non-
complicated feeding cases. The majority of these children were
getting raw milk mixtures, some were getting raw skimmed milk,
a few were on boiled milk, and a few on eiweiss milk. Some were
taking milk with a high fat content and some were taking fat-
free milk. In this series of cases, 2 things stood out most promi-
New York Academy of Medicine — Section on Pediatrics 621
nently. One was that in 36 children those who were worst were
the ones taking whole milk, unboiled. Those who were least
affected were the ones taking boiled skimmed milk. The most
striking symptom of these cases was the appearance of the stools.
After the first 24 hours, they began to have diarrhea, which
varied in intensity from 2 or 3 to 8 or 9 movements a day, which
were light green, non-homogeneous and covered with a thick
layer of mucus. They were all alkaline. Over one-half of the
children vomited their food and afterward continued to try to
vomit until the next meal. The loss of weight was striking.
The ward before this had been showing a moderate but con-
tinuous gain in weight, but after the first day, when they used
frozen milk, that was from the 21st to the 23rd or 24th of Feb-
ruary, the weight curve dropped. Three of the children were
severely depressed and 1 died. They were not sick from any dis-
cernible cause except something that upset their digestion. No
study of the milk was made except to find the bacteriological
count, and that did not vary much from the ordinary count.
When milk was frozen it was a question what element was
affected, but he believed that freezing produced a definite effect
upon the milk and that it caused vomiting and a peculiar in-
testinal toxemia. From their observations it seemed possibly
that there was some change in the fats, and also in the casein.
Dr. Chakles Gilmore Kerley said he thought they were all
very much indebted to Dr. Mixsell for making a study of this
subject. He would be very glad to use this work as a means of
reference. He thought there was no doubt whatver that a sub-
stance as delicate as milk must be influenced by freezing.
Dr. Wilcox's observations were very interesting, but the
condition of that milk before freezing occurred was not known.
It was possible that some other element beside simply the freez-
ing was involved. The fact was that very little milk reached
the city from January 1 to March 1 that had not been frozen
before reaching the consumer. It seemed that if frozen milk
was much of a factor in producing intestinal disturbances in
children, we would see many more cases that could be traced to
this source than we did. Dr. Kerley said he could still stand by
the statement which Dr. Mixsell had quoted that as a factor in
the usefulness of milk freezing cut very little if any figure.
622 New York Academy of Medicine — Section on Pediatrics
Dr. Charles Hendee Smith said it seemed that there were
2 things pretty definite about frozen milk : first, that some frozen
milk certainly poisoned some children and, second, many children
took it without any apparent ill effects. It had been his experience
that after a cold snap he always received a good many telephone
calls from mothers who reported a gastrointestinal disturbance
after using frozen milk. If the children were put on barley
water, the condition cleared up in 24 hours. It is well to bear
in mind that a great many thingc might happen to milk as the
result of freezing, and to have milk boiled after it had been frozen
and where there had been undue delay in delivering it. It was not
uncommon during a cold snap to see bottles of milk bearing a
3 day old label, and that might be one factor in producing results
that had been attributed to freezing. There had been some study
of what happened to milk that was frozen and thawed, but not
of what changes took place when it was frozen and thawed and
again frozen and thawed out. Was it not possible that freezing
changed the inhibiting qualities to bacterial growth and that
milk that had been frozen became toxic more quickly after being
thawed than milk that had never been frozen and thawed. It
seemed that boiling the milk after it had been frozen did detoxi-
cate it. At the time they had that epidemic at Bellevue they were
using Grade B milk in cans and that might not have been as
good milk to withstand the effects of freezing as some other milk.
Dr. Eli as H. Hartley asked about cream kept 3 or 4 months
in cold storage, whether that was known to poison anybody. In
April and May, when milk was abundant, the cream was separated
and placed in cold storage. It was not frozen but was kept very
close to the freezing point. It was true that such milk and cream
did sour very rapidly after being taken out of cold storage. Dr.
Bartley said it had once been his duty to investigate a case in
which ice cream had caused wholesale poisoning. He found one
particular can from one particular farm which had been kept back
over 2 weeks. This was kept in spring water and evidently in
this case the long keeping had produced a change in the cream.
When kept in cold storage, cream did not become poisonous
and he judged from what the reader of the paper said, that a
proteolysis took place, altering the protein constituents. If at
the end of 2 weeks there was a development of amino-acids,
New York Academy of Medicine — Section on Pediatrics 623
sufficient to be detected by chemical tests, at the end of 3 months
there must be quite a considerable change of that kind in the
casein, yet if this was so it was rather surprising that we did not
see more cases of gastrointestinal disturbance due to the con-
sumption of such cream.
Dr. J. FiNLEY Bell said it was not so much a question of
chemistry as of bacteriology. The lactic acid producing bacteria
were destroyed and spore bearing organisms left unharmed.
Dr. Mixsell, in closing, said he had nothing to add; he had
simply endeavored to review the literature. His experience on
the clinical side of the question was limited. He believed it bet-
ter, however, to play safe and to give some other form of milk
rather than that which had been frozen. The age of the milk and
the duration of the freezing were factors to be considered. The
consensus of opinion was that milk should be used within 48 hours,
because up to that time there was no marked bacteriological
change, but after that time there was an increase in the bacteria
and putrefying bacteria increased very rapidly. Putrefactive
bacteria were a great factor in the decomposition of milk that
had been frozen.
THE NEW YORK ACADEMY OF MEDICINE-
SECTION ON PEDIATRICS
Stated Meeting, Held May 13, 1920
Dr. Charles Hendee Smith, in the Chair
A STUDY OF THE SOCIALLY MALADJUSTED
Dr. L. Pierce Clark stated that any classification of the
socially maladapted, with or without intellectual defect or with
reactions similar to the precox, failed of large utility in any prac-
tical issue. With a great show of reasonableness some had ar-
gued that these pathologic personalities varied insensibly from
the normal individual with slight, benign defects of social adap-
tation during adolescence to those with the most malignant, en-
during intellectual and emotional instability, and that no classifi-
cation for the group was possible or even desirable — they seemed
satisfied simply to call such morbid personalities the socially un-
624 New York Academy of Medicine — Section on Pediatrics
stable. The time was not yet ripe for the use of any sharp dis-
tinctive term for the various phases of social maladaptations.
in considering the constitutional psychopathic inferiors, Dr.
Clark said that if a psychologist had first been consulted he had
frequently classed the subject as a normal, dull person, possibly
2 or 3 years retarded in one or more mental tests but not in all.
The psychologic test of the practical judgment in this class of
persons usually presented marked defects, often grading only as
high as the 12th or 14th year. They also showed defective
iiianipulation and generalization of specific tests and subjects.
There was a lack of self confidence and a half-hearted attempt to
correct the simple faults. The tested subject lacked grit to stick
to the individual problem and often graded much lower owing
to inefficient arousing of determination and will to accomplish
the required test. The mental development was almost always
more asymmetrical than the average person's of the same age
and opportunities. In the opinion of the more formal psychia-
trists this type of person was often thought to be a potential
precox or a moral imbecile owing to his instability of emotional
control. These unstable persons formed a large class of all sorts
of social and business misfits. The main practical defect was
evidenced in a weakness of will in all the human activities.
Though the intellectual endowment might be good in a superficial
estimate, it was easily shown in the majority of cases to be
mediocre. Often they were keen observers, were vivacious and
knew how to use their limited powers to the best advantage. On
the other hand, they lacked energy for continuous work, soon
grew weary and were unable to complete any course of education,
their knowledge being superficial and fragmentary. Higher in-
tellectual development was defective, conception was confused,
and judgment was immature and one-sided, while their interests
centered around frivolous pleasures and they did not respond
to the more serious side of life. There was often a tendency to
build air-castles and to day dream. Emotionally they showed
abrupt changes ; at times elated and confident, and at others spirit-
less, sensitive, and pessimistic. There was usually an increased
irritability, sensitiveness, and peevishness, though they were as a
rule harmless and good natured. They were not inclined to sub-
mit to privation but demanded comfort and luxuries, regarding
restrictions as a personal insult. As soon as they had to stand
New York Academy of Medicine — Section on Pediatrics 625
on their own feet they were helpless. Since work was not agree-
able, they often changed, hoping to find a more congenial occu-
pation. They excused their unproductiveness in various ways,
never attributing it to faults of their own. They were usually
unashamed of being dependent upon others for support, and be-
lieved circumstances justified their conduct. Many of these un-
stables were gradually forced into lives of vagabondage by their
congenital instability and not by unusual circumstances. The
same condition was shown to exist in the offspring of well-to-do
parents, who, notwithstanding an apparently good endowment
and good education continued to be wholly unstable. One rarely
failed to find in the family stock traces of degeneracy. From this
description, the essayist said it was evident that we were not
dealing with a special type of moron nor was the condition very
closely allied to dementia precox. The main concern in dealing
with these people was to acquire a more intimate knowledge of
the essential emotional defect and determine, if possible, a less
clumsy method of dealing with such people than was generally
employed. In everyday life the final termination of the career of
these constitutional inferiors was to swell the rank of vagabond-
age of high and low degree, and the ne'er-do-wells shown in al-
coholic and sexual excesses and specific antisocial tendencies to
steal, lie, and swindle. The question was, what might be done
for these individuals. It was known that if the defects were not
great a proper regimen of training might help. In order that one
might establish proper pedagogic reconstruction, certain facts
must be recognized. Society immediately took an uncharitable
and unfriendly attitude towards one stigmatized as a public con-
fessant of wrong-doing. In consequence we did not adopt the
frank and open plan of dealing with the situation, which caused
these individuals to note the hypocrisy in such an attitude and
added fuel to their innate distrust of the general currency of
moral honesty. Inasmuch as the parents, and not the socially
maladaptive individuals themselves, were seriously concerned by
the attitude of society, the latter, hardened by flagrant delin-
quencies, often "sat tight" and nonchalantly taunted those sin-
cerely interested in their welfare with the query, "What are you
going to do about it? This dilemma is not one of my choosing
or concern." If such persons could be counted as legally insane,
commitment and sanatorium care would then be possible. Social
626 New York Academy of Medicine — Section on Pediatrics
policing by camouflaged tutors and companions was difficult, and
a game in which the trump cards were generally in the inferior's
hands. Anything like a fair and open policy with these individ-
uals outside a reform school or occupational sanatorium seemed
impossible. The regime, even though it provided proper tutoring
and companionship of the trained attendant, if not backed by in-
stitutional discipline and mutual cooperative management, was
next to never adequate or successful. Absolute candor tempered
with kindly but firm sympathy constituted the necessary atmos-
phere for the care and training of constitutional inferiors. Since
everything depended upon the degree of insight the inferior
gained into his own faults of character, it became evident that
the kind of teaching needed assumed an entirely different aspect
from that ordinarily practiced even in the loose association of a
boys' outing school, although the latter combined with boy scout
training more nearly approximated the method of teaching than
any other. Personal talks in which the preaching attitude was
eliminated was the better system to follow. The most obvious
fault in the majority of inferiors was their unwillingness or in-
ability to subscribe to and to practice the usual social customs of
everyday life. Tact, perseverance, and friendliness were the main
leads in the process of education. A continual influence which
strongly emphasized the mutual cooperation of the group in the
same pleasures, instruction, and athletics would aid in getting the
best results. The main advantage sought in such a plan was to
establish a sort of free social environment in which the inferior
mechanism of the individual could adjust and get something out
of it.
It was quite obvious that the abnormal trends in development,
if not inherited, began to show themselves in the early nursery
period of the home training or as soon as the child had passed
into the care of the school with its broader associations and dis-
cipline. Therefore, training treatment should be instituted at
that time. Mental clinics should be established in connection
with our public schools where each pupil might be considered as
a probationary pupil ; where this type of child would be detected
and corrective measures applied at the time the mental con-
flicts were first shown. Dr. Clark suggested, for those incapable
of making the normal grade of social adaptation, a series of
ethical community groups, something on the plan of the George
New York Academy of Medicine — Section on Pediatrics 627
Junior Republic, of institutions providing the community environ-
ment and ethical training needed for character building, and
urged the need of education for the general public as to the
nature of these social defects.
Discussion — Dr. Bernard Glueck said he had misunderstood
the real purpose of the evening's discussion. He did not know
that Dr. Clark w^as going to confine himself to the consideration
of that fairly well defined class of the constitutionally inferior.
He agreed in the main with Dr. Clark as to the care of these
patients and thought there was need in the management of some
of them for an institution such as Dr. Clark had outlined. He
had been utilizing the George Junior Republic for this purpose.
However, he had in mind in thinking over the subject none of
the clearly defined socially maladjusted but rather those less
clearly understood and medically not wholly definable indi-
viduals concerning whose management we are not justified to
speak with such definiteness. The treatment of these individuals
is still in an experimental stage and progress rests in the main
upon a better understanding of those environmental factors
which contribute so largely to their social maladjustment. A
fuller realization of the tremendous role, which environmental
contacts and influence play in shaping of character and person-
ality and in determining conduct, empasizes the constant neces-
sity in the management of the socially maladjusted of treating
other members of the family besides the individuals directly con-
cerned. Even progressive psychiatry leans altogether too far in
the direction of a fixed static concept of the personality, and dif-
ficult and hampering traits and characteristics are assumed to be,
without much warrant, inborn fixed attributes which predeter-
mine conduct. The case for this assumption is not very strong
since we have constant proof of the fluidity and changeability of
human characteristics and traits. Social treatment, therefore,
embraces as a first step a clearer recognition of the importance
of the social setting and the social heritage in shaping character
and in conditioning conduct. The socially maladjusted, far from
being entirely definable on the basis of innate characteristics alone
will continue to constitute the most difficult problem that psychi-
atry has to deal with until we learn to estimate more accurately
social values. Psychiatry in stressing the concept of man as a
628 New York Academy of Medicine — Section on Pediatrics
biological unit has ignored altogether too freely man as a social
being. One of the most commonly met with manifestations in
the socially maladjusted is a feeling of inferiority and a sense
of having lost the esteem of one's fellow beings which renders
adequate social adaptation, if not impossible, certainly very dif-
ficult. Now a medical approach in the strict sense of the term
can do very little where the individual must be led by means of
social measures such as education, appropriate outlets in hib
work and play life, cultivation of fellowship, etc., to either a
rational acceptance of his inferiority, if such actually exists, or
to an overcoming of it, if that is possible, through the cultivation
of such assets as he does possess and through obtaining a grati-
fying sense of personal worth. Man in his craving for self-
expression and self-realization endeavors to break through "the
western front" along some sector and it is the object of social
treatment to help him discover the sector appropriate to his
needs and capacities and to make victory possible. Many of the
socially maladjusted owe their difficulties to a too pronounced
discrepancy between personal equipment and aspirations, and
while this often constitutes the bridge that makes progress pos-
sible it frequently means ruin to the personality if the discrep-
ancy is too wide or the environmental obstacles too serious. It
is another important task of social treatment to help man find
his proper niche in the scheme of life. A medical approach will
continue to be relatively impotent in the management of the
problems of social maladjustment until it recognizes fully the
value of the social approach both in the diagnosis and treatment
of these cases.
SEX CONFLICT IN ADOLESCENTS.
Dr. C. O. Cheney said that Dr. Clark's discussion demon-
strated the value of detailed individual case study of the socially
maladjusted, and emphasized the importance of mental conflicts as
causes of social difficulty. The individual, who had no conflicts
in his inner life, had no conflict with society and went along the
even tenor of his way, meeting and reacting to situations in life
in ways that were best for himself and others. Poor adjustment
to society, as shown in bad behavior or misconduct, was the out-
ward manifestation of internal maladjustment or mental con-
flict. There were no doubt many causes for mental conflict, but
New York Academy of Medicine — Section on Pediatrics 629
one of the most frequent and important causes was the diffi-
culty of adjustment in the sex life, and it was these sex conflicts
and their manifestations that he wished to touch upon here.
There was a universal and strong inner force demanding the sat-
isfaction of the sex instinct, but there was likewise an almost
universal and strong repressing force exerted by society against
this satisfaction, particularly in children and adolescents. This
situation was thus an almost perfect one for the formation of a
conflict. The curiosity and desire for knowledge of the child
were heightened in the adolescent who began to experience the
physiological yearnings and feelings. Some individuals, feeling
no restraint by bringing up or envoronment, proceeded to satisfy
their desires freely in a way that was looked at askance by soci-
ety, but which, however, freed them from any actual inner sexual
difficulty. Other adolescents, perhaps under the understanding
direction of their elders, receive an outlet for their sexually
aroused emotion in healthy social activities, sports, or amuse-
ments. Another form of outlet, perhaps less healthy, was exem-
plified in the "crushes" of girls for each other and the admira-
tion and infatuation for matinee idols. With these young people,
as well as with those who gratified themselves sexually in their
own persons but have other outlets for their emotions, there
might be little or no mental conflict in adjusting their sexual life.
That, however, this substitution for sexual activity might assume
a pernicious aspect has been admirably shown by Healy in his
"Mental Conflicts and Misconduct." In his presentation it was
brought out that instances of stealing, truancy, vagrancy, run-
ning away from home, mischief making, and cruelty might be
the outlets for emotion that had been previously aroused by sex-
ual feelings, or by the acquirement of sexual knowledge. These
young people tried to force these feelings and knowledge out oc
their minds, but as the ideas recur, to the discomfort of the
sufTerers, there resulted emotional states leading to misconduct ;
this misconduct might be of an impulsive, uncontrollable nature
and not understood by the individuals until analyzed. Finding
of the trouble, removing the conflict and aiding in the prevention
of its recurrence by change of associates or environment result
in cessation of the misconduct if the latter had not become a
fixed habit. This study of Healy, which could be only so briefly
mentioned here was extremely illurninating as to the bearing of
630 Nezv York Academy of Medicine — Section on Pediatrics
the sexual conflict upon delinquency, and was strongly stimulat-
ing for further studies along the same line.
More familiar to most of us as peculiar manifestations of
adolescence were the restlessness, general dissatisfaction with
things, irritability, moroseness, shyness, increased religious
activity, or interest in socialism, philosophy, or new thought.
There was good reason to believe that these were very often
merely symptoms of the sex conflict and mental uneasiness, with
an attempt at some form of satisfaction and adjustment. We had
no means of knowing in how many instances these attempts at
adjustment were satisfactory and the individual freed from con-
flict. As so far as he knew there were no studies made on those
who do not come under special care of observation for their
difficulties. Those who were continually in contact with malad-
justed persons in mental clinics and hospitals did know, how-
ever, that there were many adolescents who either had much
difficulty in handling their sex conflicts, or who, never making an
adjustment, needed care throughout their lives. They were
those types who, finding an outlet only in their own bodies, with
the presentation of various physical complaints, make up the
psychoneurotics or who, living in sexual phantasy, day-dreaming,
and unreality, showed the symptoms of what was called dementia
precox. "Of what concern was all this to pediatricians?" This
could be answered by saying that those in the mental hospitals
saw the late or end stages of sexual maladjustment, when the
habit from conflict had become fixed ; that in these stages they
found from trial that often attempts at helping adjustment were
fruitless ; that the time for help was best afforded in childhood
and adolescence, and that, as the physicians of these young people,
we might be of immense help to them. The question might be
asked: "What was to be done?" To this certain suggestions
might be offered based upon their frequent experience with what
had not been done.
In the first place parents should be disabused of the smug
idea that sex was not to be mentioned or thought of until mar-
riage and shown that it was natural for children and boys and
girls to have curiosity about their own bodies and how they came
to be in the world; that evidence of this curiosity should not be
met with the reproof that it was bad or naughty, but should be
met in a frank, straightforward way by explanation. If this
New York Academy of Medicine — Section on Pediatrics 631
practice of honesty was carried out there would, he thought, be
less of the antagonism, contempt, or hatred of parents by the
grown children when the latter found they hadn't been played
fair with.
And when children or adolescent patients were brought to the
physician with the report that they were nervous or cranky or
disobedient, or were otherwise showing they were not happy in
their lives, he believed it would pay to get their confidence, go
into their worries and conflicts, advise them and their parents
and, if it seemed best, change their environment. The older
adolescent persons would benefit by some advice about their
sexual physiology and be saved from resorting to quacks who
would terrify them with horrible tales of the results of sexual
self-satisfaction — the tales that we read about and heard from
our patients. Attempts to repress and stop an unhealthy sex
habit would result only in more conflict if nothing of healthy
activity or interest was given the adolescent. Each case was an
individual study and he believed that such study and treatment
of conflicts and behavior would not only promote mental health
in children coming under their care, but would be a source of
satisfaction to the physicians.
THE INFERIORITY COMPLEX IN CHILDHOOD.
Miss Edith R. Spaulding said that in the reconstruction
which was necessary in the lives of the children with whom she
had come in contact, the feeling of inferiority from which they
suffered seemed to be one of the most important points of attack.
She cited 2 cases which she was seeing at the present time, in
which this factor was an exceedingly important one. The first
case was that of a boy 7 years of age with a neurotic family
history, in which however there was no definite mental disease
in spite of a breech birth 34 hours in duration. He appeared
healthy and well nourished until 2 years of age, when he had a
fall, landing on the top of his head. At the age of 1 year he
had pneumonia, at which time he had a convulsion. At the age
of 53^ years he had whooping cough and what was apparently
a second convulsion ; his eyes dilated, he fell and became uncon-
scious. Since that time he had continued to have convulsive at-
tacks in which he threw up his arms, rolled his eyes up, and
gasped; sometimes he had fallen. These attacks were some-
632 Neiv York Academy of Medicine — Section on Pediatrics
times very slight, but were thought to have occurred 30 to 40
times a day. He also had what were termed "silent times" when
he said little for 3 or 4 days. The attacks came on when he was
disappointed, and it was thought he enjoyed working himself
up to the point where he was sure to have an attack. The inter-
esting thing was the way in which the condition the physicians
and neurologists who had seen him agreed was minor epilepsy
responded to the treatment of his feeling of inferiority. This
treatment consisted in finding constructive interests for him, in
treating him as a healthy boy rather than as a weakling and
expecting from him the behavior of a manly boy rather than
that of an infant. The bromide and thyroid treatment that he
had been having was temporarily discontinued. From having
attacks almost incessantly under the former treatment, he soon
began to have only 13 a day, and 2 weeks later only 3 daily.
While it was still an effort for him to undertake anything new,
because of his great fear of being unable to do it, when it was
actually accomplished he positively strutted with pride. There
was little danger of his having an attack at such times.
The mental tests of this boy showed his mental age to be
*but 6 months below his chronological age. His failure to do
certain tests appeared to be due to lack of training, since his
native ability and learning ability were both good. His compre-
hension was unusually good, while his difficulty appeared to be
in his power of attention, his concentration and his muscular
coordination. He had a sister 2 years younger than himself
who had a spontaneous personality and was very brilliant and of
whom he was jealous. Gradually the attitude of the family had
been to treat him as an invalid and as an inferior mentally. The
marked change that took place in the personality of this boy in
3 weeks, away from his home environment, where he had an
opportunity to develop his individuality, was quite startling.
The second case which the speaker described was that of a
boy 10 years of age, who disliked to play with other boys because
he realized that he was unable to do well in sports and come up
to the mark in physical activities. It was. this fundamental feel-
ing of inferiority, based perhaps on a slight cardiac condition,
together with an over-solicitous mother, that was the basis of his
maladjustment. In trying to compensate for his lack of popu-
larity among the boys, he had played very much by himself, or
New York Academy of Medicine — Section on Pediatrics 63^
with a single friend. If encouraged to play with other boys in
a group he said he disliked to do so, because he had to tollow
out their plans, as they were not always willing to follow his.
But if he played with only one he at least stood a good chance
of his plans being carried out half the time, and probably more
than that. Furthermore, if he was forced to play with a group
of boys part of the time he wanted at least 2 hours a day in
which he could play by himself. He said "I like to talk things
over with myself and I always feel happy in my own company."
This boy was at the present time trying to compensate for his
failure to make good in the school world by retiring into a world
of his own phantasy. He had a sex habit which he commenced
at the age of 2 and stopped at the age of 6 years. He said that
after he went to bed at night he enjoyed thinking of a very beau-
tiful woman whose face was always a blank, but whose form
seemed the composite picture of the beautiful women he had
known. Sometimes he was kneeling at her feet ; sometimes she
took him into her mouth, ate him up, and he was surprised to
find himself, after the process, alive and whole again. From
other conversation with him it seemed likely that this represented
an association with the question of pregnancy, which was ap-
parently actively present in his mind at the time, and more
specifically the facts of his own origin, and perhaps his interes'.
in the period in which he was a part of his mother. He said
that in some ways he did not wish to grow to be a man, he pre-
ferred to remain a baby. Asked why, he responded that if he
remained a baby he was much more sure of being loved than if
he grew up. And when asked by whom he wished to be loved.
he stated frankly, "My mother. I love to have her come to my
room at night and caress me." Incidentally, he felt that when
he grew up the accomplishments, which at his present age
appeared quite remarkable, would then be taken as a matter of
course. This, again, was too much for his egotism to face. In
addition, this boy had a fear of mirrors, which, when followed
up, appeared to result from a fear of thieves. This was not
because he feared they would rob him, though he was mercenary
in the extreme, but because he feared they might kill him. This
brought him to a discussion of death and immortality and he
freely stated that at the present time he beHeved there was a
God, but he was not wholly sure that he could accept a belief in
634 New York Academy of Medicine — Section on Pediatrics
immortality. There was, moreover, an interesting connecting
link between the suppression of his sex habit and his fear of
death, because of several things he had been told at the time it
stopped.
In both of these cases there were many elements and possible
points of attack for the process of re-education. The element to
be emphasized, however, was the feeling of inferiority, which in
both cases, in accordance with Adler's theories, appeared to be
based on an actual physical or nervous inferiority. It is this
weakest point that must be discovered and constructively built
up if the child's energy is to be turned into constructive and
socialized channels.
THE INSTITUTIONAL TREATMENT OF PSYCHOPATHIC INDIVIDUALS.
Dr. M. a. Harrington said that Dr. Clark had described
the kind of institution that was needed to care for this type of
patients and he would merely cite a few cases which would
show the necessity of institutional care in the treatment of these
individuals. The first case described was that of a boy who was
incapable of distinguishing between what was his and what
belonged to another person. He committed many thefts and
was finally taken to the police station and while there stole the
captain's gun. He was sent to the Children's Court and then to
Ward's Island, where he came under the speaker's care. He
seemed to be a model boy in other respects but could not keep
his fingers off of what did not belong to him. After a time the
people at the office said they would like to have the boy for a
page. They were told of his defect but said they would try him.
He was there but a short time when they asked that he be taken
away as he had acquired too many things that did not belong
to him. Among other things it was found that he had three
or four watches. Finally the boy was put in a shoe shop where
there was little or nothing to take and he got along beautifully
and worked well. If he had been left outside in the community
he would have become a burden to himself and to society, for he
was the kind of individual who made the criminal, but under
supervision he would get along all right.
The second case was quite different. This boy's trouble was
not misdirected energy but a lack of energy. He got along
pretty well in school, but when he went to work soon grew tired
New York Academy of Medicine — Section on Pediatrics 635
of it and gave it up. He held several positions with intervals
of idleness and finally gave up work altogether, became depressed
and was finally brought to the hospital. There the energy was
provided for him and he was set to work under steady pressure
and got along well. After a time his family thought he would get
along outside and he went out, but soon fell back into his old
habit of idleness. He was followed up and put into the
Y. M. C. A., but was not able to get on outside of the institution.
The third case was one illustrating, not misdirected energy,
or lack of energy, but poor control. When he started in he
worked hard all day, took work home and worked at night,
working 18 hours a day. He kept it up about 3 months, then
became fatigued, lost heart, and gave up the position, and sat
about, indifferent to everything. He was taken to an institution
and put in shape and when he got out he did the same thing
over again. At the hospital he was given work with regular
hours and his time regulated and he got along beautifully, but
as soon as he went out there would be trouble again. These
were 3 types of individual who needed institutional supervision.
SCHOOL CHILDREN WHO, THROUGH LACK OF EMOTIONAL
CONTROL, DEVELOP HABITS OF TRUANCY.
Miss Elizabeth E. Farrell disagreed with the proposition
that the maladjusted needed institutional care. She recalled that
it was not so very many years ago that she spoke of the mentally
defective and feeble-minded groups and she had stated that as
there was no one particular adjustment for the normal individual
so there could be no one particular adjustment for the feeble-
minded individual and this same statement held true of the mal-
adjusted. There could be no blanket system for the manage-
ment of the maladjusted or constitutionally inferior. As there
were personal idiosyncrasies, so education must be personal and
individual. This was the principle applied in the treatment of
physical ills and it was equally applicable in dealing with mental
conditions. The general idea was that this individual prescrib-
ing might be done in privdte schools, but it could not be done
in public schools. The private schools did not do any better in
individual training than the public schools. The point was that
education must be individual, that courses of study must not be
636 New York Academy of Medicine — Section on Pediatrics
iron-clad; they must be flexible. Provision should be made to
adapt the environment to the individual as well as to adjust the
individual to the environment. Miss Farrell cited 2 instances of
social maladjustment, the first of which was a boy who did well
in grammar school but became a confirmed truant when he got
into high school. The cause for this apparently complete change
of personality was studied and it was found that he did not
grasp ideas and abstractions ; he liked the practical and concrete
He entered a trade school which ofifered the environment to
which he could adjust, and got along well. The second case wa.s
that of a boy going through the elementary school who had
ability that he did not realize. He liked to draw but did
not get on well in the grades, and played truant. The question
came up whether he should be sent to the truancy school.
Finally it was decided to attempt to use his love for drawing as i
lever which ol^fered a chance for making an adjustment. The
boy went to public school on the morning and to the school of
design in the afternoon. His ability was such that it seemed he
should have this opportunity. There were many cases of that
kind where the adjustment could be made in the school, by a
change from public to private school or from private to public
school, etc. Frequently it was the environment that impinged
on the personality and it was our business to modify the environ-
ment. There were many ways of caring for the socially malad-
justed, but it could not be done by any cure-all, be it institutional
or extra-institutional. One way was by breaking down inflexible
barriers and by doing personal and individual teaching.
SOME MEDICAL ASPECTS OF CIIILDilOOD DELINQUENCY.
Dr. Sanger Brown, H, said one thing that must have
occurred to all while the speakers were discussing adult and child
delinquency was whether after all there was not something inher-
ent in the personality, either hereditary or constitutionally inherent,
which made for just these things. He had spent several years
with adult personalities such as were described and had thought
that in children he would find the same traits and qualities, but
he must say that he had been unable to find the same traits in
children as in adults. In speaking of static personality there
was much to be said of the development pf the personality in
the first 10 or 15 years of life. It developed from the situations
New York Academy of Medicine — SectioH on Pediatrics 637'
in which the child found himself and from the maladjustments
find mismanagements to which the child was subjected. All
these things went to form character and to make the personality.
Those things which were minor at first and perhaps open to
correction for the first few months, after they had continued for
years became traits of character and the emotional reactions
became established and formed the adult personality. This
pointed the definite indication for treating and modifying such
traits in childhood so that many could be saved from adult delin-
quency. In reviewing the causes of these maladjustments, per-
haps one-third were cases of minor neuroses and got into con-
flict with teachers who did not understand what the trouble was
and disciplined the child. The nervous child could not stand dis-
cipline and became a truant, got into bad company and started in
the wrong way. If such a child had a special aptitude it should
be found and the child given the opportunity to develop it, as
this might be the means of making a social adjustment.
Dr. Glueck said he would like more study of the physiological
•side of these cases. It might be of interest to those present to
know that at the Neurological Institute a plan was being outlined
for a Diagnostic Clinic for Adolescents, where cases showing vari-
ous maladjustments to life would receive thorough investigatior.
from every possible point of view — physiological, psychological,
mental and physical.
SOCIAL MALADJUSTMENT AS SEEN IN THE CHILDREN'S CLINIC IN
THE DEPARTMENT OF PSYCHOPATHOLOGY AT
CORNELL UNIVERSITY.
Dr. L. Blumgaut said that the Children's Clinic at Cornell was
started in 1917 in response to the need for such a clinic, so that
the State Charities Aid Association of New York and the public
schools would have a place to bring children for psychiatric advice.
The clinic was held one morning a week for just as many hours as
the psychiatrist and social worker could spare. The new cases
were limited to 2 a morning and the old patients, for whom ap-
pointments were made. Children were seen from 3 or 4 years
of age up to and through adolescence and in the course of their
experience children were met who had committed every anti-
social act possible except murder ; theft, arson, forgery, bad sex
638 New York Academy of Medicine — Section on Pediatrics
habits, etc., were not infrequent. As the work of this dinic be-
came known, other institutions sent children for advice. An
important aspect of the work was carried on by having a social
worker, and this side of the work should be emphasized. They
had a Smith graduate. One could not carry on this kind of work
without a social worker any more than he could practice medi-
cine without a stethoscope and a thermometer. The problems of
maladjustment were handled from both angles — the environment
or social background and the child itself. The child did not
come to the clinic until a complete history was obtained. The
history was taken by following an outline taken from Dr. Healy's
"The Individual Delinquent," slightly modified to meet the needs
of the clinic. In making the mental tests they followed the
Terman modification of the Binet-Simon Tests and such other
tests as Dr. Healy had suggested. These were used to bring
out certain quahties or show their absence. The child received
a physical and psychiatrical examination and such other examina-
tions as were indicated. The advice of the internist or special-
ist was available, if needed. The child was then interviewed,
likewise the parents. The case was then gone over in consulta-
tion with the social worker. In this clinic a large variety of con-
ditions were met with. They saw about 100 patients a year.
Dr. Blumgart related somewhat in detail the case of a high
school girl of 17 years of age, who was maladjusted both at
home and at school. She was finally advised to leave school, but
before leaving forged names in a Liberty Bond drive. An x-ray
examination showed a very small sella turcica. The social
worker had an interview with the mother and asked that she be
given medical treatment for a few weeks, as it was possible the
girl's behavior was not entirely due to moral obliquity. After
the girl had taken pituitrin for 2 weeks she decided to go to
business school, and she took up her music again. Her home
relations were readjusted satisfactorily. She completed a 9
months business course in 4 months, obtained a position and
taught beginners in music in the evenings. At one time the
pituitrin was discontinued and she began to relapse ; it was giyen
again and she recovered the lost ground. In another case cited,
separation frorri the family and supervision had served to adjust
the girl.
The problem of the psychoneurotic child was far beyond any
New York Academy of Medicine — Section on Pediatrics 639
conception most people had of it. One thing needed was investi-
gation to determine the exact number of maladjusted children.
Such an investigation would, he believed, confirm the findings
shown by intelligence tests in the army, that there were a very
much larger number of such individuals than we suspected. He
hoped it would be done soon. The environmental side must be
taken into account as much as the individual side.
Discussion — Dr. Foster Kennedy took issue with Dr. Pierce
Clark in regard to the statement that the greatest need of the
time was an institution for the care of the constitutionally inferior
and the socially maladjusted. Miss Farrell had taken Dr. Clark
to task for the statement and he wished to abet her effort. It
was not so much an institution that was needed as some kind of
education of the public which would prevent the production of
these people. It would seem that we doctors were usually asked
in consultation to assume a role identical with that which ought
to have been assumed by the parent, and often we were appealed
to on the ground that, because of their relationship to the patient,
their authority was handicapped from the beginning. He be-
lieved that, for the most part, we accepted the paradox of such
situations without comment and worse still without thought. Of
course, when the anti-social trends have developed, we were com-
compelled to comply with these demands and occasionally with
success. He could not help feeling, however, that as a profes-
sion we were not fully cognizant of the root causes of the grow-
ing number of the socially maladapted. As civilizations advance
there had been constantly felt a growing interference with the
family instinct by increasing rationalization and growing indi-
vidualism on the part of the child. This weakening of parental
authority occured through a loosening of the bonds of religion
— the social machinery for the transmission of traditional
thought — and, of course, among foreign-speaking people in a
new land, the parental authority was reduced to a minimum.
We didn't read enough history and if we did we were so busy
with our individual patients that we had not time to look thought-
fully at our world and do our share in its education. The im-
mense stability of China and its latent power lay in its ancestor
worship and the Greek and Roman world both dilapidated when
the potestas patris lost the authority of religion and of public
640 New York Academy of Medicine — Section on Pediatrics
opinion. The tremendous strength of the Hebrew race through
2,000 years of savage repression has lain mainly in their instinc-
tive patriarchy and reverence for tradition. The loss of these
fundamental instincts makes for ill-discipline in the family and
society and has not a little to do with sapping national strength
and with the production of these problems.
Dr. John T. MacCurdy said that as medicine was develop-
ing along the lines of prevention and as all who had spoken had
acknowledged that prevention was the most important factor in
dealing with the socially maladjusted, he wished to emphasize the
fact that the pediatrist met these cases first and had a great oppor-
tunity to advise and direct the parents so that defects in adjust-
ment could be corrected early in life. It was a joy to know that
a liaison was being established between the pediatrician and the
psychiatrist. The pediatrician saw' not only the glaring cases of
maladjustment, but he saw many of those who were mildly mal-
adjusted, and if he would call upon the psychiatrist, who, though
he could not boast great knowledge, still had a limited experience,
to examine these cases the course of their psychological develop-
ment might be modified.
Dr. Clark, in closing the discussion, agreed with Miss Far-
rell that there were certain types of mild maladjustment which
could be corrected in the ways she had suggested, and said it
was the more marked types that he had considered in his paper,
those in which more profound methods of approach were
needed.
Purulent Pleurisy in Young Children (Archives de Medi-
cine des Enfants, Paris, March, 1919). Bezy and F. Escande
explain the blunder in diagnosis in the 2 cases described as due
to the remarkable tolerance of the pleura and lung for several
months to the presence of and the pressure from the pus. The
negative results of puncture must have been due to the thick
consistency of the pus or to obstruction of the needle. The mis-
leading resonance in the space of Traube was explained by radio-
scopy showing an unusually large air bubble in the stomach. De-
viation of the heart and mediastinum is the most instructive find-
ing. The boy of 3 was given operative treatment for a supposed
osteitic process in the ribs. Radiography may be the only means
to detect these latent pleurisies. — Journal A. M. A.
Archives of Pediatrics
NOVEMBER, 1920
HAROLD RUCKMAN MIXSELL, A.B.. M.D., Editor
CHARLES ALBERT LANG, M.B.. M.R.CS., Associate Editor
COLLABORATORS :
L. Emmett Holt. M.D New York Fritz B. Talbot, M.D Boston
W. P. NoRTHRUP, M.D New York Maynard Ladd, M.D Boston
Augustus CAiLLfi, M.D New York Charles Hunter Dunn, M.D. .. .Boston
Henry D. Chapin, M.D New York Henry I. Bowditch, M.D Boston
Francis Huber, M.D New York Richard M. Smith, M.D Boston
Henry Koplik, M.D New York L. R. De Buys. M.D New Orleans
Rowland G. Freeman, M.D... .New York Robert A. Strong, M.D New Orleans
Walter Lester Carr, M.D... New York S. S. Adams, M.D .Washington
C. G. Kerley. M.D New York B. K. Rachford, M.D Cincinnati
L. E. La F£tra, M.D New York Henry J. Gerstenberger, M.D. .Cleveland
Royal Storrs Haynes, M.D... New York Borden S. Veeder, M.D St. Louis
Oscar M. Schloss, M.D New York William P. Lucas, M.D... San Francisco
Herbert B. Wilcox, M.D New York R. Langley Porter, M.D..San Francisco
Charles Herrman, M.D New York E. C. Fleischner, M.D San Francisco
Edwin E. Graham, M.D Philadelphia Frederick W. Schlutz, M.D.Minneapolis
}. P. Crozer Griffith, M.D.Philadelphia Julius P. Sedgwick, M.D. • .Minneapolis
. C. GiTTiNGS, M.D Philadelphia Edmund Cautley, M.D London
A. Graeme Mitchell, M.D. .Philadelphia G. A. Sutherland, M.D London
Charles A. Fife, M.D Philadelphia J. D. Rolleston, M.D London
H. C. Carpenter, M.D Philadelphia J. W. Ballantyne, M.D Edinburgh
Henry F. Helmholz, M.D Chicago Tames Carmichael, M.D Edinburgh
I. A. Abt. M.D Chicago John Thomson, M.D Edinburgh
A. D. Blackader, M.D Montreal G. A. Wright, M.D Manchester
PUBLISHED MONTHLY BY E. B. TREAT & CO., 45 EAST 17tH STREET, NEW YORK.
ORIGINAL COMMUNICATIONS
A METHOD OF DETERMINING THE APPROPRIATE
DOSE OF TUBERCULIN FOR THE
INDIVIDUAL TUBERCULOUS CHILD*
By Myer Solis-Cohen, M.D.,
Philadelphia.
The therapeutic administration of tuberculin, which not so
long ago was lauded in medical journals and at scientific meet-
ings, has of late become unpopular. It has been abandoned by
many leading phthisiotherapists who once were wont to enthuse
over it and to testify as to its brilliant results. This change in
attitude is doubtless due to the fact that even in the most expert
hands tuberculin often has been productive of distinct harm, and
still more frequently has failed to be of any benefit. The fault
•Read before the Philadelphia Pediatric Society, March 9, 1920.
641
642 SoLis-CoHEN : The Appropriate Dose of Tuberculin
in both instances may be attributable, it seems to me, not so
much to the tubercuHn itself as to the common method of em-
ploying it.
The Cause of the Harmful Effects of Tuberculin. — The harm
comes from the production of what I have termed an unfavorable
reaction,^ which is produced by administering a dose too large
for the individual patient. On the other hand, failure to cause
improvement is due, I believe, to the giving of a dose too small
for the individual patient.
In the course of some studies I made on hypersensitiveness
to tuberculin^ I found that patients with apparently the same
type and degree of tuberculosis differ greatly in their hyper-
sensitiveness to tuberculin, one reacting to one hundred-millionth
of the amount necessary to produce a reaction in another.
The usual method of administering tuberculin is to give to
each patient the same initial dose, which in the days of its popu-
larity was as a rule one ten-thousandth of a milligrami. This
dose would naturally produce an unfavorable reaction in a patient
hypersensitive to smaller doses. Such a danger can be avoided,
as I have previously pointed out^, by beginning with a very
minute initial dose, such as one-millionth of a milligram, and
increasing the dose gradually* until it produces what I have
termed a favorable reaction^ ; and holding this dose until it loses
its beneficial efifect, whereupon it may again be similarly gradually
increased. Upon the appearance, however, of any symptom of
an unfavorable reaction, the dose must be reduced.
Possible Cause of Failure of Tuberculin to Beneiit. — A pos-
sible cause of failure to improve under tuberculin treatment was
suggested by some observations I made in studying the relation-
ship between tuberculin hypersensitiveness, as determined by
intracutaneous tests, and tuberculin tolerance, as estimated clini-
cally in the same patients^. In patients who were improving
under tuberculin treatment, and especially those that were react-
ing favorably to the dose given, the amount of tuberculin neces-
sary to produce a reaction when injected intracutaneously usually
corresponded fairly closely with the amount the patient was tak-
ing therapeutically, whether by m|OUth or subcutaneously. The
converse naturally seemed reasonable, namely, that the appro-
priate therapeutic dose of tuberculin is probably the dose that
produces the minimal reaction when injected intracutaneously.
SoLis-CoiiEN : The Appropriate Dose of Tuberculin 643
Further studies and experiments have tended to bear out this
view and at the present time I do not hesitate to give as an initial
therapeutic dose, orally or hypodermically, the exact amount of
tuberculin required to produce a minimjal reaction when ad-
ministered intracutaneously, whether this amount be one-mil-
lionth or one-hundredth of a milligram. A circumstance lending
support to this view is the fact that in my hands a dose thus
administered has never produced an unfavorable reaction. Yet
in my former method of administering tuberculin I have seen
hemoptysis follow each oral administration of one-millionth of
a milligram over a considerable period of time and have observed
unfavorable reactions from even smaller doses'^. If therefore
tuberculin hypersensitiveness corresponds with tuberculin tol-
erance, as my studies would seem to indicate, the latter will
vary as much as the former. Consequently in the usual method
of giving tuberculin, and especially in my former method of
administering a very minute initial dose, the dose given is
frequently too small for the patient receiving it. In such in-
stances it should not be surprising if tuberculin treatment proves
a failure.
Success in tuberculin treatment in my opinion can be ex-
pected only when the individual patient is given his appropriate
dose, whether by chance, accident, in the course of systematic
gradual increases, or by first determining this dose by intracu-
taneous tests. Unless there is some reliable method of determin-
ing the appropriate dose for the individual patient, tuberculin
therapy cannot be regarded as being on a rational basis, or even
as being safe.
Such a method has been attempted by White, Graham and von
Norman, ^, ^, ^ who make a cutaneous or von Pirquet test with
one-tenth of a milligram of old tuberculin (O. T.) (never with
T. R.) and reduce or increase this amount until they produce
a minimal cutaneous reaction, namely one that gives redness and
swelling measuring 4 to 6 millimeters in diameter within 72
hours. They then inject intracutaneously the exact amount that
produced the minimal reaction every 2 weeks for a period of 3
months; after which they make another test. The average dose
they gave was one-tenth of a milligram. Most of their work
was confined to afebrile patients.
While these writers seem to obtain good results with this
644 SoLis-CoHEN : The Appropriate Dose of Tuberculin
method, few have been able to confirm them. Their method
presents a number of difficulties and sources of error. The
cutaneous or von Pirquet test is not generally regarded as re-
liable for quantitative work. Not only does the amount of tuber-
culin that is absorbed from a drop placed upon a scarified surface
naturally vary; but it is almost impossible to always obtain the
same depth in the scarification. I cannot feel that the cutaneous
test is a fair measure of the patient's hypersensitiveness to tuber-
culin, inasmuch as in their cutaneous tests the amount pro-
ducing a minimal reaction varied so little (at the most an hun-
dred times) and remained uniform over long periods of time
(as a rule 9 months) during treatment; while in my investiga-
tion the recognizedly reliable intracutaneous tests showed such
wide variations and hypersensitiveness diminished so uniformly
during the treatment. White and von Norman admit that their
test is not a correct index for determining a subcutaneous or
intramuscular dose and they have never used it for determining
the dose by mouth. A fact that makes me question whether
tuberculin hypersensitiveness or tolerance can be correctly
measured by skin tests is that no harm seems to be produced by
the one milligram generally employed for the diagnostic von
Pirquet test, while in my hands one ten-thousandth of that amount
has caused a violent reaction when injected intracutaneously-. By
testing for hypersensitiveness at intervals over long periods of
time, I have apparently been able to demonstrate that tuberculin
hypersensitiveness and tuberculin tolerance both diminish as a
patient improves, and especially as he improves under tuberculin
treatment with doses determined as appropriate for the individual
patient^. Consequently I am not impressed with a method that
gives the same dose over a period of 3 months, especially as in
the cases just mentioned I have obtained best results by increas-
ing the dose corresponding to the decrease in hypersensitiveness,
sometimes very rapidly.
Author's Method of Determining the Appropriate Dose. — In
order to determine the appropriate dose of tuberculin for the in-
dividual patient, I first make the following test for tuberculin
hypersensitiveness : Intracutaneously in a patient's forearm at the
samie time one ten-millionth of a milligram is injected distally,
one millionth of a milligram medially, and one hundred-thous-
andth of a milligram proximally, the injections being made in a
SoLis-CoHEN : The Appropriate Dose of Tuberculin 645
diagonal line. By this technique the same lymph channels are
avoided and there is less chance of having the lymphatics carry
tuberculin from the larger injections to the smaller. Twenty-four
and forty-eight hours after the injections are made, their sites
are examined for the presence of a papule or of induration, either
of which is regarded as evidence of a reaction. If no reaction
occurs, one ten-thousandth, one thousandth, and one hundredth
of a milligram are later injected similarly in the other arm, the
smallest dose being distal and the largest dose proximal. If still
no reaction occurs, one tenth of a milligram and one milligram
are then injected and, if necessary, at a still later time 10 milli-
grams.
The smallest dose that produces a distinct reaction I adminis-
ter therapeutically either by mouth or subcutaneously. The initial
dose so determined has never in my hands produced an unfavor-
able reaction, although in some cases it has been as large as one
hundredth of a milligram. If this dose produces a favorable re-
action, such as increase of appetite, reduction of temperature,
a general feeling of improvement, etc., it is repeated every 3 or 5
days until it loses its effect, whereupon it is gradually increased
until it again produces a favorable reaction. If it seems to pro-
duce no effect at all, I still repeat it for several weeks and then
increase it. Should any dose produce an unfavorable reaction,
such as rise of temperature, anorexia, malaise, etc., it is reduced.
At intervals, tests for hypersensitiveness are again made by in-
jecting intracutaneously in the forearm the dose the patient is
taking and doses one-tenth of and 10 times this amount. If no
reaction occurs from any of these, I inject intracutaneously one
hundred times, one thousand times, and ten thousand times the
amount the patient is taking. If the amount producing the intra-
cutaneous reaction is greater than the amount being given thera-
peutically, the latter is increased rapidly until it corresponds with
the former. I have increased from one-thousandth to one-tenth
of a milligram in 4 doses and from one hundred-thousandth to
one thousandth of a milligram in the course of a few days without
producing any unfavorable reaction.
My usual rate of general increase is about 50 per cent, accord-
ing to the following scheme: 1, 1, 5, 2, 3, 5, 7, 10, 15, 20, 30, etc.
Sometimes I double the dose and occasionally, when it has been
646 SoLis-CoHEN : The Appropriate Dose of Tuberculin
found to be much below the dose producing a minimal reaction
when injected intracutaneously, I increase it ten-fold.
This method of administering tubercuHn I have employed
mostly in children. The form of tuberculin given was tuberculin
Riickstand (T.R.), because in an experience with various forms
of tuberculins, sera and vaccines'' extending over a number of
years, I have obtained best results with this form. I have not
found that it makes much difference whether the tuberculin is
administered by mouth or subcutaneously. Both favorable and
unfavorable reactions have followed the former and I have fre-
quently substituted hypodermic administration for oral and vice
versa during a course of treatment without ever producing any
change in effect or reaction.
I seldom or never give tuberculin to patients who are doing
well without it. In the first place, it seems unwise to interfere
in such cases, especially as the indications are that the patient
is manufacturing the proper amount of anti-bodies and there is a
possibility that an additional stimulus miay disturb the balance.
In the second place, I do not feel competent to judge the effect or
the value of tuberculin in a patient who is already improving
without it.
Report of Cases. — The method of studying the value of
tuberculin by comparing a group of patients taking it with an-
other similar group not taking it, I regard as faulty. The group
taking it as a rule undoubtedly includes some who are taking too
much or too little; while the fact that some of the other group
improve does not signify that they might not have improved
still more with their appropriate dose of tuberculin. A much
better method in my opinion is the intensive study of individual
patients under tuberculin treatment, comparing their condition
before and after the administration of tuberculin. The grouping
of a number of patients so studied and their analysis to my mind
gives more valuable information than does the more common
method.
In this paper I desire to report 19 cases in which tuberculin
was administered to children in doses determined by intracu-
taneous tests — a small number, it is true, but one possibly suf-
ficient to illustrate some of the points referred to.
There were 8 boys and 11 girls, all patients at the Eagleville
Sanatarium, at Eagleville, Pa. One was 6 years of age, 3 were
SoLis-CoHEN : The Appropriate Dose of Tuberculin 647
7 years old, six, 8 years, three, 9 years, two, 10 years, two, 11
years, one, 12 years, and one, 14 years old. Seventeen were in the
first stage of the disease according to the classification of the
National Association for the Study and Prevention of Tubercu-
losis, and 2, in the second stage. Seventeen were in Turban's
first class and 2 were in his second class.
The initial dose varied from one hundred-millionth to one
hundredth of a milligram, being one hundred-milHonth of a milli-
gram by mouth in 1 case, one millionth of a milligram by mouth
in 1 case, one hundred-thousandth of a milligram in 12 cases — 6
by mouth and 6 hypodermically, one ten-thousandth of a milli-
gram by mouth in 3 cases, and one hundredth of a milligram by
mouth in 2 cases.
In 8 patients the initial dose was the exact dose that produced
the minimal intracutaneous reaction — one hundred-thousandth
of a milligram in 5 and one ten-thousandth of a milligram in 3.
In 9 cases I gave an initial dose smaller than that producing the
minimal intracutaneous reaction. Before experience gave me
confidence, I at first feared to give so large a dose, especially as
in some, during a previous course of tuberculin not guided by
the intracutaneous test, the dose had been a great deal smaller.
To 4 patients I gave as an initial dose one-tenth of the amount
producing the minimal reaction — one hundred-thousandth of a
milligram to 2, and one hundredth of a milligram to 2. In 3
instances I began with one hundredth of the dose producing the
minimal reaction — one hundred-thousandth of a milligram. That
same initial dose I gave to another, although it was one thousandth
of the amount that produced the minimal reaction. One patient
commenced with one ten-thousandth of the minimal test dose —
one hundred-millionth of a milligram. On the other hand, in 2
cases I risked beginning with 10 times the amount that produced
the minimal intracutaneous reaction — one hundred-thousandth
of a milligram in one and one millionth in the other.
The dose was increased in all but 2. Three patients, in whom
the dose by mouth had been increased until it was quite large,
were then given a smaller dose hypodermically, which was rapidly
increased. The dose was increased in one case 120,000 times in
7y2 months (from one hundred-thousandth of a milligram to one
and one-fifth milligrams by mouth) ; in one case 100,000 times
in 6 months (from one hundred-thousandth of a milligram to one
648 SoLis-CoHEN : The Appropriate Dose of Tuberculin
milligram by mouth) ; in one case 70,000 times in 11 months
(from one hundred-thousandth of a milligram by mouth to seven
tenths of a milligram hypodermically) ; in 3 cases 50,000 times
in 6 to 7 months (from one hundred-thousandth to six tenths of
a milligram by mouth) ; in one case 10,000 times in 7^ months
(from one hundred-thousandth to one tenth of a milligram by
mouth) ; in one 5,000 times in 2 months (from one hundred-
thousandth to one twentieth of a milligram by mouth) ; in one
2,500 times in 63^ months (from one hundred-thousandth to one
fortieth of a milligram by mouth) ; in one 1,000 times in 2^
months (from one hundred-thousandth of a milligram hypoder-
mically to one hundredth of a milligram by mouth) ; in 2 cases
500 times in 1^ and 4 months, respectively (from one thousandth
of a milligram hypodermically to one-half a milligram, adminis-
tered hypodermically in 1 case and by mouth in the other) ; in
1 case 300 times in 1^ months (from one hundred-millionth of a
milligram to three millionths of a milligram by mouth) ; in 1
case 160 times in 5^ months (from one hundredth of a milligram
to one and six-tenth milligrams by mouth) ; in 2 cases 100 times
in 17 days and 1 month, respectively, (in the former from one
thousandth to one-tenth of a milligram hypodermically and in
the latter from one ten-thousandth to one hundredth of a milligram
by mouth) ; in 2 cases 50 times in 24 days and 7 weeks respectively
(in the former from one millionth to one twenty-thousandth of
a milligram by mouth and in the latter from one hundred-thous-
andth to one two-thousandth of a milligram by mouth) ; in one
20 times in 18 days (from one hundred-thousandth to one five-
thousandth of a milligram by mouth) ; and in one case 10 times
in 13 days (from one hundredth to one-tenth of a milligram by
mouth).
Three patients had no intracutaneous tests made after the
treatment was begun. In 3 of the others the dose producing the
minimal cutaneous reaction at the last test made, corresponded
exactly with the dose being taken therapeutically at that time,
being one hundredth of a milligram in two and one-tenth of a
milligram in one. The dose being taken therapeutically was
smaller than that producing the minimal reaction at the last test
in 3 cases, being one hundredth of it (three millionths of a milli-
grami) in one case, one-third of it (three hundredths of a milli-
gram) in one case, and half of it (one two-thousandths of a
SoLis-CoHEN : The Appropriate Dose of Tuberculin 649
milligram) in one case. It was greater than the smallest reacting
test dose in 10 patients. In one it was twice as large, being one
fifth of a milligram. In 2 it was 5 times as large, being one
twenty-thousandth of a milligram in one and one-twentieth of a
milligram in the other. It was 10 times as large in 4, being one-
hundredth of a milligram in 3 and one-tenth of a milligram in 1.
In one case it was 30 times as large, being three hundredths of a
milligram; and in two it was fifty times as large, being half a
milligram.
No reaction of any kind followed the administration of tuber-
culin in 14 cases. In the other 5 most of the doses were not fol-
lowed by a reaction, but in four favorable reactions were noted
after some of the doses and in one an unfavorable reaction after
one dose.
The periods over which tuberculin was administered to these
19 patients varied from 1 to 21 months, being between 1 and 2
months in 2 cases, between 3 and 4 months in 1 case, between 4
and 5 months in 1 case, between 5 and 6 months in 2 cases, be-
tween 6 and 7 months in 1 case, between 7 and 8 months in 2
cases, between 8 and 9 months in 3 cases, between 9 and 10
months in 1 case, between 10 and 11 months in 1 case, between 14
and 15 months in 1 case, between 15 and 16 months in 1 case,
between 16 and 17 months in 2 cases, and between 21 and 22
months in 1 case.
There was improvement of the general condition in 11 pa-
tients during the tuberculin treatment, in 1 of these but slightly.
None became worse. There seemed to be no noticeable change
in 5. In 3 my notes are insufficient to permit of an opinion.
The temperature during the course of tuberculin treatment was
reduced in 13 cases, in 10 of them to the normal. It was in-
creased in 1 and unaflfected in 5.
The pulse was reduced in 4 patients during the course of
tuberculin treatment, to normal in 2. It was increased in 3 and
unaffected in 12.
Seventeen of the patients gained in weight during the tuber-
culin treatment and 2 remained the same. None lost. The gains
varied from 1 to 22 pounds. One gained between 1 and 2 pounds,
1 between 2 and 3 pounds, 2 between 3 and 4 pounds, 2 between
4 and 5 pounds, 1 between 5 and 6 pounds, 1 between 6 and 7
pounds, 1 between 8 and 9 pounds, 2 between 9 and 10 pounds,
650 SoLis-CoHEN : The Appropriate Dose of Tuberculin
1 between 10 and 11 pounds, 1 between 12 and 13 pounds, 1
between 14 and 15 pounds, 1 between 16 and 17 pounds, and 1
gained between 21 and 22 pounds.
SUMMARY
Failure of tuberculin treatment is probably due to inability
to determine the appropriate dose for the individual patient,
which may be one millionth of a milligram in one patient and
one-tenth of a milligram in another of apparently the same type,
owing to wide differences in tuberculin hypersensitiveness and
tuberculin tolerance. The usual method of giving all patients
practically the same initial dose does harm to those who should
take less and is ineffectual in those who require more. The cor-
respondence between tuberculin hypersensitiveness and tubercu-
lin tolerance suggests the determination of the therapeutic dose
for each patient as the amount of tuberculin that gives the minimal
reaction when injected in that patient intracutaneously. The suc-
cess of this method in children has been demonstrated in 19 cases
here reported, whose initial doses varied from one hundred-
millionth to one hundredth of a milligram and were increased 10
times to 120,000 times over periods of from one to twenty-one
months, practically without producing an unfavorable reaction
in any. A large proportion showed improvement in general con-
dition, reduction of temperature and gain in weight.
27 7 J Chestnut St.
BIBLOGRAPHY
1. Solis-Cohen, Myer: The Subjective and Objective Symptoms of Favorable and
Unfavorable 'Reactions to Tuberculin. Med. Record, 1914, vol. 86, p. 756.
2. Solis-Cohen, Myer: Hypersensitiveness to Tuberculin as Determined by Intra-
cutaneous Injection of Different Doses. Jour. Infect. Dis. 1917, vol. 20,
p. 233.
3. Solis-Cohen, Myer: The Use of a Very Minute Initial Dose in Tuberculin
Therapy. N.Y. Med. Jour., 1913, vol. 98, p. 268.
4. Solis-Cohen, Myer: The Determination of the Next Dose in Tuberculin Therapy.
Jour. A. M. A., 1914, vol. 63, p. 1386.
5. Solis-Cohen, Myer: The Apparent Toxicity of Infinitesimal Doses of Tuberculin in
Certain Cases of Pulmonary Tuberculosis. Interstate Med. Jour., 1914, vol.
21, p. 297.
6. White, W. C. & Graham, D. A. L. : A Quantitative Modification of the von
Pirquet Tuberculin Reaction and its Value in Diagnosis and Prognosis.
Jour. Med. Research, 1909, vol. 20, p. 347.
7. White, W. C. & von Norman, K. H. : An Individual Quantitative Basis for
Dosage in Tuberculin Treatment. Proc. Nat. Assoc, for Study and Prevent,
of Tuberculosis, 1910, vol. 6, p. 224.
8. White, W. C, Graham, D. A. L. & von Norman, K. H.: An Index to Tuber-
culin Treatment in Tuberculosis by the Minimal Cutaneous Reaction Method.
Jour. Med. Research, 1909, vol. 21, p. 225.
9. Solis-Cohen, Myer: A Comparative Study of the Therapeutic Effects of Various
Forms of Tuberculins, Vaccines and Sera in Pulmonary Tuberculosis in
Children. Arch, of Ped., 1918, vol. 35, p. 11.
EPIDEMIC ACID INTOXICATION
(Acidosis — Parke's Syndrome.)
By B. K. Rachford, M.D.,
Professor of Pediatrics, Medical Department of the University of Cincinnati.
This paper is merely a note on the treatment of epidemic acid
intoxication. No reference is here made to the etiology of this
condition, or to the voluminous and valuable contributions which
in the past few years have added so much to our knowledge of
the abnormal metabolism underlying this condition.^
I think that all pediatricians at the present time believe that
there is a rather definite and dangerous syndrome characterized
by intoxication with organic acids, which occurs not infrequently,
especially during the winter months, in epidemic form, and which
is most commonly seen between the ages of 1 and 3 years. It is
my opinion also that most writers believe that this syndrome
differs materially, in its etiology and treatment, from the so-called
cases of acidosis of the recurrent vomiting type, which occur in
older children, as well as from the so-called cases^of acidosis which
occur so frequenty in acute infectious diseases, diabetes, and
acute gastrointestinal disorders. Severe diarrheas, intestinal
intoxications, and gastric disturbances, which may produce
acetone and diacetic acid in the urine, are preeminently summer
complaints, while epidemic acid intoxication is comparatively in-
frequent during the summer months.
The syndrome of epidemic acid intoxication was very clearly
described by Thomas D. Parke^ and myself^ and since has been
very frequently described by other writers.
Symptomatology. — This syndrome commonly begins with
anorexia, nausea, and vomiting. The vomiting and extreme
nausea do not, however, commonly persist for more than 1 or 2
days, and not infrequently disappear within 12 or 24 hours. Dur-
ing this time, however, nausea and vomiting may be persistent
'In the Medical News, Oct. 25, 1902, in a paper entitled "Comparative Toxicity
of Ammonium Compounds." I discussed the subject of acid intoxications, in which
I suggested that the possible etiology of this symptom group might be due: 1. To
the loss of alkalies in the blood and tissues. 2. To the poisonous action produced by
the bases which carried the acids through the blood to their excretion by the kid-
neys. 3. To the direct poisonous action of the acids themselves. In later papers I
discussed the possibility of the symptom group being produced by a perverted liver
function caused by the acidosis.
2Thos. D. Parke, Jour. A. M. A., 1910, p. 991.
3B. K. Rachford, "Diseases of Children," 1912, p. 255.
651
652 Rachford: Epidemic Acid Intoxication
and severe. In many of these cases, after the second day the
stomach begins to retain food and medication, and continues to
do so throughout the course of the disease. In a few cases, how-
ever, the vomiting may persist to the end.
Almost coincident with the nausea and vomiting, the acetone
odor in the breath is noted, and the acetone bodies appear
in the urine. The acetone and diacetic acid in the urine very
rapidly increase in quantity, and in the fatal cases commonly per-
sist to the end. In a small majority of the fatal cases, towards the
close of the disease, the urine becomes scanty and acetone and
diacetic acid disappear.
The temperature in these cases is commonly above normal.
Some cases record very high temperatures reaching 105° and
106°. In other cases, even those which terminate fatally, the
fever, which is present from the onset of the syndrome, disappears
and the temperature may remain normal or subnormal to the end.
In the majority of cases there is, from the beginning, a rather
marked intestinal fermentation manifesting itself in diarrhea.
The discharges from the bowels are putrid in odor, and show
other evidences of putrid fermentation. The urines in these cases
show a marked excess of indican and indolacetic acid. The
diarrhea, however, like the nausea, vomiting, and fever, may vary
greatly in different cases. In some instances there is constipa-
tion, but even in these cases the discharges from the bowels, pro-
duced by a laxative, as a rule, are putrid in character, and contain
mucus, and the urine shows an excess of indican and indolacetic
acid. It is my belief that the gastrointestinal fermentation which
is commonly, but not always present in these cases, is a symptom
belonging to the syndrome and not the essential factor in pro-
ducing the acidosis. A rather fair percentage of these cases
occur in j>erfectly nourished, breast-fed infants under 1 year of
age, and many of these breast-fed babies quickly succumb to this
infection. If epidemic acid intoxication was simply one of the
symptom groups of intestinal intoxication, it would be much
more prevalent during the summer months, and would rarely
occur in breast-fed infants.
Labored and rapid breathing is present in the majority of the
cases, and is quite out of proportion to the elevation of tempera-
ture. This symptom is described by some writers as presenting
the appearance of air hunger.
Rachford: Epidemic Acid Intoxication 653
As the syndrome progresses, the child becomes more or less
apathetic and lethargic; the stupor gradually increases, until the
child fails to react to its surroundings and loses consciousness,
dying in a profound coma.
There is nothing characteristic about the pulse in this condi-
tion. It is rapid from the beginning, and in the cases that progress
to a fatal termination, the pulse may reach 150 or 200, and show
intermittency.
In many of these cases there is a marked rigidity with tendency
to retraction of the abdominal muscles, and not infrequently there
is rather marked rigidity and tenderness in the right hypochon-
drium in the region of the liver. The liver, in many of these cases,
is enlarged and extends 1 or 2 inches below the free margin of the
ribs. In a few cases bile was found in the urine, and the con-
junctivae and skin were slightly jaundiced.
Such, in brief, is the syndrome of epidemic acid intoxication.
This syndrome, which has been observed for many years in
comparatively limited epidemics, has been rather wide-spread
during the past winter, occurring in many cities of the United
States, and has been more severe in Cincinnati than ever before.
During one week I saw in consultation 7 fatal cases of this
disease.
Treatment. — My experience, during the past winter, has
convinced me that bicarbonate of soda in large doses is of no
value. All of the fatal cases which I saw had been given
bicarbonate of soda in large doses. In some of these cases the
urine became alkaline under the bicarbonate of soda treatment,
but the diacetic acid and acetone in the urine persisted.
After a rather wide experience in the treatment of this
syndrome, I not only became skeptical as to the value of bicar-
bonate of soda, but I gradually came to believe that in some of
these cases it probably had a deleterious effect, and I am still
of the opinion that bicarbonate of soda in large doses, given
intravenously and otherwise, may help to bring about a fatal
result.
Early in the epidemic I became so convinced that bicarbonate
of soda was of no value, that I gave up the use of it, and since
then I have been firmly convinced that I have gotten better
results without bicarbonate of soda than with it. I do not wish to
advance the theory that small doses of bicarbonate of soda in these
654 Rachford: Epidemic Acid Intoxication
cases are dangerous, but it is still an open question in my mind
as to whether small doses of bicarbonate of soda are of value in
the treatment of this condition. I wish simply here to register
my opinion, based upon clinical observations, that the generally
accepted opinion that large doses of bicarbonate of soda in these
cases is the all important method of treatment is fallacious.
The line of treatment which I finally adopted, and which I
believe gave me good results, is as follows : In the first place it is
most important to clear the intestinal canal as soon as possible.
To accomplish this the colon should be thoroughly irrigated with
physiological salt solution, and, as soon as the stomach can retain
medication, castor oil, milk of magnesia in good-sized doses, or
some other saline laxative should be given. Throughout the treat-
ment of this condition, cathartic medication should be repeated, if
necessary to clear the intestinal canal of mucus and fermenting
material.
I also believe that physiological salt solution given hypo-
dermically or intravenously is of great value in the treatment of
severe cases especially those where the exhaustion is great and
where fluids are not retained by the stomach.
Following the cathartic medication the Bulgarian bacillus in
some form should be given, and this should be continued in fair
sized doses until the child is convalescent.
The dietetic treatment in these cases is all important. In
beginning the treatment, when the anorexia is marked and the
stomach is irritable, it is important to let the stomach rest. Dur-
ing this period of the disease, when the stomach will not retain
food, glucose or dextrose solution should be given by the rectum,
and, in some instances it may be necessary to give these solutions
hypodermically or intravenously. But, in the great majority of
cases, by the second day it will be found possible to give certain
foods and medication by the mouth. Then the glucose solution
may be given by the mouth, and later a teaspoonful of one of the
thick malt extracts, preferably maltine, should be given every 4
hours, and as soon as possible, cereals, such as strained oatmeal
and barley, should be added to the diet. Cane sugar may be used
in sweetening the cereals. In many of these cases, before
beginning the use of cereals, Nestle's food and malted milk may
be given. These foods are readily retained by the stomach and
are most valuable in the treatment of this syndrome. They
Rachford: Epidemic Acid Intoxication 655
should be given as soon as possible and continued until the child
is convalescent. As early as possible orange juice should be
given in small quantities. If it is retained it is important it should
be given in larger quantities, diluted with sweetened water or
mixed with gelatine and continued throughout the course of the
disease. It is important that milk, fats and albuminous foods in
all forms should be omitted from the diet until the child is safely
convalescent.
The dietetic treatment as above outlined must necessarily vary
with the age and condition of the individual patient. Under this
treatment the diacetic acid and acetone in the urine should gradu-
ally diminish until they finally disappear and the urine becomes
normal.
The satisfactory way in which these cases progressed under
this treatment to a final recovery may have been a coincidence,
but my experience leads me to believe that if bicarbonate of soda
be dispensed with or given only in very small quantities, and the
above line of treatment followed, satisfactory results will be
obtained.
Skin Tuberculin Reaction in Children (Nourisson, Jan.,
1920). Germaine Mioche states that on the basis of experience
gathered during five years in Marfan's service, the following con-
clusions may be drawn as to the clinical value of the tuberculin
skin reaction : 1. It is the procedure of choice among the various
diagnostic methods in which local reactions to tuberculin play a
part. 2. Its diagnostic value is incontestable. 3. Starting with
zero in the newly born, the number of positive cutireactions in-
creases progressively with the age of the subject. 4. In children
under 1 year of age a positive reaction is a sure indication of pro-
gressing tuberculosis and usually of approaching death. In older
children it is not a reliable index of tuberculosis in evolution un-
less supported by clinical evidence; and in adults its diagnostic
value is practically zero. 5. As a method that will permit the ex-
amining physician to diagnose tuberculosis in infants it is incom-
parably better than all others, for by means of it he can recognize
the presence of the disease at its very onset and thus perhaps be
able to render some Service. — Journal A. M. A.
INTRAPERITONEAL ADMINISTRATION OF SODIUM
BICARBONATE SOLUTIONS* ■ — "
(Preliminary Report)
By J. W. Epstein, M.D.
Senior Assistant in Pediatrics, Mt. Sinai Hospital, Cleveland.
The problem that confronts the physician in cases of gas-
trointestinal disorders, where diarrhea and vomiting persist, re-
sulting in rapid losses of fluid from the body, is to find a quick
and efficacious method of replacing the lost fluids. Dehydration
of the tissues and the consequent loss of weight constitute the
most imminent dangers to the life of the child. The enormous
mortality rate resulting from these maladies is caused, not by the
toxins produced but by the rapid loss of fluid from the body,
and the correction of this condition is therefore of the utmost
importance.
The maintenance of a constant water concentration within the
body will not only relieve many symptoms that are of bad prog-
nostic import, but also may alter the entire course of the dis-
ease, and the outcome, as far as the life of the patient is con
cerned. The immediate restoration of the water balance of the
body will exercise its beneficial effects in the following ways :
1st. By enabling the organism to better utilize its reserve energy.
2nd. By dilution of the possibly toxic factors existing in the body.
3rd. By relieving the high concentration of the blood that results
from the persistent loss of fluids, i.e., by increasing blood
volume and blood flow.
4th. By its favorable effect on the temperature curve.
5th. By increasing the urinary output.
6th. By increasing the general comfort of the patient.
The administration of fluids by means of the normal channel
(the mouth), in the face of incessant vomiting, is difficult; tc
supply water per rectum by the "Murphy Drip" method, in the
presence of a profuse diarrhea, is impossible. We have, there-
fore, to search for other routes equally efficient.
A realization of the importance of a simple and successful
method for the parenteral administration of fluids has led to much
research work during the past few years in the effort to find
easily available and efficient parenteral routes, work that had been
attended with considerable success. Not only are parenteral routes
"From the Pediatric Department of Mt. Sinai Hospital, Cleveland.
656
Epstein : Sodium Bicarbonate Intraperitoneally 657
being used for the purpose of restoring fluids to the tissues, but
also to carry nutrition to the body as well as various medications.
The parenteral administration of fluids can be carried out in
the following 3 ways :
1st. Subcutaneously.
2nd. Intravenously.
3rd. Intraperitoneally.
The application of these methods in the gastrointestinal dis
orders of infancy and early childhood comprises :
(a) The administration of water in the form of normal saline
solution.
(b) Nourishment in the form of glucose.
(c) Medications, as sodium bicarbonate, to overcome symptoms
of acidosis.
The Subcutaneous Route is the route most commonly em-
ployed for the introduction of normal saline solution into the
body. Its simple technique, its comparative freedom from
danger, and the fact that it can be administered at frequent
intervals by the attending nurse, have made it the method ot
choice. A glucose solution of 5 per cent, strength can be given
subcutaneously in the same manner as saline. This can be given
in solution with normal saline or by itself, according to the indi-
cations present. Sodium bicarbonate can be given subcutaneously
in solutions of 2 to 4 per cent, strength. However, if the sodium
bicarbonate solution has been sterilized by heat, there is some
danger that necrosis of tissue will result, inasmuch as the process
of heating transforms some of the bicarbonate into the irritant car-
bonate. To minimize this danger Rowland and Marriott^ advise the
bubbling of carbon dioxide through the cold sodium bicarbonate
solution, to which a few drops of phenolphthalein have been
added, until it becomes colorless. With proper precautions the
solution may also be prepared by simply dissolving the sodium
bicarbonate in sterile water, since it has been proven that sodium
bicarbonate in bulk is sterile.
Results from the subcutaneous method may be disappointing,
however, owing to the fact that absorption from the subcutaneous
tissue is too slow to meet the emergency, especially in patient.^
that are in a moribund condition.
The Intravenous Method is undoubtedly the quickest and the
most efficient method of obtaining therapeutic results, since the
658 Epstein : Sodium Bicarbonate Intraperitoneally
solution is thrown directly into the circulation. In infants tlie
longitudinal sinus is more accessible for that purpose than any
other large vein because of its wide, incollapsible lumen and con-
stant position. Marfan, in 1898, was the first to administer
saline by way of the longitudinal sinus. Since then the sinus
has been used for the administration of glucose and sodium
bicarbonate as well as therapeutic agents, such as salvarsan,
diphtheria antitoxin and various sera. It is also used for obtain-
ing blood for chemical and bacteriological examination and for
transfusion in the hemorrhagic diseases of the new born. The
chief disadvantage of this method is that the quantity of the
solution used must be limited, in order not to throw a great bur-
den on the circulation. Also in older children where the fontanel
is closed, thus eliminating the route of the longitudinal sinus, the
intravenous method is next to impossible on account of the tech-
nical difficulties of entering the vein.
The Intraperitoneal Method consists in the injection of fluid
through a needle introduced into the peritoneal cavity. Surgeons
have long recognized the power of absorption possessed by the
peritoneum, and have made frequent use of it by introducing
large quantities of saline into the peritoneal cavity before closing
it, as a means of combating shock or serious loss of blood. How-
ever, they ventured to do so only when having the advantage of
an open peritoneal cavity before them; otherwise preference was
given to the subcutaneous or intravenous method.
The technique of thrusting a needle into the peritoneal cavity
and the direct injection of saline solution through it, is first re-
ported by Blackfan and Maxey^ in 1916, who also report that
this procedure has been used by Professor Garrod at St. Bar-
tholomew's Hospital, London. No other reference to this method
has been found in the literature. More accurate data regarding
the absorptive power of the peritoneum are furnished by Dandy
and Rountree^, of Baltimore. After injecting phenolsulpho-
nephthalein into the peritoneal cavity in order to determine the
route of absorption, they come to the following conclusions :
1st. There is very rapid absorption of fluids from the normal
peritoneal cavity.
2nd. The absorption is essentially by the blood stream and not
by the lymphatics.
Epstein : Sodium Bicarbonate Intraperitoneally 659
3rd. The time of appearance of the phenolsulphonephthalein in
the blood is from 2 to 4 minutes, and in the urine 4 to 6
minutes.
4th. The quantitative output in the urine is from 40 to 60 per
cent, in 1 hour.
Adler and Meltzer* have injected Prussian blue into the
peritoneal cavity of animals and they found that 30 per cent, of
the fluid was absorbed in 40 minutes, and that the Prussian blue
appeared in the urine in 30 minutes.
Shipley and Cunningham^, in their experiments on absorption
from the peritoneal cavity, come to the conclusion "that there is
very active absorption of foreign fluids through the peritoneal
blood vessels, not only through those in the omentum, but also
through those beneath the peritoneum of the gut and bladder.
Absorption of fluids takes place not only through capillaries but
through vessels of quite large caliber, and through arteries as
well as veins." Concerning damage to the omentum, they come
to the conclusion that there is none. This they demonstrated by
immersing the omentum in foreign fluids, the omentum showing
thereafter no exudation or hemorrhages and no signs of cellular
disturbances.
A. E. Hertzler*' says : ''Generally speaking, if the amount of
the fluid injected into the peritoneal cavity does not exceed 10
per cent, of the body weight, 30 per cent, of the fluid injected
will be absorbed in the first half hour, and at the end of 2 hours,
less than 30 per cent, will remain,"
Blackfan and Maxey^ relate the following: "In a moribund
patient 200 c.c. of saline was injected intraperitoneally. The
patient died 6 hours later. At the necropsy only 50 c.c. of the
solution was recovered."
The experiments and observations of the above mentioned
authors go to prove beyond doubt the remarkable absorptive
power possessed by the peritoneum. That the procedure of in-
traperitoneal injection of fluids is practically free from any
danger of puncturing the bowels or carrying infection into the
peritoneal cavity, my work with this method on animals, and on
a number of children in the pediatric ward of Mt. Sinai Hos-
pital has substantiated. It therefore seemed of interest to de-
termine whether the intraperitoneal route could not be used for
the administration of sodium bicarbonate in cases of acidosis as
660 Epstein : Sodium Bicarbonate Intraperitoneally
seen in infants mainly during the summer months, and with this
end in view, experiments with rabbits were begun by me in the
summer of 1918 and continued during the summer of 1919. The
uniformly successful results of these experiipents are shown by the
following protocol. The acidity or alkalinity of the urine was
determined by titration, either with decinormal NaOH or with
decinormal HCl, according to the reaction.
PROTOCOL.
Rabbit No. 1— Weight, 2,900 grams.
August 25, 1919. Given intraperitoneal injection of 85 c.c.
of 2 per cent, sodium bicarbonate solution through which CO_,
had been bubbled until the pink color of phenolphthalein disap-
peared. Urine passed 30 minutes after injection distinctly acid.
August 26, 10 A. M., 85 c.c. of the same solution injected.
Urine passed immediately after injection distinctly alkaline.
August 26, 2 P. M., 85 c.c. of the same solution injected.
Alkalinity of urine passed 14 hours after injection, 0.8 decinormal
HCl.
August 27, 10 A. M., 85 c.c. of the same solution injected
Urine passed immediately after injection alkaline, 1.1 decinormal
HCl. Urine passed 7 hours after injection acid, 0.1 decinormal
NaOH.
August 27, 6 P. M., 85 c.c. of the same solution injected.
Urine passed on the following morning alkaline, 0.3 decinormal
HCl.
August 28, 10 A. M. Animal killed. Autopsy performed by
Dr. Wahl. No evidence of infection at site of injection. Sub-
cutaneous tissue showed some edema with slight bluish discolor-
ation. Peritoneal surface smooth, moist and glistening. The
peritoneal fluid, although increased, did not exceed 20 c.c. in
amount; in character it was slightly turbid. Vessels of bladder
and intestine slightly injected, otherwise normal. A slight hema-
toma present in the left psoas muscle. Liver, heart, lungs,
adrenals, kidneys, and pancreas, normal. Urine in bladder acid,
0.3 decinormal NaOH. Cultures negative.
Conclusion. This rabbit received 5 intraperitoneal injections
in the short period of 3 days. The urine changed rapidly from a
distinctly acid reaction to an alkaline reaction. No abnormalities
were shown by the autopsy except a slight injury to the psoas
Epstein : Sodium Bicarbonate Intraperitoneally 661
muscle (due to the animal being insecurely held during an injec-
tion). The turbidity of the fluid was due to an increased cell
count, caused by the above mentioned irritation.
Rabbit No. 2— Weight, 2,500 grams.
August 27, 1919. Given intraperitoneal injection of 60 c.c. of
2 per cent, sodium bicarbonate solution, treated with COg in the
manner described above. Urine passed a few minutes after in-
jection acid, 0.1 decinormal NaOH. Urine passed 18 hours
after injection alkaline, 0.2 decinormal HCl.
August 28, 60 c.c. of the same solution injected. Urine passed
immediately after injection acid, 0.2 NaOH.
August 29, 60 c.c. of the same solution injected. Urine
passed immediately after the injection acid, 0.1 decinormal
NaOH.
August 30, 60 c.c. of the same solution injected. Urine
passed 1 hour later alkaline, 1.0 decinormal HCl. Urine passed
6 hours after injection alkaline, 0.5 decinormal HQ.
September 4. Rabbit had been entirely normal in behavior
and appearance. On this date animal killed. Autopsy com-
pletely negative.
Conclusion. This rabbit received 4 intraperitoneal injections
of a 2 per cent, sodium bicarbonate solution, 1 on each of 4 con-
secutive days. No ill eflfects followed and no signs of infection o';
irritation accompanied these experiments. The resulting alkalinity
of the urine was apparently maintained for a period of only 1
to 6 hours, the urine being again acid in reaction after 24 hours.
Rabbit iVo. 3— Weight, 2,600 grams.
August 26, 1919. Urine before experiment acid, 0.1 decinormal
NaOH.
August 27, 1919. Urine before experiment acid, 0.4 decinormal
NaOH.
August 27, 1919. Urine before experiment acid, 0.1 decinormal
NaOH.
August 28, 1919. Urine before experiment acid, 0.1 decinormal
NaOH.
August 28. Given intraperitoneal injection of 70 c.c. of a 2
per cent, sodium bicarbonate solution. Urine passed 1 hour later,
alkaline, 0.2 decinormal HCl.
August 29. 70 c.c. of the same solution injected. Urine
passed immediately after injection, 0.1 decinormal NaOH.
662 Epstein : Sodium Bicarbonate Intraperitoneally
August 30. Urine in the morning previous to the time of
making another injection, alkaHne, 0.4 decinormal HCl.
August 30. 70 c.c. of the same solution injected. Urine
passed 3 hours after injection acid, 0.4 decinormal NaOH. Urine
passed 5 hours after injection, alkaline, 0.4 decinormal HCl.
September 4. Animal sacrificed. Autopsy performed imme-
diately by Dr. Wahl, who made the following report: "On re-
moval of skin of abdomen there is no evidence of a peritoneal
puncture except a faintly congested area 2 cm. in length in left
lower quadrant. Slight ecchymosis below costal margin. Peri-
toneum smooth and glistening. Vessels of small intestine slightly
congested ; large intestine normal. No excess of fluid in the peri-
toneal cavity. A yellowish mass of tissue suggesting fat could
easily be stripped off the bladder, leaving a slightly granular sur-
face. Heart, lungs, spleen, kidneys, and adrenals, normal. Liver
normal except for a few white nodules that look like coccidiosis.
Cultures negative."
Conclusion: This animal received 3 intraperitoneal injections
of sodium bicarbonate solution, 1 on each of 3 consecutive days
with no ill efifects on its peritoneal cavity. The reaction of the
urine, which, as shown by titration on 4 successive days preceed-
ing the first intraperitoneal injection of bicarbonate solution, was
definitely acid, was changed to alkaline by the injection.
Rabbit No. .^.—Weight, 2,240 grams.
August 29, 1919. Given intraperitoneal injection of 75 c.c.
of 2 per cent, sodium bicarbonate prepared in the manner above
described. Urine passed immediately after injection alkaline, 0.1
decinormal NaCl. Urine passed 5 hours later alkaline, 0.4 deci-
normal HCl. Six hours later animal given another intraperi-
toneal injection of 75 c.c, of the same solution.
August 30. Urine at 8 A.M. alkaline, 0.3 decinormal HCl
75 c.c, of the same solution were then injected intraperitoneally.
Four hours later another 75 c.c. of the same solution were in-
jected. Three hours later another injection of the same amount
was made. Urine after the last injection was alkaline, 0.7 deci-
normal HCl. This animal was not killed but remained well and
lively during the following month, after which it was trans-
ferred for other experimental purposes.
Conclusion: This animal received 5 injections within a period
Epstein : Sodium Bicarbonate Intraperitoneally 663
of 36 hours, at intervals as short as 3 hours, with no bad results.
The urine again showed a constant increase in its alkalinity.
Rabbit No. 5. — Weight, 1.760 grams.
October 20, 1919. Given intraperitoneal injection of 100 c.c.
of a 2 per cent, solution of sodium bicarbonate sterilized under
pressure but not treated previously with CO,,.
October 21. 100 c.c. of the same solution injected.
October 22. 100 c.c. of the same solution injected,
October 23. 100 c.c. of the same solution injected.
October 24. 100 c.c. of the same solution injected.
October 26. Animal killed. Autopsy findings completely
negative.
Conclusion : This animal received 5 injections on consecutive
days of a sodium bicarbonate solution sterilized and not treated
with CO2 with no ill effects.
Rabbit No. 6. — Weight, not given.
October 21, 1919. Given intraperitoneal injection of 100 c.c.
of a 2 per cent, sodium bicarbonate solution sterilized under pres-
sure but not treated with CO2.
October 24. 100 c.c. of the same solution injected.
October 26. 100 c.c. of the same solution injected.
Animal remained well during observation of 1 month fol-
lowing.
Conclusion: As in the previous experiment on rabbit No. 5.
Rabbit No. 7.— Weight, 1,800 grams.
August 15, 1919. Given intraperitoneal injection of 75 c.c.
of a 5 per cent, solution of sodium bicarbonate sterilized by boil-
ing and treated afterwards with CO„.
August 16. 75 c.c. of the same solution injected.
August 17. 75 c.c. of the same solution injected.
August 18. 75 c.c. of the same solution injected.
August 19. 75 c.c. of the same solution injected.
August 20. 75 c.c. of the same solution injected.
August 21. 75 c.c. of the same solution injected,
August 24. 75 c.c. of the same solution injected,
August 25. Animal killed. Autopsy findings entirely
negative.
Conclusion: The injection of a sodium bicarbonate solution
664 Epstein : Sodium Bicarbonate Intraperitoneally
of even 5 per cent, strength into the peritoneal cavity produces no
bad effects.
Rabbit No. ^.—Weight, 1,900 grams.
August 17, 1919. Given intraperitoneal injection of 100 c.c.
of a 5 per cent, sodium bicarbonate solution sterilized by boiling
and treated afterwards with CQ2.
August 19. 100 c.c. of the same solution injected.
August 21. 100 c.c. of the same solution injected.
August 23. 100 c.c. of the same solution injected.
August 25. 100 c.c. of the same solution injected.
August 27. 100 c.c. of the same solution injected.
August 29. Animal killed. Autopsy findings negative. Cul-
tures negative.
Conclusion: The same as with Rabbit No. 7.
General Conclusions.
1st. The intraperitoneal route can be used for the adminis-
tration of sodium bicarbonate.
2nd. The results of the injections were the same whether
the solutions of sodium bicarbonate were treated with CO2 or
not.
3rd. A solution of sodium bicarbonate of a strength of 5
per cent, can be used, although it is probably advisable to use a
2 per cent, solution, which is isotonic with the blood.
Since the results of this work on the intraperitoneal injectior.
of sodium bicarbonate solutions in rabbits have been made known
to a number of the leading pediatricians of the city, the procedure
has been applied to infants wth gratifying success.
Unfortunately for the work of the author (though fortunately
for the babies) the last summer was mild and a true case of
acidosis a rarity. There was therefore no opportunity for the
application of this method in the ward at Mt. Sinai. Other hos-
pitals in the city, whose records are at my disposal, used > this
method of administering sodium bicarbonate as a routine one in
their cases of acidosis, and in a series of cases treated at Lakeside
Hospital, in the service of Dr. H. J. Gerstenberger, there was an
unusually high percentage of recoveries, while autopsies on cases
that did not recover failed to show any pathological effects of the
procedure. The number of cases is, however, too small to permit
of statistical deductions. At a somewhat later date, therefore, a
Epstein: Sodium Bicarbonate Intraperitoneally 665
more detailed report in regard to the clinical use and effectiveness
of the method will be made from case records.
The acknowledgments of the author are due to Dr. H. C.
Wahl for the careful autopsies made by him in connection with
the experiments that are the subject of this report.
BIBLIOGRAPHY
1. Howland and Mariott: Acidosis Occurring with Diarrhea, Am. J. Dis Child.,
1916, XI, 309.
2. Blackfan and Maxey: Am. J. Dis. Child., 1916, XV, 19.
3. Dandy and Rountree: Annals Surg., LXIX, 587.
4. Adler and Meltzer: J. Exper. Med., I, 482.
5. Shipley and Cunningham: Anat. Rec. II, 181.
6. A. E. Hertzler: "The Peritoneum," C. V. Mosby Co., St. Louis.
Diarrhea in Breast-Fed Infants (Nourrisson, Jan., 1920).
A. B. Marfan states that while diarrhea in breast-fed infants is
frequent, in its primary form it is almost never associated with
symptoms of infection or intoxication, at least not so as to present
any serious or lasting symptoms. It has no profound effect on the
nutrition, and is very rarely of a grave nature. He opposes the
idea advanced by many that diarrhea in breast-fed infants fre-
quently requires that the child should not be given the breast for
a time ; he thinks that such indications are rare. Nor does he think
that a change of nurse is often indicated. In the foregoing re-
spects a radical distinction is to be made between breast-fed and
bottle-fed infants, for the general nutrition and growth of the lat-
ter are quickly affected by diarrhea ; hypothrepsia and athrepsia
often result; toxic complications (cholera infantum) or secondary
infections may arise requiring varied and rather complicated diet-
etic treatment. In breast-fed infants, if the diarrhea is light, the
first day the intervals between feedings should be lengthened and
the time at the breast should be shortened. The intervals may be
lengthened to four hours and the time at the breast may be re-
duced to five or six minutes. During the intervals the infant
should be given a few spoonfuls of pure boiled water. The
second day the intervals are shortened somewhat ; the third day
the time at the breast may be slightly lengthened. Thus, by de-
grees, according to the effect secured, a gradual return to normal
is brought about. But in severe cases three or four feedings are
entirely suppressed and pure boiled water is substituted, a quan-
tity about equal to the amount of milk usually taken by the child
when well. — Journal A. M. A.
CYANOSIS IN THE NEW BORN.*
By Frank Cohen, M.D.
Kansas City.
Cyanosis in the new born is a very important sign because its
presence often indicates a serious pathological process, one which
often requires measures of immediate relief. So evidently prom-
inent is this symptom that in differential diagnosis of the various
maladies of the new born in which it appears, it would be highly
beneficial to depart from the usual custom of discussing it as a
concomitant symptom under various diseases, and to discuss it
as an entity in itself. By thus classifying around it the. conditions
in which it occurs, we could more easily recognize the salient fea-
tures of each.
Cyanosis has recently^ been shown to follow a condition of
increased oxygen unsaturation in the peripheral capillaries. Oxy-
gen unsaturation is defined as the difference between the oxygen
in the venous blood and the total amount of available oxygen in
the blood. When there is no condition present to prevent com-
plete oxygen saturation of the blood in the lungs, cyanosis will
not appear before the venous oxygen unsaturation is at least 13
or 14 volumes per cent. With any condition that does prevent
complete oxygen saturation of the blood in the lungs, cyanosis
will appear with a less amount of venous oxygen unsaturation.
There are factors in the etiology of cyanosis in the new born
not present in the older child. Cyanosis occurs in the new born
because of (1) the character of the labor, (2) an abnormal de-
velopmental process, (3) sepsis.
1. Character of the Labor. Cyanosis follows any condition
bringing about asphyxia neonatorum, such as prolonged labor,
cord about the neck, premature separation of the placenta, pla-
centa previa, prolonged anesthesia during labor, the asphyxia of
the new born of twilight sleep, or that following pituitrin, and in
intracranial or cerebral hemorrhage. The preceding delivery his-
tory should make the diagnosis clear. In all but hemorrhage the
cyanosis passes away with the successful treatment of asphyxia.
The additional features of intracranial hemorrhage would be:
Pallor, irregular and shallow respirations, unwillingness to
nurse and facial edema. There may be signs of compression,
bulging fontanel, slow pulse, twitchings or convulsions, paralysis.
*Read before the Pediatric Section, Jackson County Medical Society, April 12, 1920.
1 Lundsgaard, C. Studies of Cyanosis, J. Exper. M. 30:259 Sept., 1919.
666
Cohen : Cyanosis in the New Born 667
Lumbar or subdural puncture may help in the treatment as well
as in making the diagnosis.
2. Developmental Causes of Cyanosis. These are: (a) Pul-
monary atelectasis, (b) Congenital heart defects, (c) Thymus
hyperplasia, (d) Diaphragmatic hernia, and other rare con-
genital anomalies.
(a) Pulmonary Atelectasis. Cyanosis will be present in
an infant weak from prematurity or any cause, for instance con-
genital syphilis. The amount and duration of cyanosis depends
upon the extent of lung space involved and the frequency and
duration of the attacks of apnea. Absence of respiratory murmur
may be elicited. Differences of percussion are difficult to note.
(b) Congenital Heart Defects. The cyanosis of congenital
heart disease may not appear for many weeks or even years after
birth. While cyanosis may not be as often present as is gen-
erally supposed, on the other hand it is often the only sign that
directs attention to the underlying condition.
The diagnosis of congenital heart defect usually rests on the
presence of a murmur. But one must remember that a cardiac
murmur may not be abnormal during the first week of life. It
can disappear at this time with the closing of the foramen ovale
and the ductus arteriosus. But a murmur and cyanosis point
very strongly to the presence of a cardiac defect.
In uncomplicated patent foramen ovale, ductus arteriosus or
defective interventricular septum, although there is an admixture
of arterial and venous bloods, cyanosis may be absent ; or it may
occur only at times with dyspneic attacks. In these patients the
blood receives complete oxygen saturation in the lungs ; the
venous blood unsaturation must be at least 13 or 14 volumes per
cent, to produce cyanosis.
In the rarer anomalies, biloculate or triloculate heart, with a
freer mixing of bloods, there is more cyanosis.
But the extreme grades of cyanosis appear in pulmonary ob-
struction, in cases of pulmonary stenosis or atresia, and the trans-
position of great vessels. Pulmonary stenosis has besides extreme
cyanosis, a systolic murmur and enlargement of the heart. Those
cases that are not rapidly fatal have an accompanying defect, de-
fective septum, or open ductus. In the latter there would be ex-
treme cyanosis, murmur transmitted to carotids or the so-called
"humming top" murmur.
668 Cohen : Cyanosis in the New Born
In cases of transposition of great vessels — arterial trunks —
the cyanosis is extreme, but there is no murmur to draw one's
attention to a cardiac anomaly. However, in the normal infant
the inner third of the clavicular region on the left side shows a
slight dullness as compared to the right side. As this dullness is
due to the great vessels, in suspected transposition one should
look for such dullness on the right side.
The end result of cyanosis is polycythemia, an increase of red
blood cells, an attempt by nature to compensate by using more
blood surface for aeration. This, in fact, is a detriment, as the
lower water content allows the cells to circulate more closely,
obstructing the vessels still further. Lundsgaard has pointed out
that there are states of polycythemia that do not show the oxygen
unsaturation features of a true cyanosis; in fact, the skin has a
reddish hue rather than bluish. He calls this erythrosis, or
false cyanosis.
(c) Thymus Enlargements. At birth, the mechanical inter-
ference with respiration by an enlarged thymus appears to be a
more important element than a state of so-called status lymphati-
cus. In the former case because there is not complete oxygen
saturation of the blood in the lungs, cyanosis appears with less
than 13 or 14 volumes per cent, oxygen unsaturation of venous
blood.
This type of baby is often chubby and short necked. The
cyanosis may be intermittent, coming on with attacks of dyspnea
or it may be present continuously. Inspiratory stridor is often
present. There may be convulsions. Percussion reveals increased
areas of dullness on either side of the sternum. This may be
made more manifest by bending the child forward. The x-ray
can aid materially in the diagnosis.
(d) Diaphragmatic Hernia. Cyanosis may occur in the
rarer congenital anomalies, but in diaphragmatic hernia it is a
prominent and persistent symptom, because of the marked inter-
ference with lung expansion. There is an extreme grade of
cyanosis and dyspnea. The condition should be strongly sus-
pected when there are in addition signs of cardiac displacement,
absence of murmurs, absence of pulmonary resonance on one
side. The x-ray will show abdominal contents in the thorax with
displacement of the lung.
Cohen : Cyanosis in the New Born 669
Congenital goiter and lymphangioma are rare anomalies.
When either causes cyanosis its diagnosis would be facilitated
by the very size necessary to produce pressure in the neck on
respiratory organs, or interference with the circulation.
3. Sepsis. While cyanosis may be a prominent symptom
in infectious cases, there will be present either signs of peritonitis,
pneumonia, arthritis, osteomyelitis, septic conditions due to cord
infections, etc., features distinctive in themselves.
Cyanosis may take the place of rigors, just as in older children
Winckel's Disease, which is probably of septic origin, is an
exception to the above in not having any rise in temperature.
However, with extreme prostration, cyanosis will be accompanied
by the other pathognomonic signs of hemoglobinuria and jaundice.
Conclusion : In view of the fact that there are distinctive
factors in the etiology of cyanosis in the new born, a classification
of these cyanotic conditions has been made. These conditions
fall into the 3 main groups of (1) Labor processes, (2) Abnormal
developmental processes, and (3) Sepsis.
700 Rialto Bids'.
Tardy Osteoperiostitis with Inherited Syphilis (Revista
Critica di Clinica Medica, Oct. 25, 1919). A. Varisco reports the
case of a young woman who had been apparently healthy, except
for a few convulsions in infancy, until measles at 18. At 20 she
complained of pains in the legs and large joints, and the latter
began to enlarge in a few weeks, with a low continuous fever
and drowsiness. The spinal fluid seemed to be normal. Not until
the end of six months did the symptoms subside so she could leave
the bed. After a few months of slight ups and downs, painful
tumors developed in the crest of the tibia and other long bones and
the clavicles, and numerous glands enlarged. After nearly a
year from the first symptoms, a tentative course of mercurial
treatment not only cleared up the diagnosis — the previously nega-
tive Wassermann reaction veering to positive — but resulted in
practically a cure. There was nothing in the family history to
suggest syphilis except the shape of the patient's teeth and a cer-
tain pigmentation of the face. — Journal A. M. A.
CONGENITAL ATRESIA OF THE ESOPHAGUS*
By Alfred L. Kastner, M.D.
Milwaukee.
In a copy of Gibson's Anatomy, a favorite text book of the
17th century, Dr. William Thomas^ quite by chance unearthed
the following account : "About November, 1696, I was sent for to
an infant that could not swallow. The child seemed very desirous
of food and took what was offered it with greediness, but when
it went to swallow it it was like to be choaked, and what should
have gone down returned by the mouth and nose and it fell
into a struggling convulsive sort of fit upon it. It was very
fleshy and large and was two days old when I was called to it,
but the next day it died. The parents being willing to have it
opened I took two physicians and a surgeon with me. On opening
the abdomen first, the guts had some of the meconium remaining
in them, though the child had gone two or three times to stool.
The stomach had in it a pretty deal of slimy sort of liquor (or
jelly rather) somewhat like this (strained) water-gruel. (I
shall not mention any observations upon other parts of the
abdomen as being not to our present purpose). Then we cut open
the thorax and taking out the gullet with the wind-pipe, lungs,
etc., continued to the stomach. Then we made a slit in the
stomach and put a pipe in its upper orifice, and blowing, we found
the wind had a vent, but not by the stop of the gullet. Then we
carefully slit up the back side of the gullet from the stomach
upwards, and when we had gone a little above half way towards
the pharynx we found it hollow no further. Then we began to
slit it open from the pharynx downward and it was hollow till
within an inch of the other slit and in the imperforate part it was
narrower than in the hollowed. This isthmus (as it were) did
not seem to have been hollow, for in the bottom of the upper and
the top of the lower cavity there was not the least print of any
such thing, but the parts were here as smooth as the bottom of an
acorn cup. Then searching which way the wind had passed when
we blew from the stomach upwards we found an oval hole half
an inch long, on the foreside of the gullet opening into the aspera
arteria, a little above its first division just under the lower part
of the isthmus above mentioned."
•Read before the Milwaukee Medical Society, February 24, 1920.
670
Kastner: Congenital Atresia of the Esophagus. . 671
After all these years but little can be added to Dr. Gibson's
account that would make for greater clearness or a better under-
standing of this anomaly. Though congenital atresia of the
esophagus receives an unwarranted neglect in most text books,
many authors have, especially in recent years, enriched the
literature with accounts of the condition. Since Schoeller de-
scribed several cases, in 1838, Mackenzie in 1884, Kreutzer in
1905, Cautley in 1917 and Brennemann^,^ in 1913 and 1918 and
many others besides have reported and described cases in such
numbers, one is forced to believe that this anomaly is not in
reality a rare one. The striking feature of all these reports, as
pointed out by Brennemann, is the preponderance of what has
been called the inosculating type over all other malformations of
a similar character. One might say that the particular type here
described appears to be the only one that has obtruded itself for
many years. Indeed as far as the description of the anomaly
itself is concerned, excepting some very minor variations, all
reports exhibit such a uniformity that it is with some hesitancy
that I undertake to say more than, "I also have seen exactly such
a case." However, a recapitulation appears justifiable when a
condition has either an undeserved reputation for rarity or a
most unaccountably irregular distribution and incidence. As
stated by Brennemann, "Cautley reported a case in 1917, the first
he had seen in 25 years of practice mainly among children and
that in the child of a Belgian refugee." Brennemann himself
reported 3 cases in 1913 which he had seen in the period of 1 year,
and in 1918 reported 4 more cases.
Its clear cut, striking, not to say spectacular symptom-com-
plex, it seems to me, could hardly fail to arouse interest when
encountered, and incite study and investigation that would natur-
ally result in eventual, if not immediate recognition. The char-
itable view then would be that these cases fall not with impar-
tiality, but that like the malicious paper snow storm of the melo-
drama, they pursue the unfortunate up and down the stage and
snow on him and on him alone. None the less, it will be just as
well to remember that it is a human fraility to recognize most
readily what is familiar — so this subject, perhaps with profit, may
be opened again.
The theoretical explanations for the occurrence of this an-
672 Kastner: Congenital Atresia of the Esophagus
omaly are hardly germane to the purely clinical and practical con-
siderations and for a short discussion of the various theories
Huntington's* article can be recommended. It may be added that
other anomalies accompany atresia of the esophagus in a large
percentage of cases. More important is the consideration of the
anatomical peculiarities of the anomaly, for by these are de-
termined the symptoms, prognosis and treatment.
In the specimen before me, as in the diagramatic figure which
I have drawn to approximately life size, the upper and dilated
part of the esophagus measures about 4 cm. in length and has an
almost uniform diameter of a little over 1 cm. The lower blind,
bluntly rounded extremity is about 1 cm. distant from the bifur-
cation of the trachea. Its walls give the impression of being not
simply stretched and dilated, but on the contrary seem thick and
muscular.
In this particular specimen it is impossible to say whether a
fibromuscular cord connects the upper portion of the esophagus
with the lower or not. It would perhaps require a stretch of the
imagination to find it. Such connecting cords have been found,
however, and in Huntington's specimen cross sections showed the
cord to be made up of striated muscular fibres and connective
tissue. No trace of epithelial tissue was found. The presence
or absence of the cord is of no clinical importance. It is only
mentioned on account of its apparent absence in this particular
specimen and its presence in others.
The lower portion of the esophagus takes its origin, or
emerges from the posterior aspects of the trachea about 1/2 cm.
above the bifurcation, and from this point widens itself gradually
to the size of the normal esophagus of the new born, i.e., 5 m.m.
It entered the stomach in the normal manner.
When the trachea is slit up and the tracheal opening of the
lower portion of the esophagus exposed, it reveals itself as a
small transverse slit with a little groove-like depression running
upward on the internal posterior surface of the trachea, very
much like the hole left in a board when an obliquely driven nail
has been pulled out by a claw hammer. The shape of this open-
ing, in spite of its smallness, strikes one as well adapted for both
the entry and exit of fluids. It readily admits the small-sized
silver probe. Some specimens have been described in which the
lower portion of the esophagus entered a bronchus.
Kastner: Congenital Atresia of the Esophagus. . 673
As one would expect from an anomaly which holds so close
to type, the symptoms are typical in all cases. Because the drain-
age of the oral cavity is limited to one convenient route, from
the time the baby is born the mouth seems filled with an exces-
FiG. 1. Diagrammatic figures showing, on left, the upper and
dilated portion of the esophagus. The figure on the right shows
the opened trachea with a probe in the esophageal-tracheal
opening.
sive amount of mucus. This either flows from the most depen-
dent corner of the mouth, or compels attempts at removal by
an attendant when it causes choking attacks. The attacks of
choking, with or without cyanosis, occur of course when the
674 Kastner: Congenital Atresia of the Esophagus
mouth is drained by the inconvenient routes, that is, by way of
trachea or nose. When the infant is nursed these symptoms are
exaggerated. The nipple is taken greedily enough, but after a
mouthful or so of milk has been taken the oral cavity is "running
over," milk is leaving between the lips, bubbling out of the
nostrils, and getting into the larynx, as shown by choking, cough-
ing and cyanosis. At this point the child is usually instinctively
"grabbed and turned upside down to empty it."
If not helped in some manner it becomes motionless and limp,
but by no means invariably succumbs to what might appear as
an inevitable death from drowning, but after a period of almost
lifeless relaxation, recovers, is ready to suck, and will repeat the
performance if given an opportunity. It is certainly most reason-
able to believe that the trachea is more or less effectually drained
by the lower portion of the esophagus at such a time. The fact
that many of these infants live a week and longer seems also
to point that way. The tracheal opening of our specimen at any
rate would make such action seem possible. At any rate death
from suflfo^ipn is rare.
In all df^is cases Brennemann observed that the stomach
was distended with air, the rest of the abdomen being flattened,
and points out the importance of this sign from a diagnostic
standpoint, for it "establishes the fact that the stomach and
trachea are connected." The air distended stomach is well shown
in the roentgenograph of our case.
An attempt to pass a catheter down the esophagus in these
infants reveals an c^Struction at about 12 centimeters, whereas
in new borns/gfhe formal distance from, the lips to the cardiac
end of the st^iacl^is stated as 17 centimeters. I will refer to
this again. The t#iperature is usually raised by the advent of
inanition fever aftet the baby is 2 or 3 days old, and may again
be influenced when bronchopneumonia sets in. Lacking some
such modifying factor, a normal temperature prevails, dropping
to subnormal as death approaches.
The stools are composed entirely of meconium at first, later
they are bile-stained mucus. A milk stool in these infants is not
to be expected of course, but it would be a matter of interest to
know if milk in recognizable quantities is ever drained into the
stomach from the trachea. In this connection it is tempting to
hint that a harmless, insoluble, and easily recognizable sub-
Kastner: Congenital Atresia of the Esophagus.. 675
stance like finely powdered charcoal, introduced per oram during
life, might go far to prove conclusively the integrity of tracheal
drainage by the lower segment of the esophagus. Were char-
coal found in the stomach postmortem this point would be set at
rest. Brennemann's view is that most of these infants die of
starvation rather than from aspiration pneumonia, or choking,
Fig. 2. X-ray of chest showing the blind upper portion of the esophagus
filled with a milk and barium mixture. The upper portion of the air-filled
stomach can also be seen.
even though a bronchopneumonia is often found postmortem.
He points out that bronchopneumonia is usually found in maras-
mus any way, and that death by suffocation did not occur in any
of his last series of cases.
Unless the inevitable end is hastened by persistent attempts at
feeding per oram, or by some surgical interference, the infant
rapidly passes on to the clinical picture of acute inanition and, in
so many words, starves to death. None of these children live
more than 2 weeks, their average span of life being about 7 days.
676 Kastner: Congenital Atresia of the Esophagus
What is to be done for these poor unfortunates? To put it
briefly and brutally — nothing. The most that can be done is to
make an early, correct diagnosis, stop all attempts at feeding, and
spare both infant and parents all unnecssary suffering.
Attempts at feeding per oram will certainly be futile and will
only hasten the advent of aspiration pneumonia, or cause death
by drowning, or suffocation. Oral feeding is justifiable only
for diagnostic or experimental purooses. The limitations in new
bonis of nutrient enemaia offers no encouragenient for even a
trial. Naturally, in an extremity like this, one turns to the sur-
geon. Any surgical procedure designed to give an opportunity
for life in tolerable comfort must fulfill the following conditions :
1. Allow oral feeding. 2. Obviate continual danger of as-
piration pneumonia. 3. Secure freedom from infection induced
by accumulations in the blind upper portion, or at the point of
ligation of the tracheal portion of the esophagus. 5. A tech-
nique that would insure a reasonably low mortality.
The only conceivable way to meet all these conditions would
be to unite the upper with the lower portion of the esophagus.
Such a formidable undertaking under the present limitations of
intrathoracic surgery, coupled with such a poor surgical risk as a
newborn, can hardly be considered seriously.
A simple gastrotomy has often been performed on these in-
fants. It always had the same result. The lungs are flooded
through the esophagotrachcal openings as soon as fluid is put
in the stomach. Relief by this method would certainly not be
attempted by any one with the anatomy of this anomaly in mind.
Jejunostomy, as suggested by Demoulin, has also failed al-
though it tends to save the lung from flooding; it cuts off the
digestive functions of stomach and duodenum and imposes greater
surgical and feeding difficulties.
Gastrotomy comJ)ined with ligation of the lower portion of the
esophagus has been performed by H. M. Richter^ and has allowed
the introduction of food into the stomach without pulmonary
flooding. If an infant could be made to survive an operation like
this the even more dangerous anastomosis of the esopjiagus would
still be logically expected to follow. So when we consider the
peculiar anatomical conformation of the anomaly, the unfavor-
able field for successful surgery that the delicate economy of the
new born offers plus the limitations of intrathoracic surgery.
Kastner: Congenital Atresia of the Esophagus.. 677
these cases may be called hopeless from the beginning. As a mat-
ter of fact none have ever survived.
Case Report. On February 2, 1919, I was called by Dr. P.
M. Currer to see a male child be had delivered 4 days previously
and in which he suspected an esophageal occlusion. It was the
third child by healthy parents. Their first was premature and
died on the 20th day, their second is a healthy girl of 10 years.
This, their last, born normally at term, was large and well de-
veloped. Cyanosis was present at birth and some difficulty was
experienced in making the child breathe properly on account of
the large amount of mucus in the mouth. It was soon evident
that the infant did not swallow in a normal manner and though
willing to take the nipple, the milk came out of the mouth and
nose almost as soon as it entered and an alarming fit of choking
coincidently occurred.
There was nothing of moment or interest in the physical ex-
amination otherwise and the symptoms present differed in no
way from those already outlined. However, when it came to
passing a catheter down the esophagus only a small and very
flexible No. 17 F. soft rubber catheter was at hand and that
apparently passed down to such a length that it seemed it were
either in the stomach or in a diverticulum of some sort. Fur-
thermore considerable mucus syphoned out of the catheter and a
distinct clicking noise was heard coming from it, such as is
ordinarily elicited when a catheter enters the stomach.
All this was misleading of course and it sounds a warning
against a small flexible catheter, which may double and kink, for
such explorations. The "hollow viscus click" also proves itself
an untrustworthy sign. On the day following the x-ray, after
a few teaspoonfuls of milk and barium mixture were admin-
istered per Oram, revealed the true condition both by fluoroscope
and plate. The upper blind portion of the esophagus and the
air filled stomach were well shown.
No attempts at feeding were made, but Dr. Currer had a few
small doses of paregoric given by rectum. The infant urinated
several times and had the usual mucus and meconium stools.
The little body practically shriveled up and death came on the
8th day. Dr. Currer performed the partial postmortem allowed
678 Kastner: Congenital Atresia of the Esophagus
and removed the specimen described. No other anomaly was
found.
120 Wisconsin Street.
BIBLIOGRAPHY
1. Thomas, William: Congenital Occlusion of the Esophagus, The Lancet 1904,
vol. 1, p. 36L
2. Brennemann, Joseph: Congenital Atresia of the Esophagus, Amer. Tour. Dis.
Child., 1913, vol. 5, p. 143.
3. Brennemann, Joseph: Congenital Atresia of the Esophagus, Amer. Jour. Dis.
Child., 1918, Vol. 16, p. 143.
4. Huntington, James L. et al. Report of a Case of Congenital Atresia of the
Esophagus, Boston Med. & Surg. Jour., 1919, vol. 180, p. 354.
5. Richter, H. M. : Congenital Atresia of the Esophagus; an Operation designed
for its Cure, with a Report of Two Cases Operated on by the Author,
Surg. Gynec. and Obst., October 1913, p. 397.
Open Air Classes (Jour. A. M. A., Oct. 4, 1919). Leopold
Marcus describes the work of the Bureau of Child Hygiene of
the New York Department of Health and especially the estab-
lishment of open air classes in the public schools. They were
organized to provide special opportunities for the physically sub-
normal children after an experimental open air class had been
tried. There are now 110 of these at present located on the roofs
of the school buildings, in public parks, etc. Experience has
proved that in a large city these classes are best placed in the
school building. The roofs require the climbing of too many
stairs. The public parks would be an ideal location but for the
expense of the buildings required. When the school house is
originally constructed little additional cost would be incurred for
accommodation of one or more open air classes. The following
types of children are admitted : those who have had tuberculosis
or been exposed to it ; those suffering from malnutrition ; chil-
dren who show little stamina and become tired easily and are un-
able to carry on their class work ; children suffering from nervous
diseases except chorea; those subject to colds, bronchitis, etc.,
and heart disease cases when recommended by a physician. The
important factors in the success of the work are fresh cool air,
light food, correction of physical defects retarding growth and
proper hygienic living conditions. These are all provided for
during the school session. It has been found that no temperature
is too low provided the children are properly protected, and the
increase in weight occurs during the colder months. Extra feed-
ing is always provided between meals if possible, and frequent
short recesses for recreation are given. — Journal A. M. A.
A CASE OF BACTERIEMIA TREATED BY REPEATED
TRANSFUSIONS*
By Jesse F. Sammis, M.D.
New York.
J. G., age 2^ years, only child, full term, normal delivery,
no miscarriages, no history of tuberculosis, father and mother
well. Up to present time of illness she has been under my
observation at the milk station, Vanderbilt Clinic. Breast fed 11
months, did well. Weight at 1 year, 223/2 pounds. Has had no
acute illness previous to the present except influenza 1 year ago
from which she recovered promptly. One week before admission,
child was said to be feverish and 5 days before admission com-
plained of pain in the ear, and an examination disclosed acute
otitis media of the left ear, which was incised and a purulent
fluid obtained.
The examination at that time showed a well nourished girl
baby who was acutely ill, left ear discharging, right ear con-
gested, acute nasopharyngitis, tonsils large, swollen, red, and
showing many yellow spots, tonsilar glands enlarged, heart
normal, lungs scattered rales, abdomen negative, spleen not felt,
temperature 104°. The fever continued to range between 100-
104° until day of admission to the New York Nursery and Child's
Hospital.
The examination on admission was practically the same as
that previously recorded, the child appearing very sick. Cultures
from the throat showed streptococcus hemolyticus. A blood
culture was taken and showed many colonies of the same
organism. The urine showed albumin, with hyalin and granular
casts; the blood count 23,000 leukocytes, with 76 per cent, poly-
morphonuclears. Two days later the spleen became palpable and
there were many petechial spots around the ankles and on the
abdomen. The child's general condition was considerably worse,
the temperature ranging as high as 106° with wide remissions,
the child having a general convulsion. A day later the right
elbow became red and hot and swollen and subsequently was
incised and pus obtained which also showed streptococcus hemo-
lyticus. At this time, on December 31, the 10th day of her illness,
the child was given 150 c.c. of mother's blood, the citrate method
• Read before the Section on Pediatrics, New York Academy of Medicine,
January 8, 1920.
From the Pediatric Service, New York Nursery and Child's Hospital and the
Department of Pediatrics, Cornell Medical College.
679
680 Sam mis: Transfusions in Bacteriemia
being used. She was given 300 c.c. on the 3rd day, the mother
being the donor, another transfusion of 125 c.c. on the 20th day,
another on the 32nd day. Blood cultures, taken on the 13th day,
showed only 5 colonies after 48 hours. Ten days later the same
number, and 3 colonies on the 32nd day, the blood culture being
negative for the first time on the 48th day. A vaccine made from
the child's organisms was given to the mother, the donor, at
intervals of 2 days for 4 doses, the number given being 500,000,000
for each dose. On February 3, the agglutination of the mother's
serum against the streptococcus isolated from the patient's blood
failed to show any clumping in any dilution of 1 to 5 or in 1 to 100.
In addition to the usual treatment for discharging ears, the throat
was sprayed with a polyvalent streptococcus serum twice a day,
and the child was placed on a high caloric diet. After the trans-
fusions the child had 2 reactionary chills and was invariably listless
and very thirsty, and within 12 hours the temperature usually
reached a higher level than just before the transfusion, but
gradually declined to a lower level within 12 hours. The
temperature reached normal on the 40th day and has not been
above 100° since then. The pus elbow has completely healed
although there is a slight loss of function, the ears are not dis-
charging and the appearance of the drum is normal. The tonsils,
while still large, look otherwise normal except for rather large
crypts.
The child's appetite is excellent and she has gained 2 pounds
in the last 10 days, her spleen is just palpable, but much smaller
than previously. There are no heart murmurs, the urine i?
normal, there is slight abdominal distension and constipation.
We feel that the repeated transfusions, 4 in number, were
the determining factor in her recovery. When the temperature
in the early part of her illness was running very high and the
child losing ground, the advisability of removing the tonsils, as
being the undoubted original focus, was discussed and our inten-
tion was to remove them, if the course continued to grow more
severe. Inasmuch as the child showed slight continuous improve-
ment following the transfusion this was not done.
The number of the colonies in the first culture were so numerous
that they could not be counted. The second blood culture taken
after 1 transfusion and previous to giving any vaccine to the
donor showed a remarkable reduction in the number of colonies,
Sammis: Transfusions in Bacteriemia 681
only 5 colonies to 1 c.c. of blood. The improvement was as
marked following the first 2 transfusions as following the latter
2, which were given after the donor had been given the vaccine
Inasmuch as the mother's serum did not agglutinate the
child's organisms, we believe that the actual blood was the factor
rather than any immunity conveyed in the mother's blood.
Acidosis of the Recurrent Vomiting Type (Boston Med-
dical and Surgical Journal, August 19, 1920). W. W. McKibben
reports in detail the case of a child 20 months old, whose history is
illustrative of the type of acidosis known as recurrent, cyclic or
periodic vomiting. Babies and children of neurotic ancestry, he
says, and of lithemic diathesis, tend to periodic attacks of vomit-
ing. This is due to disordered fat and carbohydrate metabolism,
as well as to sensitization to certain definite food proteins to-be
found out by skin reactions, or even more important, by experi-
mentation with the foods themselves. The best way to meet the
attacks is by stopping everything by mouth and giving one or
two cleansing irrigations daily of sodium bicarbonate ; and glu-
cose or dextrose in solution by rectum ; for the interval, elimina-
tion from the diet of all proteins to which the baby is sensitive
until the baby desensitizes itself, or is desensitized ; also a low fat
and sugar intake. It is essential when nearing the cycle, or
when the slightest symptoms recur, to watch, or better still, to
have the urine closely watched by a physiochemist, so that at the
first warning, a sufficient quantity of sodium bicarbonate may be
given to neutralize the urine or to render it alkaline. It is im-
portant that these precocious children have long hours of sleep,
and play alone out of doors as much as possible. — Medical Record.
THE ORGANIZATION OF A MODERN PEDIATRIC
SERVICE -— '
Henry Heiman, M.D.,
New York.
In recent years pediatrics has received a remarkable stimulus
for development. The war has emphasized most urgently the need
for the protection, conservation and efficient medical care of the
infant and child. The pediatrician of today must be cognizant of
this ever widening sphere of activity. He must view the subjects
of child hygiene, routine physical examinations for remedial
defects, the problems of nutrition, of the child mind, and public
measures for child welfare with as keen an interest as the
diagnosis and treatment of disease.
One of the most potent factors for the realization of modern
ideals in pediatrics is the organization of hospital services on a
newer and broader plane. Various phases of this subject have
been dwelt upon by several workers, notably Charles Hendee
Smith and Frank Howard Richardson. It is our purpose to out-
line a plan for the organization of a model pediatric service in a
large modern hospital.
Such a service should include the infants' and children's wards
and the out-patient department. The latter has long been a
neglected and disorganized part of most of our institutions. The
overcrowding of patients and the irregular attendance of the
staff, often inexperienced and without definite direction, have
produced a very inferior type of pediatric work. We must realize
that dispensary cases present problems for diagnosis and therapy
as difficult and complex as those admitted to the wards. They
require the same careful analysis, the complete examination and
study as that given by the trained pediatrician at the bed-side.
They present moreover, greater opportunities for the diffusion of
social and educational work in child hygiene and preventive
pediatrics. To accomplish the best results, the dispensary must be
made an integral part of the pediatric service under one leader-
ship. This means greater efficiency in the "follow-up" system of
cases discharged from the wards ; it means opportunity for the
physicians working in the out-patient department to study
intimately cases which they refer for hospital care.
To man such a complete service we might suggest the follow-
ing functionaries: a pediatrist to the hospital, 1 associate, 4
682
Heiman : A Modern Pediatric Service 683
adjuncts, 16 senior assistants, 16 junior assistants, and an in-
definite number of clinical assistants.
The pediatrist to the hospital should primarily direct the work
of the entire service. He should be a man of broad clinical
experience, ready to employ any new scientific methods for
diagnosis or treatment emanating from the modern laboratory.
He should not only co-operate with his subordinates but inspire a
spirit of co-operation throughout the service.
The most important function of the pediatrist to the hospital
is the making of his daily rounds. They should begin at a
definite hour each morning. He should, be accompanied by 2
adjuncts and as many others of the stafif as possible. Twice a
week the whole staff should be expected to attend the so-called
"grand rounds," a longer period devoted to the presentation and
discussion of all the cases. Any unusual developments of the
week are reviewed. These rounds should include a visit to the
out-patient department where are seen those cases of unusual
interest referred for consultation by the adjunct in charge.
Special subjects for preparation outside, and appropriate ma-
terial for study in the hospital, may be assigned by the chief to
various stafif men on these occasions. Twice a month service con-
ferences should be held at which topics of interest are presented.
The pediatrist to the hospital should supervise the hygienic
care and feeding of infants and children on the surgical service.
He should be called upon to treat medical complications arising in
surgical cases. It shall be his function to outline a course of
instruction in pediatrics for nurses, to assign lecturers and pro-
vide for suitable demonstrations.
The associate should at all times know intimately the details
of the service and be ready to act as pediatrist to the hospital in
the absence of the latter. It should be his duty to visit the wards
each afternoon to see and treat all acutely ill cases as well as new
cases admitted during the same day. His rounds should end at
the out-patient department where he should act in the capacity
of daily consultant.
The supervision of the diet kitchen, the instruction of nurses
in the preparation of infant formulas and the arrangement of
the dietaries of older children are important functions which
could be intrusted to the associate.
684 Heiman : A Modern Pediatric Service
There should be 4 adjuncts on continuous service , but
ahernating as to their duties. Two of these should work in the
wards ; the others to be in direct charge of the out-patient depart-
ment. The adjuncts on ward duty are expected to make rounds
each morning with the attending. They should be familiar with,
and ready at all times to demonstrate the details of all laboratory
procedures ordered for patients on the pediatric service. They
are to be the connecting link between the services and the various
important laboratories of the hospital — the clinical, pathological,
electrocardiographic, and x-ray. If they have not already had
training in these departments such instruction should be instituted.
It should be their function to study special problems in the light
of clinical and laboratory experience.
In the absence of the associate from duty one of the ward
adjuncts shall act in such capacity. The responsibiltiy for the
supervision of the history charts and their prompt filing on the
discharge of patients may be assumed by one of the ward
adjuncts.
We recommend the appointment of a resident pediatrist. The
prescribed course for internes necessitating frequent changes in
the house staff does not work for the best interest of the pediatric
service.
In the out-patient department there should be 2 clinics, each
in charge of one adjunct. These clinics should be held on
alternate afternoons. We do not favor routine morning ana
afternoon clinics. Under proper guidance and efficient organiza-
tion, we believe that the afternoon clinics can care for all the out-
patient applicants. Such an arrangement will give the physicians
in the out-patient department an opportunity to make rounds with
the chief of the service and add much to the interest of their work.
The acutely ill cases that sometimes come to the morning classes
should be directed to the hospital admitting department.
During the morning hours the dispensary rooms could be
profitably employed for the study and treatment of special
segregated groups of cases, pertussis, vulvovaginitis, and for
consultation cases for the chief of service on "grand rounds.".
The clinics, each under direct supervision of an adjunct may
be divided into 8 classes according to disease :
Heiman : A Modern Pediatric Service 685
1.
Infant Feeding
5.
Protein Sensitization
2.
Nutrition
6.
General Pediatrics
3.
Cardiac
7.
Pertussis
4.
Preventive Pediatrics
8.
Vulvovaginitis
Each group shall be in charge of one senior assistant, who shall
direct his efforts to the study of the special problems of his
class. A case of unusual interest, however, could be seen by all
the men. A rotating service would insure a thorough and com-
prehensive training in all branches of pediatrics.
A junior assistant, and as many clinical assistants as required,
should be appointed for each class and should rotate with their
respective senior assistants.
In connection with the infant feeding class we recommend the
establishment of a thoroughly equipped milk station. Here
instruction to mothers in the preparation of formulas should be
given and the various sugars and cereals required sold at cost to
deserving applicants.
For the nutrition class, posters, diet sheets, food exhibits with
special demonstrations, individual instruction, and competition
for prizes may be employed to advantage.
Cardiac classes are now well organized in a number of our
large institutions. Provision should be made for the more ex-
tended application of functional tests and graduated exercises
to increase functional efficiency. A closer association with the
school system should be encouraged.
Preventive pediatrics is one of the most important recent
developments. The routine examination of children of pre-school
age for the correction of remedial defects is of tremendous value
in our endeavors for the health of our future manhood.
Classes in protein sensitization should include those cases in
which the disease is related to some specific protein, generally
determined only by careful study and the use of special tests.
This group would include cases of bronchial asthma, hay fever,
urticaria, and eczema.
The general pediatric class provides for all cases not treated
in the special groups.
The pertussis and vulvovaginitis classes should be held on
alternate mornings. The adjunct of each clinic might designate
2 senior assistants to take charge of this work.
An adequate number of well-trained nurses is essential for
686 Heiman : A Modern Pediatric Service
the efficient management of the service. A minimum of 1 nurse
for 5 patients during the day and 2 nurses for each ward at night
should be provided.
We strongly recommend the training of nursery maids ; the
latter, by attending to the more menial and less skilled work,
would lessen the burden of the nursing staff.
Too much stress can not be placed upon the importance of the
social service worker. The environment of the home, the mental
outlook of the parents, the special aptitudes of the patient are
becoming of ever increasing significance. Such details can be
gleaned only by the social service visitor. Instruction in child
hygiene, the preparation of infant formulas and dietetics, when
offered by a sympathetic worker in the home, is an invaluable
aid in our health program. Arrangements for the care of patients
in convalescent homes or in special institutions may be delegated
to the social service department.
The volunteer worker who came into being during the stress
of war has proved her usefulness. Efforts should be made fo
enlist more women for this cause. They are especially adapted
for out-patient work, where only 2 hours every day or every other
day are required. History taking, weighing of children, food
demonstrations, individual talks are functions in which they soon
become very proficient.
Complete recording of histories, with tentative and final
diagnosis for the ward as well as the out-patient cases, is essential
to every well organized service. There should be a complete
nomenclature of diseases. All histories of the ward and the
out-patient department cases should be double indexed according
to the name of the patient and of the disease.
We have outlined some of the important elements in the or-
ganization of a model pediatric service. To realize fully its
possibilities there must be engendered a spirit of cooperation and
the development of a genuine esprit de corps.
64 West 85th Street.
SOCIETY REPORT
THE NEW YORK ACADEMY OF MEDICINE.
SECTION ON PEDIATRICS.
Stated Meeting, Held October 8, 1920.
Charles Hendee Smith, M.D., in the Chair.
THE PSYCHOLOGY OF THE CARDIAC AND THE DOCTOR.
Dr. Robert Hurtin Halsey presented this communication,
in which he stated that children with heart disease had varying
degrees of specific deviation from the normal, and frequently cer-
tain general, acquired, mental, social, educational and environ-
mental differences. They frequently showed a lack of initia-
tive, a disinclination to associate with others; often a moderate
grade of school knowledge, and a certain eager readiness to attrib-
ute their backwardness and inefficiency to heart disease. It
seemed that these general deviations were derived from 3 sources,
namely, the family, friends, and teachers ; ' others with heart
disease, and the family physician. There was a popular tradi-
tion that "heart disease" connoted the possibility of sudden death.
Unfortunately popular tradition made and knew no distinction
in degrees or forms of the disease. The doctor frequently was
responsible for unnecessary medicine and undue restrictions be-
cause the patient was not thoroughly studied, and his limitations
determined, but rather all cardiacs were treated as hopeless cases
with the expectation of imminent early death. Since primarily
the physician must instruct family, teachers, and the cardiac, it
seemed to the writer that the means of modifying these various
mental influences, which increased the introspection of the cardiac,
increased his hopelessness and retarded his physical and mental
development. The child could and would adjust itself to restric-
tions if it had some substitute method of occupying its physical
energies as well as satisfying its mental desires. The cardiac
child reacted to environment and was stimulated by group work
to rapid development, mentally and physically. A wholesome
mental atmosphere was created by encouraging active, useful
recreation work and the pursuit of some vocational training suit-
able to the creed, race and social status of the child. The physi-
687
688 New York Academy of Medicine — Section on Pediatrics
cian could obtain better results and perform a greater service by
a more careful study of the individual cardiac and the social
problems involved. Physical exercise properly directed in
games, dancing, and occupations would help to improve the car-
diac muscle and the mental attitude or temperament of the child.
Gathering cardiac children in groups did not produce hypochon-
driac depression, but rather stimulated a rational cheerfulness.
The individuals learned to discriminate and differentiate between
the severity of their conditions. The individual improvements were
noted, and the whole group derived encouragement. When there
was better understanding of the restrictions, there was better
co-operation, and better co-operation meant better results in a
longer and productive life.
SYPHILIS IN CHILDREN OF SCHOOL AGE WITH HEART DISEASE.
Dr. Blake F. Donaldson presented this paper by invitation.
He stated that during the last school year, 28,000 children were
on the register in a district of 17 schools, located in New York's
lower East Side, assigned to the cardiac clinic of the Post Graduate
Hospital. All the new children in these schools, together with
such of the other children who were suspected of having diseases
of any kind, were examined by school medical inspectors of the
Department of Health. Seven hundred children were thought
worthy of note because of some cardiac abnormality. These se-
lected cases were then passed upon by Dr. Robert Halsey and a
staff of assistants. Of these cases, 167 were found to have or-
ganic heart disease — forceful sounds, reduplications, high pulse
rates, and accidental murmurs accounting for the rest. The De-
partment of Health of New York City reports that the incidence
of heart disease among school children, as noted by its medical
inspection in 1918 was 1.6 per cent. In their group of 167 or-
ganic cases, there were 13 cases of organic insufficiency, and 5
of pulmonic insufficiency, in combination with either mitral sten-
osis or mitral insufficiency. Of these children, 84 were selected for
medical observation in a special class connected with Public
School No. 64. The work was in the nature of an experiment
to determine the wisdom of segregating school children with heart
disease. The comparatively large number of aortic cases (8 per
cent.) in their series was rather a surprise. In the aortic cases
New York Academy of Medicine — Section on Pediatrics 689
the diastolic murmurs were best made out with the patients in
the erect position after forced expiration. One hundred and three
Wassermann reactions were made on the 84 children registered
and on the mothers and any other available relatives of the chil-
dren with aortic insufficiency. A positive Wassermann was ob-
tained in only 1 child. This was a well compensated case of aortic
insufficiency with a history of frequent attacks of tonsillitis and 1
severe attack of acute rheumatic fever. The mother's reaction
was 4 plus. Neither the mother nor the child showed any other
evidence of syphilis. One case of potential heart disease was of
special interest. This was a child with a marked anemia of the
pernicious type, with a high color index and many nucleated red
cells, a marked enlargement of the spleen and liver and slight
generalized icterus. Out of a family of 11 people, 8 members were
aflfected in almost the same manner. They all had the primary
type of anemia with splenic enlargement. The aortic cases noted
all had definite histories of acute rheumatic fever, save 1 who had
only diphtheria. In children one expected to find aortic disease
as the consequence of rheumatism, syphilis, or some extraordinary
strain. Of late years, perhaps because of improved diagnostic
methods, syphilis as a causative factor, especially in children, had
been over-emphasized. Abbott stated that by far the chief cause of
aortic disease in persons under middle age was rheumatic fever.
Statistics were quoted from a report of Poynton, Aggazzis and
Taylor on 250 autopsies on children who died of rheumatism
showing the different types of cardiac involvment found. It
might be concluded from this limited number of cases that syphilis
was not a very great factor in the causation of heart disease in
children.
CIRCULATORY REACTIONS TO TEST EXERCISES IN CHILDREN WITH
HEART DISEASE.
Dr. May G. Wilson read this paper, a preliminary report
which had for its objects: (1) To increase the number of obser-
vations of a previous study on the circulatory reactions after test
exercises in normal children; (2) To compare the circulatory
reactions after test exercise in the cardiac group with those ob-
tained in the normal group; and (3) To study the exercise toler-
ance of children with heart disease to standard test exercises.
These investigations were conducted upon a group of average
690 New York Academy of Medicine — Section on Pediatrics
normal girls 10 to 15 years of age, and upon a group of 65 chil-
dren with cardiac disturbances, including all manifestations of
organic heart lesions, congenital and acquired, as well as possible
and potential heart disease.
The test exercises utilized were: (1) swinging 1 or 2 iron
dumb-bells (2, 3, 4, 5, 7, and 10 lbs. each) ; (2) stair-climbing
tests, 2 and 4 flights (20 to 60 steps) a rise of 15 and 30 feet taken
in 20 to 30 seconds; (3) jumping rope 100 times in 100 seconds;
(4) setting-up exercises, 30 minute drill daily for 6 weeks.
The circulatory reactions, following these test exercises in the
group of normal girls, and in the cardiac group, confirmed the
results obtained in the earlier investigation. The circulatory re-
actions following the stair-case test and the rope- jumping test
were similar to those obtained in the dumb-bell test.
A working table was formulated of standard test exercises
followed by normal systolic blood pressure curves, without symp-
toms of dyspnea and fatigue. It was standardized from an an-
alysis of reactions of an average group of 35 normal children,
according to age, weight and height.
The degree of distress and type of systolic blood pressure
curve following standard test exercises was used as a gauge in
estimating the exercise tolerance of children with heart disease.
Of the 40 children having definite organic heart disease, with-
out symptoms of insufficiency, approximately two-thirds had a
normal tolerance for standard test exercises, and one-third had
a fair tolerance. An analysis of the case histories of the cardiac
group showed that in 90 per cent, the children were excused from
school exercises ; in 75 per cent, free play had been interdicted by
either physician or parent, but nevertheless 61 per cent, admitted
ability to tolerate stairs and games equally well with playmates.
Five illustrative cases were cited.
THE PLACE OF TONSILLECTOMY IN THE MANAGEMENT OF CARDIAC
DISEASE IN CHILDREN.
Dr. William P. St. Lawrence made this contribution, which
consisted in an analysis of a series of 85 children, each of whom
had present 1 or several of the rheumatic manifestations before
the tonsils were completely removed and all of whom were ob-
served during an average period of 3_5^ years after the operation
New York Academy of Medicine — Section on Pediatrics 691
was performed. The tonsils were markedly hypertrophied in 13
per cent, of the cases, and not enlarged in 18 per cent, of the cases.
They were the site of recurrent inflammation before the tonsils
were removed in 72» per cent, of the cases. "Sore throat" recurred
after removal of the tonsils in 7 per cent, of these. At least 2
operations were necessary before the tonsils were completely re-
moved in at least 22 per cent, of the cases. The tonsillar lymph
nodes were enlarged in 100 per cent, of the cases before the opera-
tion was performed, while in 59 per cent, of the cases they were
impalpable afterwards. One or more attacks of acute rheumatic
fever had occurred in 42 cases before the tonsils were removed.
After tonsillectomy there were no more recurrences in 35 cases,
or 84 per cent. One or more attacks of chorea had occurred before
the removal of the tonsils in 40 cases, and there were no recur-
rences of the chorea in 20 of these cases, or 50 per cent. Sixty-
one cases showed myositis and bone or joint pains before operation
was performed, and there was no recurrence in 47 cases, or 77
per cent. Fifty-eight cases of organic disease of the heart were
present in the series. Twelve of these patients had suffered at
least 1 attack of cardiac failure before the tonsils were removed.
One patient suffered 1 attack afterward. The exercise tolerance
seemed to be favorably influenced by tonsillectomy in the cases of
cardiac disease in the instances in which indications existed for
the removal of the tonsils. Nutrition and general health were
improved, and intercurrent disease was less frequent after the
tonsils were removed. Tonsillectomy (complete removal of the
tonsils) would seem to be the most important measure at present
available for the prevention of acute rheumatic fever and the allied
rheumatic manifestations.
Discussion — Dr. Theodore B. Barringer, Jr., said he thought
Dr. Wilson had presented a very important piece of work because
it furnished the groundwork for the intelligent treatment of heart
disease in children by exercise. Of course it might be assumed
with much reason that children would respond to exercise treat-
ment in the same way that adults did, yet the actual proof had been
lacking until now. The speaker stated that he had been watching
Dr. Wilson's work on a number of occasions and was impressed
by the careful and conscientious technique she used. As regards
her results, it was quite interesting to see how rapidly the pulse
692 New York Academy of Medicine — Section on Pediatrics
returned to normal, almost invariably inside of 2 minutes. This
return to normal was of no value in children as a criterion of their
exercise tolerance and really of but little value in adults. The
effects of exercise upon the blood pressure curve showed the same
types as in adults. The term exercise tolerance Dr. Wilson used
very frequently. He felt that we should be very clear in our
minds as to the significance of that term. The term exercise
tolerance simply put before us the conception that the best way of
judging of a heart's capacity was by the way the person tolerated
exercise. That was a valid conception because the best way of
ascertaining any organ's capability was by setting it doing its own
particular work, and basing our judgment on the result of such
experiments. Whether a person tolerated exercise depended es-
sentially upon the heart's reserve power, assuming that the lungs
and muscles were functioning in a normal way. Dr. Wilson
qualified the term by specifying the amount and kind of exercise
and that was a very necessary qualification, because the term
exercise tolerance might mean very different things. One person
might tolerate walking on the level very easily, but would be
distinctly overtaxed by climbing stairs. One point brought out
was that 90 per cent, of cardiac children did not take exercise
in the public schools because it was interdicted. That was a
striking commentary on the way these children were being treat-
ed. Exercise undoubtedly increased the resistance to general
infections in those children exactly as it did in normal children,
and also in all probability increased the resistance of the heart
itself to reinfections. Dr. Wilson had made a very valuable con-
tribution because she had provided a sound experimental and
physiological basis for the treatment of heart disease in childhood
by physical exercise.
Dr. L. E. La Fetra said the important lesson to be drawn
from the papers was that as physicians we should foster a more
cheerful sentiment among the laity with regard to heart disease;
we should exercise the varicose vein of gloom.
Dr. Henry Heiman said he wished to say a word on Dr.
Halsey's paper. It was extremely difficult to tell what the future
was going to show when a child had his first and primary attack
of heart disease, whether this was going to recur or not. He
believed we were not in a position to say whether there would be
a recurrence. One met with instances in which there was 1
New York Academy of Medicine — Section on Pediatrics 693
attack and not another, while others had regular attacks perhaps
5 or 6 times until an attack terminated fatally.
In regard to Dr. Donaldson's paper, Dr. Heiman said he
agreed with him that in every aortic cardiac case the Wasser-
mann test should be made, but in very few would a positive
Wassermann be found. He also agreed with Dr. Barringer that
Dr. Wilson had given them a very valuable contribution. She had
given a test for the physiological heart and for the pathological
heart, so that one could test practically and accurately what a
patient could do. It recalled Gertel's work in mountain climbing
for adults with heart disease.
As to Dr. St. Lawrence's view of tonsillectomies, he stated
that a great many men gave merely opinions on the subject.
What we need is broader clinical observation. When a patient
was brought to us to determine whether the tonsils should be
removed or not, he thought all were agreed that there must be
definite indications for removal. These indications were (1)
hypertrophy with marked obstruction. (2) infection. (3) re-
peated attacks of tonsillitis. (4) enlarged adjacent lymphotus.
Of course when the tonsils were removed the child no longer had
repeated attacks of tonsillitis but there might be manifestations
of systemic infection. Many of these children previously diag-
nosed as having tonsillitis, after the tonsils were removed may
develop a pharyngitis, a faucitis or an adenitis, lasting 3 or 4
days. This is often diagnosed as a cold, or if there are symptoms
referred to the stomach, as stomach trouble. ' He believed the
systemic disease that would have caused tonsillitis if the tonsils
were not removed was present and frequently manifested itself
in other ways. It would be interesting to know whether diph-
theria develops, since this is an organism with a predilection for
the tonsils, after tonsillectomy. One word of warning in con-
nection with the subject of tonsillectomies might be in place. One
should never promise that a tonsillectomy would prevent a cold,
and it should be recommended only in cases in which it was
definitely indicated.
Dr. Herbert B. Wilcox said it should be gratifying to every
one interested in the handling of sick children to hear Dr. Halsey
emphasize the importance of the mental reaction of these young
patients to the limitations which their infirmity places upon them,
694' New York Academy of Medicine — Section on Pediatrics
and its possible exaggeration by the attitude of the parent, friends,
and particularly the physician, who alone often initiates this at-
titude, or is in the best position to control it. Whether this dis-
ability be due to cardiac or other systemic disturbance, there is
no more important element in determining the degree of effect
which the lesion is to produce on the child's life, than the failure
or success of those in control to produce in this child a proper
attitude toward his physical condition. This important factor
has been largely neglected ; it is probably true that the majority
of us have thought more of the physical effect of exercise than the
mental effect.
In regard to the role of the tonsils as a portal of entry, and a
seat of elaboration of toxins, Dr. St. Lawrence's experience and
belief must be those of all of us.
Children who have asthma, those who suffer from chronic
digestive disturbance with periodic exacerbations resulting in all
the evidences of acute gastrointestinal disturbance with toxemia ;
those who present repeated attacks of vomiting without apparent
cause ; each of such type seems to divide itself etiologically into
2 groups, the one depending upon continued absorption of the
products of bacterial activity from a known or unknown source,
the other depending upon the constant absorption of toxic ma-
terial due to disturbance of the chemistry of digestion. These 2
causative factors are about equal in importance, and of the former
the tonsil is at fault in the majority of cases.
Re-growth of the tonsil may occur more or less frequently
according to age, and of course according to the completeness of
its enucleation, and if recurring may cause a repetition of the
former poisoning.
There can be no doubt that the lingual tonsil is quite as im-
portant as the faucial tonsils in causing cough as a result of
mechanical irritation of the throat, and in increasing suscepti-
bility of the upper respiratory tract to infection. How much the
lingual tonsil is responsible for symptoms due to absorption is
less certain. It should however be considered in each case, and if
the growth of lymphoid tissue at this site is abnormal, it should
be as carefully removed as the contents of the tonsillar fossa.
Dr. Louis Faugeres Bishop said he thought the section was
to be congratulated on the meeting. He liked the idea of taking
the gloom out of heart disease. There was nothing greater which
New York Academy of Medicine — Section on Pediatrics 695
came to the man dealing with heart disease than the satisfaction
derived from the restoration of confidence. It was a great satis-
faction to see the psychological effect on the family of the child
who had heart disease when they learned that the child could do
many things that other children did. He had seen these children
with cardiac disease, who were practically invalids, after they
had learned that they could exercise come back at the end of a
year looking cheerful and bright, doing everything within reason,
and in every way different beings all because somebody used the
experimental method and the child was allowed to do anything
it could without objective or subjective discomfort. There was
no rule as to the amount of exercise that should be permitted.
He thought the old fashioned method of putting children to bed
for prolonged periods of time was very foolish. When the period
of infection had passed, there was certainly no reason for keeping
the child in bed. After a certain time the hypertrophy was no
greater if the child was allowed to be about than if it was kept
quiet. There was another very important point in the prognosis
and that was with reference to the effect of diet. These children,
especially those with aortic involvment, had a strong tendency
to develop kidney complications, and kidney complications were
much less likely to happen if the child was kept on a lacto-
vegetarian diet. A fatal termination in some of the worst cases
was indefinitely postponed by strict attention to diet. Also the
question of resistance needed emphasis. He felt sure these chil-
dren were much less apt to have infections if they were kept in
good health. If they were kept in bed their resistance was
lowered and they were much more likely to have infections than if
allowed to be about and play.
However, this doctrine of experimental determination of the
limits of exercise must be applied also to those with failing com-
pensation and those who do not respond must be duly restricted.
We have given the exercise pendulum such a push that it is sure
to go too far in unskillful hands.
Dr. Roger H. Dennett said he understood Dr. St. Lawrence
to advise the removal of the tonsils in 80 per cent, of the children
with cardiac disease. He did not see why Dr. St. Lawrence did
not say 100 per cent, of cardiac cases, in a child with good com-
pensation. It was perfectly obvious that we did not know what
was at the bottom of a tonsil by looking at the outside. If there
696 New York Academy of Medicine — Section on Pediatrics
was any opportunity for preventing the return of cardiac symptoms
by removing the tonsils, why not take out the tonsils in every case ?
He said that Dr. Wilcox spoke of the many cases of periodical
vomiting and cyclic vomiting and that many of these cases were
due to the tonsils. He thought that in the list of those conditions
in which the tonsils should be removed nephritis should be in-
cluded, and that the tonsils should be removed in 100 per cent,
of nephritis cases. Here was something we could do in a curative
way and in a very definite way, so why not do it every time?
With reference to Dr. Wilson's tests, he wondered whether she
had ever felt that the tests had ever done any harm in giving the
severe tests.
Dr. William Rosenson thought the psychological effect on
the patient and the patient's parents could not be emphasized too
strongly. We should not make a diagnosis of cardiac disease, as
often occurred, from simple auscultation of a cardiac murmur.
Frequently we saw cases diagnosed as cardiac disease by school
physicians and general practitioners simply because a cardiac
murmur was present. He had seen several such cases in which
there were loud, rough, blowing murmurs transmitted to the left
which were observed for some time and had entirely disappeared.
The electrocardiograms, however, were normal, the x-ray showed
no enlargement, and there was perfectly good function. He had
seen also a number of cases, about 10 per cent, in 200 at Mount
Sinai Hospital in which aortic insufficiency was associated with
mitral disease, and he did not think that aortic disease was as
rare as was once believed. In 1 case, in which there was a definite
aneurysm, the Wassermann was positive. Dr. Rosenson asked if
there were any direful effects from the strain of the tests ; if
dyspnea, pain and cyanosis were produced. He had seen 2 cases
of mitral stenosis without attacks of decompensation, both of
which developed definite auricular fibrillation, and went down hill
rapidly. These came on after moderately severe exertion.
Dr. Theodore B. Barringer, Jr., said he was much interested
in one question Dr. Rosenson brought up, and that was the result
of physical over-exertion in cardiac cases. His experience had
been quite negative in that respect. Some years ago he had had
3 cases that showed decompensation, which required 2 or 3 days
in bed and the administration of digitalis. Since then he had
New York Academy of Medicine — Section on Pediatrics 697
seen no such cases of decompensation due to over-exertion. A
paper was about to be published based on 1,000 cases of heart
disease treated by physical exercise out of doors in which the
author had seen only 2 or 3 instances of trouble following physi-
cal exertion and as a rule that cleared up after a day in bed. It
was extremely unusual to have decompensation due to over-exer-
tion ; he believed it was due to reinfection instead of over-exertion.
He would like to ask the last speaker whether he saw these cases
at the time the over-exertion occurred or 2 or 3 weeks afterward.
As a rule if the attack did not come on within 2 or 3 hours after
the over-exertion it was due to reinfection. In angina, recur-
rences are often the result of over-exertion.
Dr. L. E. La Fetra said that although it was a rare ocpur-
1 ence, sudden excessive physical exertion did produce decompen-
sation, and it was important to bear that fact in mind. These
cases reported as being subjected to the tests were under the
supervision of a physician and in these circumstances there was
no danger. There were, however, children who, if they walked
rapidly up 2 or 3 flights of stairs, would develop acute dilatation
at once from cardiac strain. As an illustration, Dr. La Fetra
said he had had a child under his care for valvular disease who
was doing quite well. Written instructions had been sent to the
boarding school she attended that she was not to walk up more
than 1 flight of stairs and that she should stop half way up the
stairway for 2 minutes. During a celebration at the school the
teacher who had the child under her special charge was called
away and the child ran up 2 flights of stairs. She was taken im-
mediately with faintness and there was difficulty in restoring her.
She developed an acute dilatation at once, had auricular fibrilla-
tion and later had a recrudescence of the cardiac infection, so
severe that she died after about 3 weeks.
Dr. Charles Hendee Smith said he wished to echo Dr. La
Fetra's experience. He had seen a young man, an athlete, 2 or 3
years out of college, carry a canoe weighing 75 pounds over a
mountain. Following this exertion the apex of the heart moved
out of the nipple line, there was a systolic murmur and dilatation
of the heart. Dr. Smith said he felt sure that Dr. Wilson and
Dr. Barringer did not give the exercise tests to hearts really
affected, and he did not believe any damage would result from
the test exercises as he had seen them given and had tried them
698 New York Academy of Medicine — Section on Pediatrics
himself. A child who had decompensation and whose heart muscle
was flabby and infected would not be harmed by these exercises.
Dr. Smith said that Dr. Halsey's paper on the psychology in
these cases had interested him very much. He had heard much
criticism that they were making these cardiac children neurasthen-
ics by putting them in a class by themselves. The organic case
was in a class by himself and the sooner he learned what he could
do and what he could not do the better for him. He could be
made perfectly cheerful, but he must learn his lesson, and the
sooner he learned it the better his chance for a long life. A
cardiac class was no more gloomy than a nutritional class or a
syphilis class or any other class.
About the tonsillectomies, it might be well to recall that tonsils
re-grew, and the leucocytes could come and reinfiltrate the same
region. He had seen cases in which the tonsils were removed
and within 3^ years there was re-growth of tonsillar tissue.
At the moment he could recall 2 children in whom the tonsils
were entirely removed when the children were 2 years of age.
Each of these children now had a beautiful pair of tonsils. Be-
side the lingual tonsil which remained and could be infected was
the postpharyngeal tissue which could also be reinfected just as
the tonsil.
Dr. Halsey, in closing the discussion, called attention to one
great advantage of physical exercise in cardiac cases — that was
the effect it produced on their psychology, making these patients
more optimistic. The old mental attitude toward heart disease
was still practically the rule, and it was only since exercise had
been begun in these cases that the mental attitude toward cardiac
cases was changing. He wished the confidence of physicians in
physical exercise to become such that they would feel safe in
going ahead and prescribing exercises, remembering always that
there must be a differentiation between individuals with different
conditions of the heart muscle. The danger was that in the great
enthusiasm over the application of exercise in the treatment of
heart disease, differentiation would not be made and they would
have patients doing 20 pounds of work when they should be doing
only 2 or 3 pounds, in which case, results such as Dr. La Fetra
had just related, would ensue. The lesson was to be very careful
until the patient learned the capacity of his own heart muscle.
In applying work they had seen a marked improvement in the
New York Academy of Medicine — Section on Pediatrics 699
mental attitude and that was one of the great helps that exercise
afforded. Children who had been shut out from games and ex-
ercise, and who spent their time in bed, improved rapidly when
they found they were no longer shut out from all activity.
Dr. Halsey cited the case of a girl 8 years old who had an
operation for appendicitis and it was found that she had a cardiac
murmur. After that discovery she was never allowed to leave
her mother. She was not allowed to play ordinary games, was
kept out of school and was a source of great anxiety to her
family. To find that she could play games and do many things
that other children could do was a great relief to the family and
a great joy to the child, and that was what exercise did; it im-
proved the psychology as well as the physiology.
Dr. May G. Wilson said she appreciated the question raised
by the gentlemen as to the danger of any harm resulting from the
exercise tests. She had felt the same way about a year ago, and
for this reason first investigated the reactions of normal children.
As Lewis advised, she proceeded slowly with cardiacs, first giving
simple tests that were not at all strenuous, and then gradually
working up. She did not wish to leave the impression that car-
diacs had been given test exercises which produced distress.
The initial test exercise was always much below the tolerance of
the child, and gradually increased. Of course it was understood
that one did not need to give an exercise tolerance test to a child
with cardiac failure ; that child belonged in bed.
Dr. William P. St. Lawrence said he thought Dr. Dennett
was right and he wished he had had the courage to take out the
tonsils in 100 per cent, of the cardiac cases. With reference to Dr.
La Fetra's case of heart failure following over-exertion. Dr. St.
Lawrence said he had had 25 cardiac children who had been ex-
ercising for 3 or 4 years and he had never seen any ill eflfects
from exercise within reason and with moderation. It would be
interesting to know whether in the case Dr. La Fetra cited there
was any other infection, and whether the child had a temperature
before the exertion. It was their custom to take the temperature
before allowing exercise, and if the child showed an elevation of
temperature it was excused from exercise.
Dr. La Fetra replied that the temperature had not been taken
before the child went up stairs. On the other hand, the child had
been free from temperature and the child was inspected each day.
700 New York Academy of Medicine — Section on Pediatrics
Emphasis should be placed on the fact that these test exercises
were given under the supervision of a physician. The cases of
heart failure occurred from over-exertion when the children were
not under such supervision. He quite agreed that cases of heart
failure from over-exertion were exceedingly rare in children un-
less there was infection, but they did happen. It was to be under-
stood that his remarks referred to the cardiac child who was
allowed to go to school and run up 3 or 4 flights of stairs when
there was no physician to regulate his exercise.
Dr. William P. St. Lawrence, in closing the discussion, said
he thought he had said that about 90 to 95 per cent, of cardiac
children presented indications for the removal of the tonsils. A
few cases presenting no indication other than slightly palpable
tonsillar nodes showed no recurrence of the rheumatic manifes-
tations after tonsillectomy. In these cases, however, the exercise
tolerance was in general much less favorably influenced than in
the cases where definite indications existed. With reference to
Dr. La Fetra's case of cardiac failure. Dr. St. Lawrence said that
he had been studying the exercise problem in a class of 125 car-
diac children during the past 4 or 5 years. In the absence of some
other factor, he had never seen harmful results from exercise in-
telligently administered. He had been impressed with the im-
portance of infection and toxemia in relation to the exercise tol-
erance in all degrees of cardiac disease but particularly in second
and third degree cases. It would be interesting to know if the
case Dr. La Fetra cited had any infection and whether the tem-
perature had been taken before the exertion. In the absence of
such a determination, he felt that infection could not be ruled out
by a physical examination, for he had frequently found tempera-
tures of 99 4-5° to 100 4-5° without symptom or sign of acute
disease. It was their custom at the cardiac exercise classes to
take the temperature at the beginning of each exercise period, and
when found to be above normal, exercise was forbidden.
DEPARTMENT OF ABSTRACTS
Cautley, Edmund: Alveolar Sarcoma with Metastases
IN THE Skull. (British Journal of Children's Diseases, July-
September, 1919, p. 144.)
Cautley records a case in a child 2^/2 years of age. When first
seen, he looked pale and drowsy, and lay on the right side with
the knees drawn up and his hand raised to the left ear. There
was slight rigidity of the neck, no ocular signs or fundus
changes. Normal knee jerks, slight tache cerebral and right
facial palsy. This latter persisted and some 5 weeks later the
head showed bilateral temporal bulgings. The head became
gradually larger when finally nodules about the size of marbles
appeared, especially on the vertex. Some of the lumps were hard,
others soft and almost fluctuating. These gradually assumed a
greenish tinge. He also developed enlarged inguinal, cervical, and
sub-maxillary lymph modes, hard tumors in the iliac fossae, and
abdominal lumps suggestive of a bilateral enlargement of the
kidneys. The presence of a tumor in the abdomen and metastases
in the skull suggested hypernephroma, and the curious color of
the child was in favor of chloroma. Both types of case are apt to
begin with anemia, or with a tumor of the orbit leading to
exophthalmos. Some cases of chloroma are ushered in with facial
palsy. But although the blood picture is not constant in chloroma,
it is generally a lymphemia of large cells, and the disease is some-
times regarded as a tumor of myeloblasts, arising primarily in
the bone marrow and causing metastases. In this patient the
blood-picture was one of a secondary anemia with a reversion of
the blood to a more infantile type, as so often occurs in diseases
in early life. During life the diagnosis of chloroma was considered
uncertain, and the case was looked upon as more likely to be one
of hypernephroma with secondary metastases. C. A. Lang.
Campbell, Harry : The Etiology, Prevention and Non-
Operative Treatment of Adenoids. (British Journal of Chil-
dren's Diseases, July-September, 1919, p. 140).
The author considers as the immediate cause of the hyperplasia
of adenoid tissue, some defect in the plasma bathing the indi-
vidual cells. The central factor in the causation as intestinal in-
digestion, due mainly to an excess of imperfectly insalivated
starchy food. This intestinal indigestion gives rise to the plasmic
701
702 Department of Abstracts
defect by the absorption of intestinal poisons. As a result of
this toxemia the tissues are saturated with poisons and nutrition
suffers. In consequence of this, the resistance to microbic in-
fection is lowered, especially noticeable in the case of those
microbes which give rise to catarrh ; there is a pronounced tend-
ency to catarrhs of the nasal passages, nasopharynx, bronchi and
intestines. These microbes generate toxins which, when conveyed
to the related adenoid tissues, cause the latter to take on hyper-
plasia. Thus catarrh of the mucous membrane related to the
pharyngeal tonsil tends to cause hypertrophy of the latter namely
adenoids. He also considers defective mastication as an impor-
tant factor in the causation. This may operate injuriously in 3
different ways: (1) If the jaws are not adequately used in
mastication, the nasal passages and nasopharynx fail to develop
properly, and it is generally acknowledged that adenoids occur
more frequently in those in whom these parts are ill-developed
than in others. (2) Vigorous mastication promotes the flow of
blood and lymph in the nasopharynx and related parts and thus
tends to establish a healthy condition of the mucous membrane
lining them; defective mastication has the opposite effect; (3)
Defective mastication, implying as it does imperfect salivary
digestion, promotes intestinal indigestion. In order to diminish
the prevalence of adenoids dietetic customs should be altered.
Crusty bread should be substituted for the spongy article ; pud-
dings should be limited to one or two days a week, and the quan-
tity of sugar should be kept within reasonable limits. On the
other hand, more raw vegetable food should be consumed in the
shape of salads and fruit. C. A. Lang.
Denis, W., and Talbot, Fritz B. : A Study of the Lactose.
Fat and Protein Content of Women's Milk. (American
Journal of Diseases of Children, August, 1919, p. 93.)
While the limits and variations in the fat and protein content
of human milk are well established, considerable uncertainty still
exists regarding the question of the amount of lactose in this
fluid. Denis and Talbot, during the past year, have by the help
of the titration method, collected data regarding the lactose fat
and protein content of human milk and have summarized as fol-
lows:
(1) There is a rapid increase of lactose during the first few
Department of Abstracts 703
days when colostrum changes into milk, and a further increase as
lactation progresses. The reverse is true of protein which, after
the first rapid decrease during the change from colostrum into
milk, tends to further decrease during the course of lactation.
After the colostrum period, there does not seem to be any relation
between the stage of lactation and the amount of fat in the milk.
(2) There is usually a higher percentage of lactose at the
beginning of a single nursing than at the end. Although this dif-
ference may be one or more per cent., it is usually less. It is al-
most the rule for the percentage of fat to be much higher at the
end of nursing than at the beginning. There is very little, if any,
difference in the protein.
(3) The milks taken simultaneously from both breasts of the
same woman tend to have the same composition, but often vary in
respect to the percentage of fat.
(4) Toward the middle or later afternoon the volume of milk
in a woman tends to diminish. The percentage of fat is as a rule
higher at mid-day or mid-afternoon than at other times of the
day. C. A. Lang.
Allan, James W. : Prenatal Tuberculosis. (The Glasgow
Medical Journal, January, 1920, p. 1.)
The author believes that ante-natal tuberculous infection is
more common than generally supposed and deplores that the
pendulum of medical opinion has swung so violently toward the
doctrine of contagion. In support of his contention he quotes the
evidence contributed individually by Bonney and Warthin relating
to intrauterine infection, through the placental circulation, and
Baumgarten's views relating to direct transmission of the bacilli
in utero. L. L. Shapiro.
FiNNEGAN, Francis A.: Institutional Control of Diph-
theria. (The Boston Medical and Surgical Journal, January 22,
1920, p. 93.)
Citing the success of protection obtained in two Massachusetts
institutions, and in New York by Park and Zingher by actively
immunizing with toxin anti-toxin in positive Schick cases, which
after two or more years showed negative re-Schick tests, Finne-
gan suggests the application of this test to a community. In this
way, the knowledge of the permanent immunes and the immuni-
704 Department of Abstracts
zation of the susceptible ones would control a disease, which con-
tinues to be one of the biggest issues of preventive medicine.
L. L. Shapiro.
Chodak, Hazel H. : A Case of Chorea Complicated by
Gangrene of the Fingers. (British Journal of Children's Dis-
eases, July-September, 1919, p. 148.)
The author records a case in a girl aged 12 years. The
patient suffered from a moderately severe attack of chorea, all
parts of the body being affected. There was very little loss of
strength on the left side, but the right hand grip was poor and
feebly sustained. The apex-beat of the heart was found in the
fourth interspace, half-an-inch inside the nipple line. A soft
blowing murmur accompanied the first sound at the apex, and was
transmitted a short way toward the axilla ; the second sound was
accentuated at the base. Ten days later the right hand began to
go white, the finger nails blue. The onset was rapid rather than
sudden, and it was fully a week before gangrene of the finger-tips
and ball of the thumb had definitely set in. The pallor gradually
spread up the forearm and the pulse disappeared from the wrist,
but the brachial artery could be felt pulsating about half-way down
the upper arm, and after a time there was distinct pulsation in
the superior profunda artery. The pain which was gradual in on-
set, became very severe after the first few days. The cardiac
signs became more marked and finally the apex beat was displaced
slightly outside the nipple line. Later still the brachial pulse slowly
disappeared from below upwards and the brachial artery could be
felt as a thick cord along the arm. The choric movements sub-
sided rapidly after gangrene was established and the heart signs
also disappeared. The little finger recovered and lines of demar-
cation gradually formed in the remaining fingers. The ball of the
thumb appeared at first to have escaped as the discolored skin
peeled away from it, but it subsequently appeared that there had
been damage to the muscles of the thenar eminence, which, fol-
lowed by contraction of the scar tissue, led to considerable deform-
ity of the thumb. He gives as the possible causes of the gangrene
(1) embolus; (2) arteritis leading to thrombosis; (3) arterial
spasm resembling Raynaud's disease. C. A. Lang.
ARCHIVES OF PEDIATRICS ADVERTISER
Just Published
Fifth Edition, Revised and Enlarged
The Diagnosis
of Nervous Diseases
By SIR JAMES PURVES STEWART, K.C.M.G., C.B., M.D., Edin., F.R.C.P.
Senior Physician to the Westminster Hospital; Physician to the Royal National Orthopedic Hospital;
Consulting Physician to the West End Hospital for Nervous Diseases; Membre Correspondant de la
Societe de Neurologic de Paris; Corresponding Member of the Philadelphia Neurological Society; Colonel,
Army Medical Service,
Seldom in practice are diseases met with in their fully-developed, so-called
"typical" forms ; more often patients exhibit signs and symptoms common to
several diseases. This volume approaches the subject of diagnosis from the
clinical standpoint, avoiding abstruse details of purely theoretical interest;
treatment is not discussed save incidentally here and there.
Since the fourth edition of this work was published three years ago, the
European War has happily come to an end. But even during the recent war
neurology has not ceased to advance. Numerous new and important facts
have been learned with reference to war injuries and diseases, whilst fresh
problems have also arisen in civilian neurology, many of them yet unsolved.
The present edition has been revised and in part rewritten. A short chapter
upon war neuroses, regarded from the clinical standpoint, has been added, but
without attempting to discuss the various metaphysical theories, more or less
abstruse, propounded to explain them by eminent psychologists of diflferent
schools.
SOME MEDICAL REVIEWS
"This well known and excellent work well de-
serves to appear in a new edition. The author
is singularly free from being insular in his views
and knowledge. Any contribution which has
proved fruitful in neurology is given fair men-
tion, whether emanating from home or abroad,
from friend or foe." — Journal American Medical
Association.
"The scheme of the book is well worked out.
It is not intended by any means to be an ex-
haustive text-book, but, as the title indicates,
it is a diagnosis. The anatomy and physiology
are adequately and well done. The fact that it
has reached its fifth edition is ample evidence
that the book is well worth while. — American
Journal of Medical Sciences.
"This work has already established itself among
the classics of neurology, and, as far as it relates
to organic nervous diseases, a hi^h measure of
praise may be awarded for its lucidity and com-
pleteness and the excellence of the plates and
diagrams." — London Practitioner.
"Of the value of this book to the student and
practitioner too much cannot be said. The teach-
ing of the intricate subject is based on a wide
personal experience and on a minute knowledge
of the literature. These have been skilfully woven
into a lucid exposition. A feature of the work
is the profusion of illustrations, both in black
and-white and colors. A diagram is never want-
ing when a point can be made clearer by one." —
London Medical Review.
8vo, 628 pages, with 298 illustrations, many in colors, from original dia-
grams and clinical photographs; also colored plates; cloth, prepaid, $11.00.
E. B. TREAT & CO., Medical Publishers
45 East 17th Street New York
ARCHIVES OF PEDIATKICS ADVERTISER
The Management of an Infant's Diet
In extreme emaciation, which is a characteristic
symptom of conditions commonly known as
Malnutrition,
Marasmus or Atrophy
it is difficult to give fat in sufficient amounts to satisfy
the nutritive needs; therefore, it is necessary to meet
this emergency by substituting some other energy-giving
food element. Carbohydrates in the form of maltose
and dextrins in the proportion that is found in
MELUN'S FOOD
are especially adapted to the requirements, for such
carbohydrates are readily assimilated and at once
furnish heat and energy so greatly needed by these
poorly nourished infants.
The method of preparing the diet and sugges
tions for meeting individual conditions sent to physi-
cians upon request.
MELLIN'S FOOD COMPANY
BOSTON, MASS.
ARCHIVES OF PEDIATRICS ADVERTISER
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ARCHIVES OF PEDIATRICS
Subscription $4.00 a'Year, in Advance Foreign, $4.50 Single Copy, SO Cents
Editorial Communications address to H. R. Mixsell, M.D., 134 East 76th Street, New York
Business Communications address to E. B. Treat & Co., 45 East 17th Street, New York
ORIGIIVAL ARTICLES, brief reports of REPRINTS (100) of original articles
rare and interesting cases, or new modes will be furnished gratis to authors mak-
of treatment are solicited, but none will ing the request direct to the publishers,
be considered for publication except with immediately upon receipt of galley proof,
the distinct understanding that it is Covers to these and extra reprints will be
contributed exclusively to this journal. furnished at cost. Or, in lieu of reprints,
All articles must be typewritten. The the publishers will, if so desired, mail to
editor and publishers will not be respon- individual addresses furnished by the au-
sible for views expressed. thor, twenty-five magazines.
ILLUSTRATIONS, as in the judgment of DISCONTINUANCES. — The publishers
the editor are necessary, will be furnished must be notified when a subscriber
free when black and white drawings or wishes his journal stopped and all arrear-
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on white paper. is desired. Journals returned are not
^^^,r.^,^,,.., ,, , notice of discontinuance.
COPYRIGHT. — Matter appearing in this
journal is covered by copyright, but no REMITTANCES should be made by
objection will be made to its reproduc- check, bank draft, money or express or-
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CHANGE OP ADDRESS NOTICE should give both the old and the new address
CONTENTS
ORIGINAL COMMUNICATIONS
Acute Otitis Media in Influenza from the Pediatric Standpoint.
By Percival Nicholson, M.D 706
The Etiology of Chorea. Report of a Relapse Accompanied by a Periton-
sillar Abscess.
By I. Harrison Tumpeer, M.D 717
End Results of Tonsillectomy.
By John A. Viktor, M.D 721
Lymphatic Leukemia, with Report of a Case.
By A. J. Scott, M.D 726
CLINICAL DEPARTMENT
Case Reports.
By Charles G. Kerley, M.D. and Edward J. Lorenze, Jr., M.D 733
Case Report.
By Philip S. Potter, M.D. and C. Clement Silverman, M.D 744
Contents continued on page v
ARC HUES OF PEDIATRICS ADVERTISER
When a patient conies to
you with that rather
vague complaint
*^ Rheumatism^ ^
What he wants first, and wants quick, is Relief.
Relief from the Pain, the Inflammation and the Congestion.
Relief from the Soreness and Stiffness of Limbs.
This accomplished, he will be ready and eager for the course of
general treatment mapped out by you for his particular type of
Rheumatism.
ATOPHAN seldom fails to relieve, and in the acute forms, it is
often all that is needed.
Its freedom from untoward by-effects on the heart, the kidneys
and the gastro-intestinal tract is as freely and generally conceded
as its superior efficacy.
U. S. A.— MADE AND AVAILABLE EVERYWHERE.
Literature and Information from
SCHERING & GLATZ, INC., 150 Maiden Lane, New York
DIATUSSIN
promptly and surely
Relieves
WHOOPING
COUGH
ASTHMA
BRONCHITIS
Write for samples and literature
Ernst
BIschoff Co-
Inc.
80
W. Broadway
New York
B. B.
CULTURE
A capable culture of Bacillus
Bulgaricus has a very definite place
in biological therapy, especially as
related to the practice of the
pediatrician.
B. B. CULTURE is in no sense
exclusively a "baby culture," but
the results of the past ten years
have shown it to be particularly
effective in this special work.
Samples and literature upon request.
B. B.
CULTURE LABORATORY
INCORPORATED
YONKERS NEW YORK
ARCHIVES OF PEDIATRICS ADVERTISER
CON TE N TS— Continued
MISCELLANY
Sinus-Thrombosis following Measles 747
Chickenpox Complicating Scarlet Fever 747
Meningismus from Severe Throat Infection 748
DEPARTMENT OF ABSTRACTS
Ross, Fred E. : Acute General Peritonitis in Infants 750
Hill, Lewis Webb: A Critical Discussion of certain phases in the Devel-
opment of Modern Infant Feeding ; their Influence upon present Teach-
ings 750
Epstein, J. W. : Intussusception in Infants with a Report of five cases. . . . 751
Stern, Arthur: The Umbilical Colic of Friedjung in Older Children.... 752
Hand, Alfred : The Diagnosis of Empyema in Children 752
Morse, John Lovett: A Study of the Relationship of Convulsions in In-
fancy and Childhood to Epilepsy 753
Rodda, F. C. : The Coagulation Time of Blood in the Nevv-Born 754
Clendening, Logan : The Cause of Abscess of the Lung after Tonsillectomy 755
Newton, McGuire : Chronic Appendicitis in Children 755
Contents continued on page vii
THE DIET IN TYPHOID
and other fevers and diseases prevalent
at this season
As the intestinal tract is seriously in-
volved in Typhoid fever, the dietetic
problem is one of first consideration. A
liquid diet is largely essential, in which
connection "Horlick's" has important ad-
vantages, being very palatable, bland and
affording the greatest nutriment with the
least digestive effort.
Samples prepaid upon request
Horlick's Malted Milk Co., Racine, Wis.
^"•W mn fOOD^S^HUTRITlOUS TABLE ORlW
Prepared by Dissolving in WaJ
»4>(JufACTURtR5 __
- _ J Malted MILK ^"••
c,,„ "-^C/NE. WIS., U. S. A. o.
^'" 8»ITAIN: SLOUCH. BUCHS. tHOt^''
Avoid imitations by prescribing
"Horlick's the Original"
ARCHIVES OF PEDIATRICS ADVERTISER
PREPARATIONS
TABLETS -CAPSULES— LIQUID CULTURES
INTRODUCE
tke Bacillus Acidophilus wKicK is an organism of Kigk acid
producing (antiputrefactive) qualities wKose
Normal Habitat is tHe Human Intestine
To ensure a suTiiciency of tnis natural derensive organism, -wken depletion
or extinction occurs Trom any cause "whatever, -we now offer tins
Bacillus Acidophilus in i^/l/^J/^ Preparations as a new
mmwlm/Mw§ therapeutic agent
LITERATURE-BIBLIOGRAPHY~ON REQUEST
Guaranteed and Manufactured ONLY by
THe Arlington CHemical Company
YONKERS, N. Y.
For Forty Years
Vaporized Cresolene
has held its position as a valuable remedy
for certain bronchial diseases of childhood.
It is particularly useful in the treatment of the very young.
Cresolene is indicated in Whooping Cough, Spasmodic Croup, Bron-
chitis, Asthma, Broncho-pneumonia, Coughs and the bronchial compli-
cations incident to Scarlet Fever and Measles.
Vaporized Cresolene is destructive to Diphtheria bacilli and may be
advantageously used in connection with the treatment of this disease.
Let us send you our descriptive and test booklet which
gives liberal sample offer.
TUi? ir Aork r^DC-crki CMC t^C\ ♦"* Cortlandt Street. NEW YORK
THE VAPO-CKtaOLtlNh CO., LeemlnB-MIIesBulldinB, Montreal. Canada
Widemann's Evaporated Goat Milk
A 100% Goat Milk Baby
The milk that gets results when all
other foods fail. Highly recom-
mended by the foremost physicians
and dietetians in cases of malnutri-
tion, and as a diet for tuberculars and
inxalids.
Samples and literature on request.
Widemann Goat Milk Company,
San Francisco, Cal.
ARCHIVES OF PEDIATRICS ADVERTISER tH
CONTENTS— Continued
Halsted, VV. S. : The Upturned Edge of the Liver over Acutely Dis-
tended Empyematous Gall-Bladder — A Diagnostic sign of some value 756
Myers, E. Lee : Adenoid Diphtheria — Report of a case 756
Reid, Mont R., and Montgomery, J. C. : Acute Cholecystitis in Children
as a Complication of Typhoid Fever 757
Brown, Alan, MacLachlan, Ida F., and Simpson, Roy: The Efifect of In-
travenous Injections of Calcium in Tetany and the Influence of Cod
Liver Oil and Phosphorus in the Retention of Calcium in the Blood. . 757
Mattill, P. M., Mayer, K. M., and Sauer, L. W. : Dextrose Tolerance in
Atrophic Infants 758
ITEMS
Atypical Epidemic Meningitis 725
The Foot Phenomenon in Meningitis 732
Bacteriologic Findings in Epidemic Encephalitis 746
Eczema in Infants 746
Physical Signs of Foreign Bodies in Bronchi 749
Subarachnoid Meningeal Hemorrhage 749
MADE IN AMERICA
Maltine Malt Soup Extract
— with which the preparation of Malt Soup becomes
easy and satisfactory.
Pamphlet reflecting the views of Dr. Keller will be
sent to physicians on application.
THE MALTINE COMPANY, Brooklyn, N. Y.
J
AKCHINES OF PEDIATRICS ADV KUTISKi4
ANY DEVITALIZED
CONDITION
calls for
REVITALIZATION
such emergency depend upon
GUDE'S PEPTO-MANGAN
(LIQUID)
(TABLET FORM)
to relieve the anemic element in Chlorosis, Amen-
orrhea, Bright's Disease, Chorea, Tuberculosis,
Rickets, Rheumatism, Malnutrition, Convalescence.
Prescribe in original packages only — never sold in hulk.
Samples and Literature upon request
M. J. BREITENBACH CO., New York, U. S. A.
Our Bacteriological Wall Chart or our Differential Diagnosis Chart will be sent to any Physician upon request.
ERGOAPIOL (Smith)
ITS UTILITY IN THE TREATMENT OF
Amenorrhea, Dysmenorrhea and other
Disturbances of Menstruation
Despite the fact that Ergoapiol
(Smith) exerts a pronounced analgesic
and sedative effect upon the entire
reproductive system, its use is not
attended with the objectionable by-
eflfects associated with anodyne or nar-
cotic drugs.
The unvariable certainty, agreeable-
ness and singular promptness with
which Ergoapiol (Smith) relieves the
several varieties of amenorrhea and
dysrnenorrhea has earned for it the un-
qualified endorsement of those members
of the profession who have subjected it
to exacting clinical tests.
O O 8 A O S ! OrdinwUx, one to two capaules
■honid be admiiilatcrad three or four time* a day
MARTIN H. SMITH CO.
NEW YORK. U. S. A.
The BLUES
(Splanchnic Neurasthenia)
By AI.BERT ABRAMS, M.D.
The object of this volume is to direct atten-
tion to a form of nerve weakness, popularly
known as "ike blues."
From the author's vast experience, he
knows of no variety of neurasthenia which
is more amenable to treatment. His methods
are described in detail and may be easily
executed.
In meeting the demand for a new edition the
author has taken opportunity to thoroughly
revise the text and to add a most important
chapter on "Augmenting the Tone of the
Splanchnic Circulation."
FOURTH EDITION Revised and Enlarged
8vo. 304 Pages. Illustrated. Cloth, $2.00
E. B. TREAT & CO., Medical Publishers
241-243 Weit 23d Street - NEW YORK
ARCHI\ KS OF PEDIATRICS ADVKRTISEK
LISTERINE
A N on- Poisonous, Unirritating Antiseptic Solution
Agreeable and satisfactory alike to the Physician, Surgeon, Nurse and
Patient. Listerine has a wide field of usefulness, and its unvarying
quality assures like results under like conditions.
AS A WASH AND DRESSING FOR WOUNDS.
AS A DEODORIZING, ANTISEPTIC LOTION.
AS A GARGLE, SPRAY OR DOUCHE.
AS A MOUTH-WASH-DENTIFRICE.
Operative or accidental wounds heal rapidly under a Listerine dressing,
as its action does not interfere with the natural reparative process.
The freedom of Listerine from possibility of poisonous effect is a dis-
tinct advantage, and especially so when the preparation is prescribed
for employment in the home.
LAMBERT PHARMACAL COMPANY
SAINT LOUIS, MO., U. S. A.
3A/heatsworfli
W W TIME IVM KSI$TERCD US. WT. OFF
pNDORSED and prescribed by lead-
■*-' ing Pediatrists, especially in Con-
stipation Diets.
A genuine whole wheat food product,
containing all of the bran and natural
mineral content of the wheat.
Extremely digestible, deliciously pal-
atable.
Full size, sample package mailed free
to physicians on request. Address,
F. H. BENNETT BISCUIT CO.,
130 Avenue D., New York City.
THE WHOLE WHEAT
CRACKER
ARCHIVES OF PEDIATRICS ADVERTISER
Quotations from Doctors: No. 8
"Recently I was called to see a pneumonia
case and found the man in a very bad condition
—disease allowed to run several days without
medical assistance. Examination revealed
complete consolidation of the lower lobe of
right lung; severe dyspnea, temperature! 04,F.,
high pulse-cyanosis.
"I left some medicine from my pocket
case-ordered a large can of
no wrapper on can-only my own directions.
It was correctly applied-patient's son reported
next day father much better. Following
morning found patient greatly improved— he
was restful— free from pain; cyanosis gone,
temperature lowered. Patient said: I don't
know what the application was, but I am
certain it saved my life.
R. C, M. D..
CHICAGO. ILL.
THE DENVER CHEMICAL MANUFACTURING COMPANY, NEW YORK
ARCHIVES OF PEDIATRICS ADVERTISER
A HUMAN BAROMETER
THIS COMPANY IS GREATLY INDEBTED TO THE MEDICAL PROFESSION FOR ITS
PHENOMENAL SUCCESS OF THE "PERFECTION" SPRINGLFSS BABY SCALE
The success of today was little dreamt of eight years ago when the first
"Perfection" was made.
The physicians who saw it then encouraged us by their assurance that a
scale of this character will fulfill a great need, and to go on, and on we went
regardless of cost, until we finally perfected a scale that is now used broadcast
with the utmost satisfaction.
Amongst its many users we include institutions such as
Post Qraduate Hospital of New York
^ellevae Hospital of New York
Columbia Hospital of IVashington, D. C.
Etc.
What Makes the "Perfection" the Acme of Accuracy
Is its simplicity of construction and that it is SPRINGLESS. The "Perfection" regis-
ters the weight of every quarter of an oimce up to 37 pounds or 52 pounds (latter ca-
pacity furnished by request only.)
Perfection with basket or metal tray, same shape as basket $22,50
Perfection with metal scoop $20.00
52 pound capacity $1.00 extra. F.O.B. New York.
Write for "Perfection" literature. Order through your dealer or direct from us.
The "Detecto" is a very desirable scale for weighing adults,
due to its compactness. Takes only 12 inches of space, yet regis-
ters every pound accurately up to 300 pounds. Equipped with a
7 inch dial registering a person's weight by stepping on the plat-
form. Price, $17.50.
The "Detecto" as well as the "Perfection" are of neat design,
white enameled and nickeled parts. Hence, a very pleasing ap-
pearance.
THE JACOBS BROS. CO.y INC-, new york city
Factories: 223-231 Wallabout Street, Brooklyn, N. Y.
ARCHIVES OF PEDIATRICS ADVERTISER
AUTHORIZED AMERICAN TRANSLATION
The Disorders of
METABOLISM
and NUTRITION
BY PROF. DR. CARL VON NOORDEN
COMPLETE WORKS
I — Obesity (Indications for Reduction Cures) $1.00
The conclusions as to appropriate diet, regimen and therapeutic measures for
its cure are very clearly laid down.
lI^Nephritis $1.50
The author's handling of the subject is bold and original. He prescribes a
therapy, the effectiveness of which he has proven.
Ill— Colitis (Colica Mucosa) $1.00
This valuable monograph contains the most clear-cut and satisfactory direc-
tions for the treatment of membranous catarrh of the intestines.
IV — The Acid Autointoxications $1.00
Cases of diabetes and other obscure chronic diseases cannot be managed
successfully without some knowledge of this subject.
V — Saline Therapy $1.00
The influence of the sodium chloride waters on the digestion, as well as in
gout, diabetes and other diseases is here discussed.
VI— Drink Restriction (Thirst Cures) $1.00
While many drink too little, of water particularly, the author has clearly
proven that many drink too much.
VII — Diabetes Mellitus. Its Pathological Chemistry and Treatment $1.50
Progressive practitioners will welcome this work of original investigations.
The section on treatment is exceptionally full.
VIII — Inanition and Fattening Cures $1.50
The author's criticism of innumerable dietetic fads and fallacies is of greatest
practical use as he provides something of value in their stead.
IX — Technique of Reduction Cures and Gout $1.50
The practical dietetics and general treatment of the subjects are given with
great exactness and make very interesting and instructive reading.
X — New Aspects of Diabetes. Pathology and Treatment $1.50
The author's vast experience with all phases of this disease enables him to
here set forth what has been found to be most true today concerning it.
Special Price on Complete Set, 10 Volumes, $12.00
Volumes Also Sold Singly. Add 7% for postage.
E. B. TREAT & CO., Medical Publishers - 45 East 17th Street - NEW YORK
AKCIIUES OF PliDlAI UlCS AlU KRTl.shR
The great reeonstructioe
potoers of ^/iROL
liave again and again been exhibited in re-
markable cases of Malnutrition, Emaciation,
and Wasting, whether from Tuberculosis or
other causes.
The series of Before and After photo-
graphs which we have published in this
Journal during recent months afford striking
illustration of the building-up properties of
Virol.
The value of Virol in Convalescence from
Fevers, Whooping Cough, and Measles, after
operations, and in such conditions as Gastri-
tis and Gastric Ulcer, has led to its use in
more than 2000 Hospitals, Infirmaries, and
Consumption Sanatoria in Great Britain.
Virol has a marked effect on the metabo-
lism of the body, increasing the production of
opsonins and stimulating phagocytosis. As
an adjuvant to the natural defensive proc-
esses of the patient in all diseases of bac-
terial origin its value can scarcely be over-
estimated. It is, moreover, unequalled as a
repairer of tissue waste, and is therefore of
especial value in those conditions which are
associated with the debilitating influences of
the specific fevers.
Liberal samples of VIROL and interesting litera-
ture will be mailed to physicians on request.
Virol is com-
posed of Red Mar-
row, extracted
from ox rib and
calves' bones by
C. P. glycerine ;
refined Marrow
and Beef Fat ;
highly diastasic
Malt Extract ;
Eggs; Lemon
Syrup and soluble
phosphates.
IN GLASS JARS:
SOc.tl.OO and $2.00
Sole Agents for U. S.
GEO. C. COOK & CO., Inc., .59 Bank Street, New York
ARCHIVES OF PEDIATRICS ADVERTISER
SECOND EDITION NOW READY
The blood
A GUIDE TO ITS EXAMINATION.
AND TO THE DIAGNOSIS AND
TREATMENT OF ITS DISEASES
By G. Lovell GuUand, F.R.C.P.E. ^ Alexander Goodall, F.R.C.P.E.
Physician to the Royal Infirmary fj^ I,ecturer on Physiology and ou Diseases of the Blood
and to the Royal Victoria Hospital for Consumption in the Edinburgh Post-Graduate Courses in Medicine
CONTENTS BY CHAPTERS
PART I.— METHODS OF EXAMINATION OF THE BLOOD
1. Examination of Fresh Specimens : Enum- 3. Estimation of Hemoglobin — Color Index,
eration of Red Corpuscles. 4 Examination of Stained Films.
2. Enumeration of Leucocytes. 5. Special Methods of Examination.
PART II.— THE FORMEE ELEMENTS OF THE BLOOD
6. The Erythrocytes. 10. The Blood in Infancy, Old Age, etc.
7. The Leucocytes. 11. The Blood in Certain Animals.
8. Number and Proportion of Leucocytes. 12. The Bone-Marrow and Its Reactions.
9. The Blood-Plates — Hemoconia. 13, Development of the Cells of the Blood.
PART III. DISEASES OF THE BLOOD, BONE-MARROW, AND LYMPHOID TISSUES
14. Pernicious Anemia. 22. Lymphadenoma — Hodgkin's Disease.
15. Chlorosis. 23. Multiple Myeloma,
16. Secondary Anemia. 24. Hemophilia.
17. Aplastic Anemia. 25. Purpura.
18. Splenic Anemia — Phagocytic Anemia. 26. Paroxysmal Hemoglobinuria.
19. Hematogenous Cyanosis — Lipemia. 27. Blood Diseases of Infancy and Childhood.
20. Leucocythemia. 28. Congenital Family Cholemia.
21. Leucocythemia — {Continued.) 29. Lymphatism.
PART IV.— THE BLOOD IN SPECIAL DISEASES
30. Infectious Diseases. 34. Diseases of the Ductless Glands.
31. Septic and Inflammatory Conditions. 35. Diseases of the Circulatory System.
32. Malignant Disease. Fractures and Wounds. 36. Diseases of the Skin, Genito-Urinary and
33. Diseases of the Alimentary System. Nervous Systems — General Diseases.
PART v.— DISEASES DUE TO ANIMAL PARASITES
37. Malaria or Ague. 41. Diseases Due to Spirochetes in the
38. Blackv«rater Fever. Blood — Relapsing and Tick Fevers.
39. Kala-Azar. 42. Filariasis.
40. Trypanosomiasis. 43. Piroplasmata — Hemogregarinida, etc.
Journal of the A. M. A., says: "The authors have had large experience in
teaching this subject and the volume bids fair to be one of great practical utility.
It is illustrated by a large number of colored plates showing, with beautiful
clearness, the appearance of the blood in various conditions. ' '
British Medical Journal, says: "The research and learning of the authors and
the richness of the clinical opportunities from which they have drawn their con-
clusions justify the opinion that this volume will, for a long time, be an authori-
tative guide to a most difl&cult but important medical subject. The excellent
colored plates deserve high praise. ' '
Second Edition— Large Sto., 60 excellent illustrations and
colored plates, cloth, prepaid, $7.00.
E. B. TREAT & CO., Medical Publishers - 45 East 17th Street - NEW YORK
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Archives of Pediatrics
DECEMBER. 1920
HAROLD RUCKMAN MIXSELL. A.B., M.D., Editor
CHARLES ALBERT LANG. M.B.. M.R.C.S.. Associate Editor
COLLABORATORS:
L. Emubtt Holt. M.D New York Fritz B. Talbot, M.D Boston
W. P. NoRTHRUP, M.D New York Maynard Ladd. M.D Boston
Augustus CaillS, M.D New York Charles Hunter Dunn, M.D.... Boston
Henry D. Chapin, M.D New York Henry I. Bowditch. M.D Boston
Francis Huber, M.D New York Richard M. Smith, M.D Boston
Henry Koplik, M.D New York L. R. De Buys, M.D New Orleans
Rowland G. Freeman, M.D....New York Robert A. Strong, M.D New Orleans
Walter Lester Carr, M.D. ..New York S. S. Adams, M.D Washington
C. G. Kerley, M.D New York B. K. Rachford, M.D Cincinnati
L. E. La FfiTRA, M.D New York Henry J. Gerstenberger, M.D. .Cleveland
Royal Storrs Haynes, M.D... New York Borden S. Veeder, M.D St. Louis
Oscar M. Schloss, M.D New York William P. Lucas, M.D... San Francisco
Herbert B. Wilcox, M.D New York R. Langley Porter, M.D..San Francisco
Charles Herrman, M.D New York E. C. Fleischner, M.D....San Francisco
Edwin E. Graham, M.D Philadelphia Frederick W. Schlutz, M.D.Minneapolis
{. P. Crozer Griffith, M.D.Philadelphia Julius P. Sedgwick, M.D. . .Minneapolis
. C. Gittings, M.D Philadelphia Edmund Cautley, M.D London
A. Graeme Mitchell, M.D. .Philadelphia G. A. Sutherland, M.D London
Charles A. Fife, M.D Philadelphia J. D. Rolleston, M.D London
H. C. Carpenter, M.D Philadelphia J. W. Ballantyne, M.D Edinburgh
Henry F. Helmholz, M.D Chicago Tames Carmichael, M.D Edinburgh
L A. Abt, M.D Chicago John Thomson, M.D Edinburgh
A. D. Blackader, M.D Montreal G. A. Wright, M.D Manchester
PUBLISHED MONTHLY BY E. B. TEEAT A CO., 45 EAST 17TH STREET, NEW TOBK.
EDITORIAL NOTE
With the December number, Archives of Pediatrics will
inaugurate a special Clinical Department which will appear from
time to time during the forthcoming year, as warranted by the
material offered. This will comprise short reports of interesting
clinical cases. Subscribers to AIrchives are cordially invited to
submit reports to this department. Other features of interest
for the new year will be semi-annual letters on current pediatric
progress in England and France, and a special English number
of Archives, which will appear in March. It is the opinion of
the editor that these new features, and in particular the Clinical
Department, will prove of great value, not only to the general
practitioner but also to the man who is specializing in pediatric
work and who is more interested in the purely clinical side of
pediatrics in contradistinction to the* laboratory and experimental
side. It is our intention to devote somewhat less space to the
various society reports, and more space to original articles,
and, to a lesser degree, to abstracts and book reviews.
ORIGINAL COMMUNICATIONS
ACUTE OTITIS MEDIA IN INFLUENZA FROM THE
PEDIATRIC STANDPOINT
By Percival Nicholson, M.D.
Ardmore, Peiina.
This subject of acute otitis media is an especially important
one for the pediatrist. Its importance has been clearly under-
stood by some pediatrists and many otologists; but in spite of
the tremendous prevalence of acute otitis media, there is an
appalling lack of definite understanding on the subject, as espe-
cially related to children and infants. That you may realize that
I am not alone in this view I wish to give a few quotations :
Dr. Charles Hunter Dunn^ says: "Infection of the cavity of the
middle ear is one of the commonest affections of infancy and
early childhood and is frequently met with in older children."
Dr. Charles P. Grayson^, from the standpoint of the otologist,
says : "Diseases of the tympanum comprise fully two-thirds of
all the diseases of the ear." Of acute otitis media, Dr. C. G.
Kerley' says : "The disease is of much more frequent occurrence in
children than adults. The younger the child, the greater the ap-
parent susceptibility. Otitis in young children is probably more
frequently overlooked by the practitioner than any other dis-
ease of childhood; it is because of its indefinite manifestations,
and the faulty teachings of the text books as to the symptoma-
tology of the disease."
That the incidence and diagnosis of acute otitis media is not
well understood is clearly shown by the large number of cases
sent to the children's hospitals with diagnoses of pneumonia,
meningitis, etc., which, on careful examination, are found to be
acute otitis media. I well remember the first time an electric
otoscope was used in the medical wards of the Children's Hos-
pital, when 4 cases, diagnosed as central pneumonia, turned out
to be acute otitis media.
In September, 1918, I saw a boy of 6 months who had had
a temperature of 104° to 106° for 5 days previous and who had
been seen by 3 physicians and diagnosed central pneumonia. The
706
Nicholson : Acute Otitis Media in Influenza 707
ears had been examined twice previous to my visit but nothing
had been found. An examination of the chest and throat was
negative. Otoscopic examination showed markedly bulging white
ear drums; both ears were opened and a large quantity of pus
escaped, the temperature falling to 102° in 2 hours. The child
fortunately recovered without any mastoid complications.
In one afternoon medical dispensary at the Children's Hos-
pital, out of 20 medical cases there were 3 cases of acute purulent
otitis media and one of acute purulent otitis media with marked
mastoid symptoms. The latter case, a 5 months infant, had
been seen one day previous when the temperature was 104°
and the only symptoms were those of enteritis. No otoscopic
examination had been made; but a note was made of a normal
chest. Diagnosis at the first visit was intestinal influenza. When
seen 24 hours later, the left ear drum was a brilliant red and
markedly bulging. There was tenderness over the mastoid tip
with edema and a temperature of 104°. On incision of the ear
drum, there was. a free flow of pus. The child was admitted to
the hospital ward and died 2 days later of mastoid abscess. From
the above you can easily understand that acute otitis media is a
very common disease of infancy and childhood, often not properly
diagnosed and treated. With this in view let us now briefly con-
sider acute otitis media, especially in relation to influenza.
Otitis media may be divided into (a) acute catarrhal or non-
suppurative; (b) acute suppurative otitis media; though from
a practical standpoint this classification is of little importance.
Etiology. Otitis media is almost always an extension by
continuity, through the eustachian tube, of an infective process
in the nasopharynx, therefore it is very seldom primary. Adenoid
vegetations, diseased tonsils and nasal obstructions are contrib-
uting factors. Owing to the patency of the eustachian tube in
infants and children and the tendency to adenoids, enlarged ton-
sils and throat infections, children and infants arc especially
liable to develop otitis media. Dentition is also a contributing
factor. The suppurative form of otitis media is especially liable
to affect infants and children as it is a frequent complication of
the more common children's diseases — measles, scarlet fever,
diphtheria, pneumonia, typhoid fever and influenza. Dr. S. Mac-
Cuen Smith* says: "Measles and influenza are probably produc-
tive of more serious aural disturbances than any other diseases
708 Nicholson: Acute Otitis Media in Influenza
combined. This is especially true of influenza as is shown by the
fact that, before its advent, tympanic and mastoid inflammations,
requiring operative intervention, were comparatively rare, whereas
at present these are among our most common diseases."
It is with the acute otitis media of influenzal origin that we
are especially concerned. Influenza is the commonest cause of
acute otitis media and in most cases, of the acute suppurative
type. The infection may involve children from birth to adult
life but is especially frequent in infants. In acute otitis media,
the bacteria may be the streptococcus, staphylococcus, pneumo-
coccus, Klebs-Loeffler, and influenza bacilli. On examination of
a purulent ear discharge, a mixed infection is often found in
which other organisms than the inciting ones may predominate,
so that frequently an influenzal ear infection may show few or no
influenzal bacilli in the discharge, other organisms predominating
and overgrowing them. In some severe cases, however, we may
obtain a pure culture of influenzal bacilli.
Lesions and Pathology. Infection in the nasopharynx enters
and travels along the eustachian tube into the ear, often causing
merely a hyperemia and swelling of the eustachian tube, and a
hyperemia of the tympanic cavity with varying degrees of hyper-
emia of the drum membrane. The hyperemia is followed by the
formation of a thin, bloody or straw-colored serum, which still
later may become purulent. The infection may end in any one
of these stages. Otitis media, due to an influenzal infection, is
very prone to rapidly become purulent. In influenzal otitis media,
owing to the large numbers and virulence of the bacteria, the
cellular tissue of the tympanum is involved and in most cases the
mastoid antrum as well. All cases with a profuse purulent dis-
charge involve the mastoid. The pus, if not evacuated by opera-
tion, in most cases ruptures through, and causes sloughing of
the drum membrane. This takes place in from 1 to 4 days in
severe cases; in mild, purulent cases, 10 to 14 days, discharging
profusely 1 to 2 weeks, then subsides. In 3 to 4 weeks it ceases
in the average case. The ear ossicles and bony walls of the ear
may also become involved and later we may have mastoiditis,
sinus thrombosis, pachymeningitis, brain abscess, etc.
Symptomatology. No more erroneous statements can be made
than those in the average text books on ear diseases. That in-
fants and young children, who are the most commonly affected
Nicholson : Acute Otitis Media in Influenza 709
of all the classes of otitis patients, have an entirely different symp-
tomatology from adults, does not seem to be considered. The
symptomatology in infants and children is most varied and often
vague. I shall simply mention the important symptoms and re-
view briefly their variations. The most constant symptom of
acute otitis media is elevation of temperature ranging from 100°
to 106°, though the usual range is from 100° to 103°. Dr. L.
E. Holt^ says of otitis media : "Of all the inflammatory conditions
which may be met in early life, there is perhaps none which more
frequently gives rise to obscure febrile symptoms." Often one
is called to see an infant or older child, who is quite restless,
cries day and night, without cause, will not take any food, and
has a sudden rise of temperature, from 101° to 103° or higher.
On close examination, one may determine that 3 to 7 days prior,
the child had a rhinitis, was exposed to influenza, or had a mild
attack of grippe. General examination discloses nothing. On
otoscopic examination, a well-marked acute otitis media will be
discovered.
Then again you may see a child with apparently all the symp-
toms of a pneumonia — rapid respirations, high temperature, rapid
pulse, dilating alae. At first sight, anyone would be inclined to
diagnose pneumonia, especially if the infant or child had been
sick a day or two with undoubted influenza. The examination
of the chest, while it would not give any definite signs, would not
eliminate a central, or more correctly speaking, a peripheral pneu-
monia, as the clinical signs might not be capable of determination
so early. A careful otoscopic examination in experienced hands
will often make the diagnosis of an acute otitis media plain. One
has to be on one's guard as often one will be treating an infant
or child for influenza or influenzal pneumonia where the tem-
perature, being already elevated, will not be an aid in diagnosing
acute otitis media. Just a few days ago an infant, evidently very
sick, with a temperature of 102°, and respirations of 30, was
brought to the dispensary. Examination: Ears, mouth, throat
and chest were negative and a tentative diagnosis of influenza
was given. Two days later I saw the infant, who then was quite
sick, face and both extremities showed considerable edema, the
temperature was 101°, respirations 50, weight 17 pounds, 1 ounce,
alae dilating, mouth and throat negative. The chest, posteriorly
on the right from the spine of the scapula to the base, was very
710 Nicholson : Acute Otitis Media in Influenza
dull and bronchial breathing was marked over the same area, no
rales. There was an easily diagnosed pneumonia. Ears: Both
external auditory canals were small with numerous hairs and a
large amount of wax. The wax was partially removed; the ear
drums were a normal color, no evidence of congestion and to
all appearances concave and normal. As the child was so sick, a
more extended examination was made and the ear drum was found
to be opaque and the normal light reflection absent, but there was
no bulging. Both ears were incised and thick pus exuded
through the incision.
On the other hand do not expect an elevated temperature in
all cases of uncomplicated otitis media. A child of 4 was
brought to me because the parents thought he seemed dull and did
not hear well, possibly on account of adenoids. Examination of the
nasopharynx was negative and otoscopic examination revealed
nothing' abnormal. The temperature was normal. The condi-
tion remained the same, the child being examined for 3 consecu-
tive days, when the ear drum became distinctly reddened and
showed slight bulging, but no elevation of temperature. On
incision of the ear drum, there was a flow of clear straw-colored
serum and the child's hearing gradually returned to normal.
After spontaneous rupture or incision of the ear drum, the
temperature usually falls promptly, though a slight elevation may
persist for a short time. A persistent high temperature, after a
paracentesis, means either an incomplete drainage, due to too
small an opening or too thick discharge, or that there is a com-
plication as mastoiditis, meningitis, etc.
Elevated temperatures in children and infants, whenever the
cause is not clear, demand otoscopic examination. While it is
not safe to expect an elevation of temperature in every case of
acute otitis media, in the influenzal type it is almost always found.
Next to temperature, pain is the most reliable symptom of
acute otitis media. While in older children you often have com-
plaints of distinct and violent ear-ache, and in infants pain is
sometimes exhibited by restlessness, fretfulness, crying and sleep-
less nights, many times in acute otitis media no such symptoms
are found, especially if the otitis media is a complication of some
other disease. The severity of the general condition overshadows
all local symptoms of pain. There are many cases, especially in
Nicholson: Acute Otitis Media in Influenza 711
infants, in which pain does not seem to be a factor, in fact, evi-
dence of localized pain in the acute otitis media of infancy is
more often lacking than present and is a very unreliable symp-
tom, and even older children often fail to show pain. This lack
of pain does not seem to be clearly understood, one often hearing
a physician say: "I did not think the child had ear trouble; he
did not show any sign of pain in his ear." Pain when found
in acute otitis media is a valuable aid in directing one to a cor-
rect diagnosis, but its absence should never cause one to fail to
examine the ears of a sick child. As a rule the degree of pain
depends on the acuteness of the inflammation, but even more
especially varies with the amount of pressure exerted by the
secretion pressing on the ear drum. Often in infants the first
evidence of acute otitis media is a purulent discharge without
any evidence of pain. Older children experience more pain on
account of the greater density of the drum membrane causing it
to rupture later. In a few cases there will be pain or tenderness
in front of thei external auditory meatus or over the mastoid
antrum. There are cases in which there is severe agonizing
ear-ache, which subsides, without apparent cause, often to return
again later. This process may be repeated one or more times
and finally recover without perforation of the ear drum. Here
you have a purulent otitis media which, by its own pressure and
the resistance of the ear drum, forces the purulent material down
the relatively large eustachian tube into the throat. Older chil-
dren describe the pain of acute otitis media as stinging. The
pain is usually paroxysmal, worse at night and often associated
with deafness and noises in the ear.
Prognosis. Almost all cases of acute purulent otitis media,
with early diagnosis and prompt treatment, recover without any
complication or subsequent involvement of hearing. Repeated
attacks of acute otitis media, no matter how well treated, eventu-
ally cause middle ear catarrh, with impairment of hearing, hence
the importance of removing tonsils, etc., as a form of preventive
treatment. In severe cases, (very few) mastoiditis, involvement
of the internal ear, facial paralysis, sinus thrombosis, meningitis
and brain abscess may develop. The facility with which menin-
gitis may be occasioned is explained by the close anatomical rela-
tion between tympanic and cranial cavities through the medium
of the petrosquamous suture in infancy. In infancy, previous
712 Nicholson : Acute Otitis Media in Influenza
to the closure of the fissure, a duplication of the dura mater
projects through it into the tympanum and blends with the muco-
periosteal lining of the cavity.
Diagnosis. The symptoms of acute influenzal otitis media
are often very obscure. Temperature, while usually present, is
by no means always found. Pain is a valuable aid but its absence
is of no diagnostic value. Leucocytosis in influenzal otitis media
is late usually when there is a complication, as mastoiditis or sinus
thrombosis. In uncomplicated influenza otitis media in 1918, we
found the count was usually 8,000 to 10,000, contrary to the usual
text-book figure of 15,000 to 20,000. As a diagnostic aid the
white cell count is of no value except to aid in determining the
onset of mastoiditis and sinus thrombosis.
A sudden elevation of temperature or persistence of tempera-
ture in the course of an influenzal infection should cause one to
suspect otitis media.
The temperature curve has no particular characteristics and
the onset of acute influenzal otitis media is similar to the onset
of any severe infection and may be accompanied by vomiting,
diarrhea, convulsions and a long train of symptoms none of
which are in any way characteristic of otitis media.
In a word, the diagnosis erf acute otitis media comes down to
this, every physician treating children should understand and
carry out careful otoscopic examination on every infant and child
who has a temperature, and at frequent intervals during the
course of every case of influenza. As the definite symptoms of
ear involvement are so often lacking, it is only by careful oto-
scopic examinations that acute otitis media can certainly be
recognized. The technique with a modern electric otoscope is
comparatively simple.
The more common appearances of the ear in acute otitis media
are easily recognized. You may have simply an intensely hyper-
emic drum head, a hyperemic and bulging ear drum, or a dull,
lusterless, white, opaque, bulging drum, or a bulging, opaque,
white tympanic membrane with distinct lines of clear cut red
blood vessels running in from the periphery toward the center
of the drum, which appears as a dimple; or you may find a con-
dition seldom seen in any other infection than influenza, an
intensely red drum with what appears as localized, highly raised,
deeply injected blebs, where the drum head joins the canal wall.
Nicholson : Acute Otitis Media in Influenza 713
situated usually in the posterior superior quadrant and often ex-
tending down into the posterior inferior quadrant. Unless you
carefully cleanse the external auditory canal of all waxy secretion
and epithelial scales, especially around the posterior margin, your
inspection will often fail to reveal the bulging drum where it is
easiest seen. It is also important, with a cotton-tipped applicator,
to wipe out any loose epithelium, lying right over the drum,
which often gives the appearance of a normal ear drum, when
in. reality the true bulging red drum lies beneath.
In infants especially, where the auditory canal is relatively
small and the hairs numerous, great care must be used not to
overlook a diseased ear drum.
Mastoiditis as a complication should be suspected in the
course of an acute otitis media when there is a rise of tempera-
ture with increase in general symptoms with no explainable cause
in the ear or infection elsewhere. Also suspect mastoiditis when,
after a paracentesis or rupture of the ear drum with a free dis-
charge, the temperature does not drop. An increasing leucocyte
count, tenderness back of the auricle and, on inspection, a drooping
of the posterior wall of the external auditory canal wall give
further confirmation of mastoiditis.
Treatment. The treatment depends on how early the case
is seen. If very early and the ear drum is slightly red and no
bulging, it is often well to apply, on an applicator through the
nose, a 1-2000 adrenalin solution in a 2 per cent, solution of
cocain, directly to the eustachian orifice, followed by an applica-
tions of 25 per cent, argyrol solution. This treatment can be
repeated daily and, in addition, an oil may be dropped into the
nose ervery third hour. With the local treatment combine purga-
tion, light diet and absolute rest in bed. The ear may be syringed
with hot boric acid solution, though I prefer not as it obscures
the progress of the case ; better use a 5 per cent, carbolic solution
in glycerin in the ear.
The ear should be examined at least daily and better oftener
and if in 24 hours symptoms are more marked or ear drums
appear more acutely inflamed, or if there is any bulging of the
drum head, perform immediate paracentesis. The importance of
early incision of the ear is well expressed by Dr. S. MacCuen
Smith* as follows: "The most important procedure, therefore.
714 Nicholson : Acute Otitis Media in Influenza
is the early and free incision of the membrana tympani, and,
although the rule still prevails, in the usual case, to wait until
the drum head bulges, this is a late and unsafe indication in acute
suppuration of the middle ear complicating the exanthemata and
influenza. It is best therefore, in all severe infections, to incise
the membrana tympani early, as this is our best means of pre-
venting additional complications. When the case is seen suffi-
ciently early, the drum head should never be allowed to rupture
spontaneously, as it is in such cases that complications most fre-
quently occur." If ruptufe has already taken place be sure that
the opening is large enough to afford good drainage, otherwise
enlarge it.
Paracentesis requires surgical cleanliness and in most cases
is a decidedly painful operation. Carefully remove all the wax
and loose epithelium and with an applicator place in the ear a
small pledget of cotton, wet with a solution of equal parts of
menthol, cocain and carbolic acid crystals, and leave it in contact
with the ear drum for 5 minutes. This will both anesthetize thor-
oroughly the drum and sterilize the external auditory canal.
After removal of the cotton pledget, with a straight bistoury
bladed paracentesis knife, make a clean, curved incision in the
ear drum, beginning in the lower posterior quadrant near the
canal wall and extending well up for one-quarter of the circle
into the upper posterior quadrant. If there is a free flow of
blood, serum, or thin pus, wipe out with an applicator, then
apply 5 per cent, carbolic acid in glycerin and plug the ear loosely
with sterile absorbent cotton. A word of caution: Do not force
the point of the paracentesis knife too deeply through the ear
drum and injure the bony wall beyond, nor extend the incision too
far up and injure the ear ossicles.
When the discharge is thick and will not flow out through
the incision, use slight pneumatic suction and then treat with
5 per cent, carbolic solution as before. Do not irrigate the ear,
especially if there is a bloody or serous discharge.
Dr. Francis B, Packard^ s^ys : "If the middle ear is free from
pus and the wound does not become infected, the incision will
as a rule heal completely within 48 hours. It is of the utmost
importance in catarrhal cases to refrain from syringing the ear
after the performance of a paracentesis. The introduction of
Nicholson : Acute Otitis Media in Influenza 715
fluid into the ear under these circumstances ahnost invariably
results in establishing a suppurative otitis media."
I think that this statement is also equally true of the sup-
purative forms of otitis media. By irrigation you are liable to
cause a secondary mixed infection and greatly increase the dan-
ger of severe complications.
Almost all text-books advise irrigation of abscessed ears after
incision, second, third or fourth hour, with hot aseptic or anti-
septic solution. Up to December, 1918, I used the same treat-
ment, varying it with wick drainage in some cases, but since
December I have in no instance used irrigations and have had
many less complications, in fact no operative ones, and the gen-
eral course of the otitis cases has been much shorter.
The after-treatment consists of daily inspection of the ear,
mopping out any pus and, if very thick, an occasional application
of pneumatic suction, then the application of 5 per cent, carbolic
acid in glycerin to the ear drum and external canal. A sudden
cessation of discharge, usually with increased constitutional symp-
toms, demands immediate inspection of the ear and, if there is
the slightest doubt as to good drainage, do a paracentesis at once,
followed by pneumatic suction if necessary.
If the drainage is not good or the drum bulges, the opening
is enlarged. Frequent paracentesis may be necessary during the
course of the case, without any subsequent bad effect on the
hearing, in fact safeguarding the membrana tympani from catarrh,
with thickening of the drum.
Early incision may be followed by a bloody discharge, with-
out any pus. The paracentesis however usually gives marked
and immediate relief. When in skillful, hands and with surgical
care, it is better to err on the side of operation rather than delay.
Dr. L. E. Holt^ expresses it very clearly when he says : "The
advantages of early paracentesis in acute otitis media can hardly
be overstated. I favor incising the drum membrane in cases of
doubt rather than waiting for more definite indications, with the
attendant risks of delay."
Whenever there is long continued very profuse discharge,
long continued elevation of temperature, after a free incision of
the ear drum, or mastoid tenderness, or edema, place an ice bag
just back of the ear. Do not be deceived by the fact that many
text-books lead to the assumption that mastoid cases are not
716 Nicholson : Acute Otitis Media in Influenza
found in infants. During this last year I saw 8 operative mas-
toid cases in infants from 9 to 15 months of age. All these
infants had perfect recoveries by early operation, with no im-
pairment of hearing.
In acute cases of otitis media, which in spite of daily cleansing
and the application of 5 per cent, carbolic acid in glycerin, and
paracentesis whenever the drum bulges, show a continued high
temperature, or the leucocyte count suddenly rises, suspect mas-
toid involvement, even if no mastoid tenderness or edema is
present.
Some cases have a persistent discharge in spite of any treat-
ment, though the temperature be normal. These cases bring
up the question of the use of vaccines. So far there is no reliable
evidence of the value of either stock or autogenous vaccines in
either the acute or chronic forms of otitis media.
Following an attack of acute otitis media, to prevent subse-
quent trouble, see that diseased tonsils and adenoids are removed.
A year ago a case of discharging otitis media of 4 months dura-
tion, which would not get well under any local or constitutional
treatment, cleared up the day following the removal of the ton-
sils and adenoids.
Summary. The symptoms of acute otitis media are so vague,
the number of cases so numerous, especially since the advent
of epidemic influenza, that every infant and child, with a tem-
perature, or with any of the exanthemata, or influenza should
have careful and repeated otoscopic examinations. If these cases
of otitis media are diagnosed and properly treated there will be
many less people with catarrh of the middle ear and impaired
hearing, and the number of operative mastoid cases will become a
negligible quantity. Diagnose carefully, treat early and never
await spontaneous rupture of the ear.
BIBLIOGRAPHY
1. Dunn, Charles Hunter: Pediatrics, The Hygienic and Medical Treatment of Chil-
dren.
2. Grayson, Charles P.: Diseases of Nose, Throat, and Ear.
3. Kerley, C. G.: The Treatment of the Diseases of Children.
4. Smith, S. MacCuen: Sajous' Analytical Encyclopedia of Practical Medicine.
5. Holt, L. E. : Diseases of Infancy and Childhood.
6. Packard, Francis B. : Diseases of the Nose, Throat and Ear.
THE ETIOLOGY OF CHOREA
Report of a Relapse Accompanied by a Peritonsillar
Abscess*
By I. Harrison Tumpeer, S.M., M.D.
Chicago
Since the definite etiology of chorea has not been established,
any observation on the appearance of a definite lesion with the
development of chorea would appear to be of value from the
suggestive standpoint. This case is reported because it demon-
strates the causative relation between the development of choreic
symptoms and a septic focus in the tonsil. A child with chorea,
who had so far recovered that twitchings had ceased, suflfered
an attack of acute tonsillitis with a subsequent peritonsillar ab-
scess. Coincident with the development of these complications,
the nervous symptoms returned with greater intensity than upon
entrance and as suddenly disappeared with the rupture of the
abscess and the subsidence of the tonsillitis. It is interesting to
note that there was a history of frequent tonsillitis but no history
of rheumatism. In the medical management of the case there
occurred a skin eruption following the administration of veronal.
Case Report. The patient was a girl of 10 years, admitted to
the service of Dr. I. A. Abt for muscular twitchings, inability to
hold objects and a speech disturbance. The disorder began 3
months before in the form of restlessness. Later there occurred
twitchings of the right shoulder. These jerky movements ex-
tended to the legs so that she could not stand still. The arms
were involved so that she could not hold a cup without spilling
its contents. She was awkward in feeding herself and spoke
in a halting manner. She had had frequent attacks of tonsil-
litis, measles 5 years before, whooping cough 7 years before, and
had suffered fractures of both arms and scalp wounds in a street
car accident 4 years before. Five other children in the family
were living and well. There were no miscarriages.
Physical examination revealed a well-nourished child who
did not appear acutely ill. She was extremely fidgety and tossed
from one side of the bed to the other. She grinned throughout the
examination and appeared contented. There were gross tremors
of the fingers when extended and parted, coarse twitchings on
* From the Sarah Morris Memorial Hospital.
717
718 Tumpker: Tlic Iltiology of Chorea
both sides of the body and jerky, slurred speech. The tongue,
also, exhibited a coarse tremor. There were many decayed
stumps of teeth, and the tonsils were enlarged and buried behind
the pillars. Cervical adenopathy was not marked. There were no
remarkable cardiac findings save an accentuated second pulmonic
tone.
Repeated urinary examinations yielded no pathological find-
ings, and a catheterized specimen was negative for bacteria. The
throat culture contained a variety of the common organisms but
no diphtheria bacilli. There were 4,8(X),(XX) erythrocytes, and
of 13,200 leucocytes on entrance there were 67 per cent, neu-
trophiles, 20 per cent, lymphocytes, 9 per cent, large mononuclears,
2 per cent, eosinophiles, and 1 per cent, transitionals. The hemo-
globin was 70 per cent. Systolic blood pressure was 90 ; diastolic
58; and pulse 32. Rectal temperature varied between 99.2° and
100°. Pulse was 88 to 112; and respiration 20 to 24.
Initial treatment consisted of absolute rest in bed isolated
from the other children. She was given a wet pack for 20 min-
utes every 4 hours for a week and an enema daily. Fowler's
solution was given in increasing and diminishing doses from 1
to 5 minims 3 times a day for 2 weeks. After an interval of 2
weeks she was given 2 grains of veronal 3 times a day for 10
days. The child developed a diffuse, erythematous, maculopapu
lar rash, particularly on the forearms. There were some lesions
on the cheeks and a few on the legs. In a few days the eruption
disappeared. Luminal was administered for 1 week after a pause
of 10 days following the veronal.
Three weeks after entrance, the nervous symptoms had prac-
tically subsided. One month after entrance the pulse became
irregular with a pause after every third or fourth beat. Occa-
sionally the first systole after the pause was rough. Seventeen
days after the irregularity was observed, the electrocardiograph
still showed a slight arrhythmia with a normal cardiac mechanism.
A routine white count 7 weeks after entrance showed 9,600 leu-
cocytes. A few days later she complained of headache and sore
throat. The tonsils and pillars were red and angry. The twitch-
ings returned with greater intensity than they had ever shown.
There was pain in the left ear. The temperature was 103°,
pulse 146, and respirations 20. Thei leucocyte count was now
16,600. The throat cultures contained streptococci but no diph-
TuMPEEK : The Etiology of Chorea 719
theria bacilli. Four days after the onset of the tonsillitis there
was slightly more prominence of the left side of the throat, and
adenopathy and tenderness were more marked on the same side.
The white count was now 28,400. The next day the bulging on
the left side was more marked, and later in the day the abscess
burst spontaneously with prompt relief of the symptoms in the
throat. Simultaneously the twitchings ceased, and the child
rested quietly proceeding to recovery.
DISCUSSION
Although no specific agent can as yet be ascribed to chorea
one may conclude from the literature that an infectious factor is
at work. Many observers have isolated organisms from the
blood, spinal fluid and brain tissues. The findings, however, are
inconstant, and the organism is not the same. Westphal, Was-
sermann and Makoff^ isolated a diplococcus from the spinal fluid
which produced polyarthritis in rabbits. Painese^ found a diplo-
bacillus and a diplococcus and was able to produce experimental
chorea by injection of cultures of these organisms. Poyn-
ton and Paine^ isolated a diplc 'occus from a joint in rheumatism
which produced polyarthritis, endocarditis and chorea in animals.
Preobrazhensky* isolated a streptococcus in a severe case suc-
cessfully treated with antistreptococcus serum when sedatives
failed. In this case it would be difficult to determine that the
recovery was not spontaneous. Reichhardt' found a staphylo-
coccus in the blood in a post-mortem examination of a case. This
may easily have been an agonal invasion.
The brain, itself, has been sought as the focus of infection.
Gowers" expressed the opinion that chorea was due to a toxic,
infectious lesion of the cerebellum not sufficient to cause gross
anatomic changes. Griffith^ reports the recovery of bacteria from
the cerebral tissues in 2 fatal cases. The finding of organisms
in the blood or in the brain tissues is exceptional. Many believe
that there is no conclusive evidence that the organisms found are
concerned in the production of the symptoms of chorea despite
the reports of animal inoculation. Oppenheim^ believes that the
evidence of microorganisms in the brains of choreic cases sup-
porting the theory of cerebral infection is scanty and uncer-
tain.
For the most part rheumatism is credited with preparing the
soil for the production of chorea. Cheadle early called the atten-
720 Tumpeer: The Etiology of Chorea
tion of medical men to the relation of tonsillitis, endocarditis,
rheumatism and chorea. Since his time the conception has re-
mained. Hirt** states his position this way : Chorea is the result
of a toxic agent which affecting the cortex produces chorea and
affecting the joints causes rheumatism. Wollenberg terms it a
metarheumatic affection. Duckworth calls it rheumatism of the
brain; and Heubner regards chorea as the rheumatic equivalent.
Still" believes that the post-scarlatinal cases of chorea belong to
the rheumatic group because in his experience such cases are
usually accompanied by other manifestations of ordinary rheu-
matism.
The prominence of the rheumatic factor leads to a considera-
tion of the tonsil both as a source of rheumatic infection and as
a portal of entry. Dunn^^ states that there is strong reason for
believing that chorea is one of the manifestations of tonsillar in-
fection while Chapin and Pisek^- remark that hypertrophied ton-
sils are associated with the disease. Graham^^ suggests that the
organisms gain entrance through the tonsil. Jochmann" states
that the tonsils frequently contain plugs of caseous material in
the lacunae and that this is the seat of the chronic infection.
When these foci are removed he maintains that the disease clears
up. Morse and Floyd^*^ found diseased tonsils in 42 per cent,
of cases. Abt and Levinson^® reviewed 135 cases of which 35
per cent, gavei a history of tonsillitis.
CONCLUSION
The case reported here is unusual because it illustrates a
relation between the development of choreic symptoms and the
formation of an acute tonsillitis and a peritonsillar abscess. Grant-
ing the presence of a nervous, in this case choreic, basis, we
should conclude that the relationship is, at least, of an exciting
nature.
BIBLIOGRAPHY
1. Westphal, Wassermann and Makoff: Berl. Klin. Woch., 1899, 36, 638.
2. Painese: Oppenheim Text Book, 1911, Vol. 2, 1284.
3. Poynton and Paine: Researches On Rheumatism, 1914, 238.
4. Preobrazhensky: Filatov, Dis. Child., 1904, 364.
5. Reichhardt: Deut. Arch. Klin. Med. 1901, Vol. 72, No. 5 and 6, 506.
6. Gowers: Pfaundler and Schlossmann, 1908, Vol. 4, 316.
7. Griffith: Dis. Child., 1919, 2, 259.
8. oppenheim: Edin. 1911, Vol. 2, 1284.
9. Hirt: Sachs, Nerv. Dis. Child., 1899, 485.
10. Still: Dis. Child., 3 ed., 1915, 516.
11. Dunn: Syst. Ped., 1917, Vol. 2, 790.
12. Chapin and Pisek: Dis. Inf. Child., 1911, 2 ed., 512.
13. Graham: Dis. Child., 1916, 841.
14. Tochmann: Lehrbuch. Infek., Berlin, 1914, 303.
15. Morse and Floyd: Tr. Am. Ped. Soc, 1916, 28, 215.
16. Abt and Levinson: J. A. M. A., 1916, 67, 1342.
END RESULTS OF TONSILLECTOMY*
By John A. Vietor, M.D., F.A.C.S.
New York.
The following is a statistical report of 500 consecutive cases
of tonsils and adenoids operated upon by the Second Surgical
Division of the New York Hospital from April 1, 1915, to Octo-
ber 1, 1919. The end results are arrived at through our Follow-
Up Clinic. It has been our endeavor to follow all cases for one
year after their discharge from the hospital, the first examina-
tion taking place in 3 months, and subsequent examinations at
such intervals as seems of interest to the surgeon or importance
to the patient. All cases are personally seen by one of the at-
tending surgeons, except in those instances where it is im-
possible to have the patient return. Reports based solely on
letters or visits by our Social Service nurse are not classed as
end results.
On each return to the FoUow-Up CHnic, a careful history is
taken. This covers the progress of the patient since the discharge
from the hospital or from the time of the last examination.
Emphasis is laid on the gain or loss in weight and strength;
occurrence or frequency of sore throat; change in breathing,
voice or hearing. The patient is then examined by one of the
attending surgeons and notations are made of any remaining
tonsillar tissue, the condition of the pillars, fauces and uvula. The
breathing is noted and presence or absence of ear discharge is
looked for.
The result at each examination is put down, but not classed
as an end or final result until the patient is discharged from the
Follow-Up Clinic. This tentative result is classified under 2
headings: "The Anatomical Result," and "The Symptomatic
Result." Under each heading we classify again: "Good, Fair
or Poor." Consequently a patient may have a good sympto-
matic result and a poor anatomical result.
Of the total 500 cases, 394 or 79 per cent, have been fol-
lowed for an average period of 5^ months. 106 cases or 21 per
cent, were lost, or observations were based solely upon the re-
•Read before the Section on Surgery, New York Academy of Medicine,
November 5, 1920.
For the privilege of collecting and reporting this series of cases, I am indebted
to Dr. Eugene H. Pool, Attending Surgeon of the Second Surgical Division.
721
722 ViETOR : End Results of Tonsillectomy
ports of the Social Service nurse. Of the 394 cases, 327 or 88
per cent, were children referred to the Service by local school
boards, or public health officers for frequent sore throats, faulty
breathing or simple hypertrophy. The remaining 44 cases were
admitted for other complaints. In some of these cases the tonsils
or adenoids were an independent or a relatively minor lesion ;
in others, they were apparently an etiological factor of an infec-
tious process elsewhere.
In 26 cases, the tonsils were hypertrophied and were removed
as a prophylactic measure at the time of an operation performed
for an independent condition, such as : circumcision, hernia,
chronic appendicitis and Pott's fracture.
The cases in which the tonsils and adenoids acted as a con-
tributary or an etiological factor were : tubercular lymph nodes,
8 ; arthritis of knee, 3 ; chronic valvular disease, 2 ; chorea, 2 ;
chronic otitis media, 3 ; 18 in all.
Of the 394 cases followed, 97 per cent, were reported sympto-
matically good and 3 per cent, as fair. Anatomically, the results
were 84 per cent, good, 10 per cent, fair and 6 per cent, poor.
In the 3 per cent, reported as symptomatically fair, the com-
plaints were as follows : Two complained of frequent sore
throats ; 1 of difficulty in breathing and 2 as not being benefited
by the operation. One of the 2 complaining of frequent sore
throats had a recurrence of tonsillar tissue, was operated on
secondarily, and was later reported as good. The case that com-
plained of diflficulty in breathing had, on examination, a deviated
septum and was referred to the Nose and Throat Clinic for treat-
ment. The 2 cases not benefited by the operation refused further
treatment.
In classifying the anatomical results, the amount of tonsillar
tissue present, whether in one or both fossae, the condition of
the pillars, the ease of breathing and the condition of the uvula,
determined the rating. If a small piece of tonsillar tissue was
seen on one side, the condition was classed as fair, while if on
both sides, as poor.
Taking up the results of the 18 cases in, which the tonsils
and adenoids were supposed to be etiologic or contributory fac-
tors, we have the following: The 2 cases of chronic valvular
disease were not benefited by operation. Of the 2 cases of chorea,
1 was markedly benefited by operation for l^^ years, then had a
ViETOR : End Results of Tonsillectomy 723
relapse and was readmitted to the hospital on the medical service.
Since that time the patient has been lost track of. The other was
not benefited. Of the 8 cases of cervical lymph nodes, 2 cleared
up entirely. One of these was a man who also had syphilis and
took anti-luetic treatment after his operation. Possibly his
cure was due to the anti-syphilitic treatment. However, as the
general opinion is that the tonsils are often the portal of entry
for tuberculosis of the cervical lymph nodes, it has been our policy
to perform a primary tonsillectomy and later a node dissection,
if necessary. Consequently, the effect on the nodes by the ton-
sillectomy is not ascertained, as enough time is not given to get
an end-result.
Chronic otitis media affords a brilliant field for adenoidectomy.
Three cases in which the ear discharge had been present from 1
to 7 years were completely relieved of the discharge within a
week after the operation, and had not recurred when last heard
from 6 months after leaving the hospital.
Three cases of chronic arthritis were operated upon believing
the tonsil to be the seat of the infection. One case was not bene-
fited. The other 2 showed immediate and permanent relief from
all joint symptoms, one, 2 weeks after operation, and the other
2 months after, and continued to be without any joint symptoms
when last heard from 5 months after the operation.
The routine treatment of tonsil cases is practically the same
in all cases. A complete physical examination, including a urine
examination, and in children, a Schick test, is made on admission.
If any contra-indication, as recent tonsillar or respiratory infec-
tion, is found or suspected, the operation is postponed or omitted.
On the evening before the operation, castor oil is given followed
by a soap-suds enema in the morning, and nothing by mouth.
The operation itself was performed in the operating room un-
der a general anesthetic (nitrous oxide gas and ether) with only
2 exceptions, when a local anesthetic was used and the operation
was performed by Dr. James P. Erskine, the consulting laryn-
gologist. No operations were done in the Out-Patient Depart-
ment, as that procedure is considered unsafe and dangerous on
account of subsequent bleeding and danger of infection in an
open throat.
Technique. — Since the fall of 1915 the tonsils have been
724 ViETOR : End Results of Tonsillectomy
enucleated by dissection with instruments instead of by the finger.
The Rose position, combined with the Hitz mouth gag and the
Pool and Kenyon aspirator, with a specially designed suction tip,
is used in order to get the best exposure and protect the patient
from aspiration of blood, mucus and pus. The tonsils are re-
moved by the snare and adenoids by curette, followed by finger
palpation to insure a perfectly clean nasopharynx. After opera-
tion, patients are put to bed and kept quiet, special observation
being kept for any undue hemorrhage. If 1 day after operation
the temperature is normal, patients are allowed up on doctor's
order. Children are usually kept in bed a day longer than adults,
and no throat irrigations or applications are employed on either
as routine.
Complications. — Complications are divided into 2 groups:
early and late. The early ones comprise those arising in the hos-
pital before discharge. The late ones are those which develop
after discharge.
Of the early cases there are : hemorrhage, 5 ; lobar pneu-
monia, 1; abscess of neck, 1; diphtheria, 1; acute mastoiditis, 1.
To take up briefly the individual cases : Of 5 cases of hem-
orrhage, 3 necessitated a secondary procedure (which consisted
of ligation of the bleeding vessel) under a general anesthetic.
The other two cases were controlled by pressure. In no case was
the hemorrhage severe enough to do any radical operation, or the
sequelae bad enough for infusion or transfusion. The end re-
sults of all these cases were reported good. It is striking that
there was only 1 case of post-operative pneumonia. This was
of the lobar type and the patient had an uneventful recovery and
good final tonsil result. The reasons for this relative freedom
from pneumonia are to my mind :
1. Care in selection of the cases based on careful and complete
physical examination.
2. Postponement of the operation after a recent tonsillar or
respiratory infection.
3. Ante-operative preparation.
4. The Rose position, and the use of the aspirator during opera-
tion, preventing aspiration.
5. Post-operative observation in the hospital.
Although the Schick test was made in every child, 1 developed
ViETOR : End Results of Tonsillectomy 725
diphtheria shortly after the operation. This case was transferred
to an isolation hospital where it made an uneventful recovery.
This child was examined and reported as a satisfactory result.
One case of acute mastoiditis developed 2 days after its dis-
charge from the hospital. It was readmitted and operated upon
for this condition ; had an uneventful recovery, and 3 months later
was reported good for both conditions.
Of late complications in all cases followed for at least 3
months or more, there are few to record. Lung abscess, a con-
dition so much feared and mentioned by so many authors as a
frequent occurrence after tonsillectomy, did not occur to our
knowledge in any cases either followed or heard from. Late
conditions noted by the examining surgeon, but not complained
of by the patient, were: scar tissue contractions of the pillars
and loss of the uvula (1 case).
CONCLUSIONS
1. Tonsillectomy and adenoidectomy in well chosen cases,
performed by general surgeons, in a general service, under proper
conditions, show 97 per cent, symptomatically good results.
2. The complications arising either early or late are few
and not severe in character.
3. The benefits arising both in simple cases and those in
which tonsils act as a portal of entry, warrant their removal.
4. The dangers of the operation are almost nil, as shown
by the fact that there were no deaths due directly or indirectly
to the operation in this series of 500 consecutive cases.
8 East 66th Street.
Atypical Epidemic Meningitis (Gazzetta degli Ospedali e
delle Cliniche, Milan, Nov. 30, 1919.) In G. Salvetti's two cases
the onset was insidious, suggesting ordinary influenza at first.
There was no vomiting, and the mind was clear throughout except
just before death in one case. The temperature was always rela-
tively low, and the lumbar puncture fluid seemed to be normal ex-
cept for slight turbidity only at the first or second puncture, but
the meningococcus was cultivated from the fluid in both cases.
The fatal outcome in one case was a surprise after the extremely
mild course in both. — Journal A. M. A.
LYMPHATIC LEUKEMIA, WITH REPORT OF A CASE
By a. J. Scott, Jr., M.D.
Los Angeles.
The study of lymphatic leukemia, as reported in the current
literature and in most of the text-books, seems to be devoted
principally to the disease as manifested in adults. Very little is
outlined of what is seen in very young children, although cases
are mentioned as occurring in the young.
Briefly some salient points of the disease are :
Age. Usually according to the cases reported in the litera-
ture, from 9 years up. Ruhrah mentions a case which is reported
in an infant of 16 days. Cabot^ mentions 5 cases, 2 to 4 months
of age, and 3, from 1 to 10 years. The age incidence and num-
ber of cases increase in direct ratio.
Sex. In this type of disease the males seem to predominate.
Etiology. There is no uniformity of opinion. No real cause
is known for the disease. Many theories are advanced, but they
all sum themselves up into 2 general ideas, namely: 1, a type of
tumor with metastasis; and 2, an acute infectious process. Tak-
ing the former first, Mallory- considers it as "really a circulating
tumor metastasis". Stengel and Fox^ say: 'Tt is impossible to
classify leukemia with certainty, but the evidence at present
seems to justify the belief that it is closely related to neoplastic
processes." MacCullum* says: "The question is hard to settle
satisfactorily, but in the one case the formation of cells in an un-
accustomed organ, such as the liver, would resemble the mode
of distribution and proliferation of a tumor. In the other we
must assume that the tissues of the capillary walls of the liver,
the splenic pulp, etc., are capable of reacquiring the power of
blood formation which, as all agree, they possessed during em-
bryonic life. To me the transplantation and growth of cells seems
more plausible although there is some good evidence in favor
of the idea of metaplasia." Mcjunkin^ says : "It was not until
extensive studies were made on the organs and tissues of leukemic
cases that many observers came to regard the leukemias as
malignant neoplasms. The study of cases of malignant disease
(lymphoblastoma) before and after the entrance of tumor cells
in large numbers into the peripheral blood, aided in this con-
726
Scott: Lymphatic Leukemia 727
ception. Whatever the ultimate solution of tumor etiology may
be, it is likely that the leukemias shall remain as typical examples
of true tumors."
On the other hand, the advocates of the acute infection theory
offer good arguments. Stein" quotes Virchow in that the disease
has a leukocytosis which is progressive, and an associated factor
of infections. He goes on further to state that as lymphocytes
have lipolitic property, possessing a fat splitting ferment, lym-
phocytosis may be defined as an antagonistic reaction of the blood
against antigens of a lipoid character. This is an interesting
observation. He also considers the pharynx as a portal of entry
of the leukemia infection and cites some work done on Vincent's
angina in support of this. He concludes with the statement
that, given a condition of thymolymphatic state and an acute
infection superimposed, it results in a stimulation and over-pro-
duction of lymphatic tissue. Ward^ says that the theory of in-
fection derives its support from the acute cases and reviews the
histories of several hundreds of cases. He records 6 cases of
congenital leukemia, giving references, similar to clinical cases
as seen. There was no evidence of the mothers being leukemic,
the duration of life being from still-birth to one month. He
states that there is no evidence of lymphatic leukemic mothers
having leukemic infants and no evidence of leukemic infants
having leukemic mothers. He says there has been no evidence
of the disease being infective, although he cites a number of
cases with apparently such a condition. He concludes his article
by comparing the disease to metastatic or malignant disease,
except that there is no cellular reaction to the leukemic growth
nor any destruction of adjoining tissue except by pressure.
Ryan* reports a case complicating pulmonary tuberculosis,
concluding with the statement that the pulmonary tuberculosis
was the initial disease and that 2 years later she developed the
leukemia, of which she died.
Associated Enlarged Thymus. This condition is mentioned
by several observers. Among whom Major® reports a case where
the thymus was 10x7x7 cm., and reports several other observers.
As to children, he says: "We seem to have no definite criteria
by which to judge which is primary, the thymus or the blood
disease. Moreover the relationship between lymphosarcoma and
728 Scott: Lymphatic Leukemia
lymphatic leukemia is so close as to suggest that in some cases
they are merely dififerent manifestations of the same disease".
In another case: "The suggestion is strong that the enlarged
thymus was an indication of an abnormal lymphatic state pre-
disposing to disease of the lymphatic apparatus which later mani-
fested itself by the appearance of an acute lymphatic leukemia."
Rappaport^° reports a case with the thymus 18x12x9 centimeters,
in an adult.
Blood Chemistry and Metabolism. Very little has been done
on this. Means & Aub^\ quoting Magnus-Levy and Edsall's cases,
state that there was a negative nitrogen balance, and marked
output of uric acid. Quoting Folin and Denis, the blood uric
acid was markedly increased. There was a retention of the phos-
phates due to rapid building lymphatic tissues which is especially
rich in phosphates. After radiation with x-ray, there is an increase
in uric acid and purin bases and a decrease in leucocytes and a rise
in total urine nitrogen. They quote observations of the x-ray
on normal tissues, in which the white cells have a nuclear frag-
mentation, then lysis of the entire cell. The metabolism of leu-
kemic blood is more active than normal blood. The nitrogen
balance is usually negative in acute leukemia. Endogenous uric
acid elimination and uric acid content of the blood is increased
(nuclear destruction of blood, cells).
Blood Counts. When attempt is made to spread the blood
drop in a film, due to the excessive masses of leucocytes, the
film is thick and viscous (observation of Cabot and self). The
highest white counts we find record of were reported by Cabot
where one case had 1,505,000, ahd another, just before death,
1,631,000. Peutz^- reports a case of 720,000 leucocytes. In this
case the child had a fall 2 weeks before any symptoms, and the
shock from this, superimposed on a status lymphaticus (as the
child was always pale from birth), may have caused the lym-
phatic leukemia.
Prognosis. The older the person the better the prognosis.
As a rule no case recovers. The duration may be from a few
days to 6 months for acute cases, the average being about 3
months. The x-rays and benzol seem to prolong life and in some
cases, particularly older individuals, seem to cure. But remis-
sions do occur. The prognosis is especially bad in children under
Scott: Lymphatic Leukemia 729
10 years. Marked and increased anemia of the aplastic type is
a constant finding in fatal cases.
Treatment. X-rays, softened according to the age of the
patient, and fairly long exposure twice weekly, or every day
with shorter exposures, or stronger rays at longer intervals, all
have their advocates. Warthin^^ divides the action of the rays
into 2 types: 1st, immediate action, degenerative; and 2nd, reac-
tive changes. As to the minute changes produced in lymph
tissues by exposure to the rays, he concludes : "Prolonged irradia-
tion of the hemopoietic organs in leukemia first causes a degenera-
tion of the young and maternal cells, leading to a great decrease
of leukocytes. After these destructive effects there follows a
reaction in which cells of a more resistant type are formed, and
the essential leukemic process remains unchecked, although al-
tered in character."
Benzol benzene acts on the leukopoietic apparatus of the
body, "expends its activity primarily on that portion of the bone
marrow which is concerned in the production of the granular
leucocytes, leaving unaffected the tissue which manufacture non-
granular lymphocytes and erythocytes. But benzol causes inhi-
bition and then hypoplasia so that we quickly get a reduction in the
granular white cells and a gradual increase in the red blood
cells."^* Benzyl-benzoate, 20 per cent, alcoholiq solution, dose,
adults 10 drops in water after meals, has been used successfully
in one case reported by Haughwout and Asuzano.^^
Case Report. S. B. Complaint: noticed swelling of the
glands in his neck. His appetite fair, sleep restless ; bowels in
good shape.
Born December 12, 1915, first pregnancy; in labor 18 hours,
normal, vertex presentation. Weight 9}i pounds. Required
spanking to resuscitate, but mother had chloroform as anesthetic
so does not recall details. Was put to breast and received plenty
of milk at end of third day. Breast fed 13 months but at irregular
intervals; then fed cow's milk, cereals, toast, poached egg, but
never a hearty eater. Held up head at 3 months, and sat up at
5 months, was a strong baby, walked at 14 months. Started
talking at 2 years. Had measles at 3 years, "hives" at 2 years,
and off and on since with no assignable cause. Would have fever
on slight provocation but cleared up on good dose of castor oil.
730 Scott : Lymphatic Leukemia
No other illnesses. On September 7, 1919, there was noticed a
swelling of neck, slight on left, but marked on right.. Was ex-
amined by Dr. D. J. Beatty about October 1. He found enor-
mously hypertrophied tonsils, and removed the same on October
3, with normal post-operative convalescence.
Family History. Mother had no illness except childhood
diseases and during the pregnancy of this child never felt better.
Father always well. No history of similar trouble on either side
of family. Maternal parents living and well except grandmother
who is asthmatic. Paternal mother well and strong; paternal
father died suddenly after ^ hour illness.
Examination. Weight, 37^ pounds. 4 P. M. temperature,
101.6°. Lower border of spleen in the nipple line, 11^ centi-
meters below border of the ribs, or 2 centimeters below the navel
and 2 centimeters to the left of the navel.
On inspection, child's complexion is normal, clear, with marked
prominence of the posterior and anterior cervical glands, some
enlargement of the sub-maxillary, some enlargement of the pre-
and post-auricular on both sides, size of a large pea, while the
cervical glands are 3 or more centimeters in diameter. Axillary
glands are the size of peanut kernel to almost an almond, visible
upon marked extension of arms. In the groin, several glands
varying in size from a kernel of rice to a navy bean, 6 to 10 in
number, are felt on either side. Testicles are both descended,
liver is enlarged 4 centimeters below the lower costal margin.
Heart dullness 4 3/10 centimeters to the right of the median
line and 9^/2 centimeters to the left. At the base of the heart the
area of dullness extends 4 centimeters to the right below the right
clavicle, and 4 centimeters to the left below the clavicle. On
auscultation, heart tones clear at the apex, at the base pulmonic
second clear, aortic second not distinctly marked but a swirling
musical note transmitted along the right subclavian. Right auric-
ular ventricular clear cut. Posteriorly dullness extends down to
within 2 centimeters of the angle of the scapula, laterally 5 centi-
meters to the left above, and 4J/2 to the left below, 5 to the right
above, and 4^ to the right below.
Skin is fairly well nourished, no enlargement of the epitroch-
lear glands ; knee reflexes slightly sluggish ; plantar reflexes nor-
mal, no Kernig, no Babinski.
Scott: Lymphatic Leukemia 731
Urine examination specimen was negative.
Blood examination made October 29, 1919: Reds, 3,888,000;
whites, 43,000 ; polymorphonnclears, 5 ; small mononuclears, 92 ;
large mononuclears, 5; eosinophiles, 1%; myelocytes, 1% ; hemo-
globin, 82% ; nucleated reds and degenerated whites present in
the stained specimen.
Von Pirquet, negative.
Stool examination : November 17, 1919 — Normal stool.
November 14, 1919; Whites, 243.000. Diflferential shows
97% lymphocytes.
November 17, 1919: Benzol, grs. 192; Calc. lactate, IV drams;
Syr. Tolu, VI ounces.
November 17, 1919, showed spleen had diminished so it was
about 1 centimeter above the navel line. The glands of the neck,
particularly on the right side, which had been so markedly en-
larged were diminished to very small pea size, but there was some
development of the sub-maxillary glands. The temperature was
102.6°. He has now had 5 treatments with the x-ray and aver-
aged 2 drops 3 times a day of the benzol. His appetite is poor,
but the breathing which, prior to the treatment of the x-ray, had
been very dyspneic, probably from pressure of the enlarged
thymus on the trachea, was a great deal better, and the child was
resting at night. He has days when he feels good and other
days when he feels very wretched and seems to have fever.
December 4, 1919: Died this A. M. under Christian Science.
Mother states that prior to death all swelling of neck had sub-
sided, that he looked quite natural again. Had some profuse
gastric hemorrhages from which he died.
Dr. Arthur Grover reports: "The tonsils and 'adenoids that
were submitted for examination show as follows : Grossly there
is marked hypertrophy in both. Microscopically the hypertrophy
is seen to be due to a hyperplasia of the lymphoid elements. That
is to say, the germinal centers are markedly obliterated by the
immense collections of lymphocytes. V'ery few polymorphonu-
clear leucocytes can be seen so there is no acute inflammatory
reaction. The number of endothelial leucocytes appears to be
normal. There are no eosinophiles or plasma cells to be noted.
There is some increase of fibroblasts. There is no evidence of
malignancy nor any evidence of tuberculosis. The whole ap-
732 Scott : Lymphatic Leukemia
pearance of the section is entirely compatable with lymphatic
leukemia."
i^oi S. Figueroa Street.
BIBLIOGRAPHY
1. Cabot: Osier & McCrae, Mod. Med., 1915, Vol. IV, p. 670 at seq.
2. Mallory: Principles of Pathological Histology, 1914, p. 332.
3. Stengel & Fox: Text Book of Pathology, 1915, p. 438.
4. MacCullum: Text Book of Pathology, 1917, p. 765.
5. Mcjunkin: Clinical Microscopy & Chemistry, 1919, p. 62.
6. Stein, Richard: Med. Record, Vol. 90, No. 4, p. 147 (July 22, 1916).
7. Ward, Gordon: British Journal Children Diseases, Vol. 14, p. 10 (Jan'-^Iarch,
1917).
8. Ryan, Michael L.: J. A. M. A., Vol. 72, No. 7, p. 472 (Feb. 15, 1919).
9. Major, Ralph H.: Johns Hopkins Hosp. Bull., Vol. 29, No. 331, p. 206 (Sept.,
1918).
10. Rappaport, B.: Trans. Chicago Path. Soc. Vol. 10, No. 1, p. 19 (Dec. 1, 1915).
11. Murphy, J. B., Means, J. H., and Aub, J. C: Arch. Int. Med. Vol. 19, No. 5,
Part 2, p. 890 (May 15, 1917).
12. Peutz: J. A. M. A. Vol. 72, No. 20, p. 1503 (May 17, 1919)).
13. Warthin, Alfred Scott: Am. Jour. Med. Sciences, Vol. CXLVII, No. 1, p. 72
(Jan., 1914).
14. Barry, Jos. M., and Ketcham, Jane M. : Jour. Med. Ind. State Med. Assn.,
Vol. IX, No. 8, p. 315 (Aug. 15, 1916)
15. Haughwout, Frank C, and Asuzano, M. A.: N Y. Med. Jour., Vol. 90, No. 5,
p. 180 (Aug. 2, 1919).
The Foot Phenomenon in Meningitis (Revista di Clinica
Pediatrica, Dec. 1919). A. Nizzoli cites conflicting evidence from
various writers on the constancy and significance of the various
signs of meningitis in children, of which he enumerates a long list.
The excitability of the nervous system in children causes a host of
symptoms which obscure the diagnosis. The signs which depend
on reflex action are the most instructive in children, as they
cannot fight against them. In two cases of tuberculous meningitis
he noted dorsal flexion of the big toe and a fanlike spreading of
the other toes when he tried to induce the identical contralateral
reflex. The other leg became spontaneously flexed, and the toes
assumed the position mentioned above. The reflex is induced on
the recumbent child, with legs extended, by flexing one on the
thigh and on the pelvis, with moderate compression, watching the
behavior of the other leg. This foot phenomenon could never be
elicited in healthy children, but could be induced at will in both
these meningitic children. In others with the disease more
advanced the response was negative, confirming that the
phenomenon is an earlier sign. — Journal A. M. A.
CLINICAL DEPARTMENT
Patients selected from office clientele of Charles G.
Kerley and Edward J. Lorenze, Jr.
New York.
case no. 1. Female, age 10 weeks, weight 9 pounds, 1 ounce.
Complaint. Baby very hungry, vomiting a large part of each
feeding, having 4 or 5 loose green stools daily, failure to gain
in weight, cries a great deal. Mother thinks child should have
more food.
Family History. Mother is 31 years old, father 41. Both
parents are well.
Personal History. First child, full term, forceps delivery,
weighing at birth 7^/2 pounds. Infant was breast fed entirely for
2 months. At present there are 5 bottle feedings of 4 ounces
each, of the following formula: 4 oz. whole milk, grade A; 6
oz. water; 1^ oz. Dextri-Maltose No. 1, and 2 breast feedings,
both breasts being used at each nursing. In case the breast
feedings had not been sufficient a supplementary bottle feeding
had been given.
The condition of the child had been satisfactory and he had
gained in weight until the eighth week when there began to be
an insufficiency of mother's milk. Since that time there had been
no gain and the vomiting had been very persistent.
Inspection. Child appears bright, active and is fairly-well
developed. The skin is clear but rather pale. Eyes, nose and
mucous membranes apparently normal.
Physical Examination. Fontanel one inch by one inch, su-
tures closed. No enlargement of the epiphyses, no beading of the
ribs, muscles soft and flabby, heart, lungs, liver and spleen nega-
tive. There were no glandular enlargements. Urine and blood
examinations were not made. Mouth and throat were normal.
The abdomen was negative. A pyloric tumor could not be
found.
Management. The following formula to be prepared at home
was advised: 8 oz, top 15 of 1 bottle of certified milk; 13 oz.
water ; 2 oz. lime water ; 1 oz. Imperial Granum ; 1 oz. milk sugar.
This was cooked in a double boiler for 30 minutes, the lime
water and sugar being added at the completion of cooking. She
was given 4^ ounces, 5 feedings daily together with 2 breast
733
734 Clinical Department — Cases by Kerley & Lorenze, Jr.
feedings, 7 feedings in 24 hours, at 6-9-12-3-6-10-2. Atropine
1/1000 of a grain was given in a teaspoon of water 10 minutes
before each feeding. She was weighed before and after nursing
to make sure that at least A]^ ounces was taken. At the end of the
first week there was a loss of 4 ounces. The nourishment, breast
and bottle, was taken eagerly, the vomiting continuing as before.
She was now given a formula prepared by the Walker Gordon
Laboratory of: 1.50% fat; 1.50% protein; 6% milk sugar; 2%
starch; 6% lime water.
CASE No. I—WEIGIIT CHART.
.'\. Top IS oz. formula, 4 oz.- — 7 feedings; 15. Evaporated milk formula — prepared by
Walker Gordon Laboratory, atropine used; C. Evaporated milk formula. Fat
and sugar reduced. Protein increased — 3% barley added; 1). Whole milk
formula — with 6 tablespoonsful farina. Atropine stopped; E. Same
formula with addition of Dextri-Maltose. 5 oz. — 6 feedings; F.
Quantity of milk increased; G. Quantity of milk increased;
H. Quantity of milk increased.
In 38 days there was a gain of 30 ounces.
Nursing proved to be a failure and was discontinued. The atro-
pine was continued. In the preparation of this formula evaporated
milk was used. After 3 days with continuation of the vomiting
the formula was changed, sugar and fat reduced, protein and lime
increased as follows: 1% fat; 2% protein; 3% starch; 8% lime
water; 3% cane sugar.
As above, AYz ounces was given at 3 hour intervals, 7 feedings
daily. On this combination the vomiting ceased largely and there
was a gain of 3 ounces in one week. During the following 3 days
Clinical Department — Cases by Kerley & Lorenze, Jr. 735
there was a loss of 3 ounces, with the vomiting worse than at
any time. There was no retention after 3 hours at any time —
several tests were made. A pyloric tumor could not be felt and
there was no visible stomach wave. She now vomited both during
and after feedings. The stools were scanty but normal, weight
8 pounds, 13 ounces.
After 18 days of ineffectual attempts to control the vomiting,
we gave, the patient the benefit of thick gruel feeding. Not hav-
ing had a brilliant success with the use of barley for this purpose
we applied the suggestion of Dr. H. R. Mixsell (Archives of
Pediatrics, Aug., 1920), and used farina as indicated in the
formula: 12 oz. whole milk; 18 oz. water; 1 tablespoonful cane
sugar; 6 tablespoonfuls farina.
4^ ounces were to be spoon fed at 3 hour intervals. Atropine
was now eliminated as it seemed to be of no value in the dosage
given. In 5 days on this mixture there was a gain of 7 ounces, with
no vomiting. Stools were normal and sleep was natural and child
was happy. During the following 7 days there was a gain of 7
ounces and the vomiting ceased entirely. At this time the formula
was increased to: 15 oz. milk; 20 oz. water; 1 tablespoonful cane
sugar; 1 tablespoonful Dextri-Maltose ; 6 tablespoonfuls farina.
5 ounces were given at 3 hour intervals, 7 feedings in 24 hours.
In preparing the thick formula the farina was added to 20
ounces of water. This was brought to a boil and then allowed
to simmer for 2 hours in a double boiler. Milk was then added
and the mixture was cooked 30 minutes. While hot, the cane
sugar and the Dextri-Maltose were added. On October 29,
1920, 36 days after the beginning of the thick gruel feeding, the
child had gained 30 ounces. Her physical condition was very sat-
isfactory, stools were normal, she slept well and cried very in-
frequently. There had been no further vomiting.
case NO. 2. Male: AVi years old. Weight, 38>< pounds.
Height, 40J^ inches.
Complaint. Habitual constipation, poor appetite.
Family History. Entirely negative.
Personal History. First child, full term, forceps delivery,
birth weight 7 pounds. No noteworthy illness, occasionally mild
bronchitis. Since birth there has always been obstinate constipa-
tion. Upon further questioning, the mother maintained that this
736 Clinical Department — Cases by Kerley & Lorenze, Jr.
statement was absolutely correct, that the child's bowels had never
moved without medication, enemata or suppository since birth.
She was very much discouraged and felt that all treatment would
be useless and came only because of the insistence of her family
physician.
Inspection. A pale but fairly well nourished child showing
fair muscular development. There was moderate drop shoulder,
slight tendency to knock-knee and defective arches. E^yes, nose
and lips appeared normal. Skin clear, abdomen distended.
Physical Examination. No bony changes, muscles rather soft,
teeth normal, tonsils slightly enlarged and cryptic, heart, lungs
and, all other organs were negative. Mouth and throat were
normal.
Blood Examination. Hemoglobin 78%, red blood cells, 4,-
800,000.
X-ray Report, Dr. L. T. LelVald: 15 minutes after the
opaque meal the stomach is slightly dilated. The greater curva-
ture is just above the level of the umbilicus. After 24 hours
there is a considerable portion of the meal remaining as far
back as the cecum. A portion of the meal has reached the sig-
moid. At the end of 48 hours, the sigmoid is filled, showing
definite evidence of dilatation and stasis.
Injection of Colon. There is most striking evidence of re-
dundancy of the sigmoid flexure. There are 3 definite loops, one
of which extends for a distance of 3 inches above the level of
the umbilicus in the vertical position. The loops appear to be
movable. The cecum is dilated, together with the right half
of the colon. The ileocecal valve appears to be competent. The
cecum is ptosed, its lower line reaching to the level of the ace-
tabulum.
Summary. Extreme redundancy of the pelvic colon asso-
ciated with colonic stasis and secondary dilatation of the cecum
and right half of the colon.
Management. We have found that a great deal may be ac-
complished in cases of constipation, due to mechanical agencie's,
by properly adjusted diet. It is not to be expected that such influ-
ences will be felt immediately. But when persistently carried out
it is of invaluable assistance. As is our custom, the mother was
given our "Constipation Menu," from which she was to select the
child's food.
Clinical Department — Cases by Kerley & Lorenze, Jr. 7Z7
Menu:
7.30 A.M. Cornmeal, oatmeal, wheatina, hominy (all cooked
4 hours the day before in water) served with butter and sugar,
maple syrup and butter or milk and sugar. Minced chicken,
bacon, soft boiled, scrambled or poached eggs.
A drink of milk or malted milk, bread stuffs as below.
1 T-C-^ --^ 1
/^l
LEWELOF UMBILICUS / /I
vV^ Vil
'
t'^i^
RECTUM ^HIJI^H
1
Case No. 2. — Male, 6 years, elongated sigmoid. Persistent consiipation. Never an
evacuation without medication.
11 A.M. The juice of 2 oranges or 6 ounces of prune juice.
12.30 P.M. Baked or boiled halibut or cod fish, beef steak,
lamb chop, roast beef, roast lamb, poultry.
Baked or mashed potatoes, spinach, asparagus, string beans,
peas, squash, white turnip, carrots, celery, onions and cauli-
flower.
738 Clinical Department — Cases by Kerley & Lorense, Jr.
Desserts : Stewed apples, stewed prunes, stewed figs, baked
apple, bread, tapioca or gelatine pudding, all stewed or raw berries
in season.
Bread stuffs. No milk at this meal.
4.00 P.M. Apple, pear, grapes or banana.
6.00 P.M. Chicken or mutton broth with rice jelly, farina
or cream of wheat (cooked 2 hours in water) or one of the above
cereals served as above. Cream cheese or honey on bread or
crackers. Custard, corn starch, junket, stewed fruits may be
given as a dessert when broth is given. A drink of milk or 4
ounces of milk, 4 ounces water and 1 teaspoonful of Phillip's
cocoa and sugar to sweeten. Bread stuffs.
Bre^<i'.stuffs. Wheatsworth Biscuits, whole wheat bread, rye
bread and oatmeal crackers.
One-half glass of water 15 minutes before each meal.
Mix 1 tablespoonful of Kellogg's bran with cereal once or
twice a day. Give plenty of green vegetables. Potato rarely.
We have learned that the habitual use of enemata is the worst
measure to be used in cases of prolonged constipation. Drugs
must always be used early in the treatment.
Thirty drops of fluid extract of aromatic cascara sagrada
(Parke, Davis & Co.) were given 3 times a day. At the end of 2
weeks there had been no improvement in the boy's constipation
and he lost ^ of a pound in weight. The usual enemata was
required daily. The diet was continued and he was given a
capsule containing extract belladonna, yi grain ; extract nux
vomica, y^ grain; extract cascara sagrada, 1^^ grains, 3 times a
day. No effect was produced on the constipation during the next
2 weeks. Daily enemata were required. He lost further, now
weighing 36 pounds, 12 ounces.
He was now given the advantage of daily abdominal massage,
and 15 drops of fluid extract cascara sagrada aromatic, 3 times
daily after meals. A satisfactory daily evacuation followed
without enemata. This scheme of management was continued
during the next 6 months, at the end of which time he weighed
41 pounds, 4 ounces, and showed satisfactory general improve-
ment. The medication had been gradually diminished in dosage
and discontinued after 9 weeks. Massage, having been carried
out daily for the first 4 months, was later applied every
Clinical Department — Cases by Kerley & Lorenze, Jr. 739
third day. The stools remained normal in the meantime. At
the present time, one year since the last report and 2^ years since
first coming under observation, the weight is 52 pounds, height
AAJ4, inches. The child is well in all respects. The tendency to
constipation still exists, however, and the diet as outlined must
be carefully followed, but massage, enemata and drugs are not
necessary.
Remarks. It has been found by Le Wald, through fluoroscopic
examination, that intestinal peristalsis is defective in many pa-
tients with an elongated sigmoid and in other abnormalities
of the large intestine. It is our effort, in the use of frequently
repeated small doses of the cascara and in massage, to establish
and maintain a better peristalsis. So called mechanical therapy is
habitually neglected by the regular profession in many cases when
it might be used with benefit. All of which accounts for the
success in different tyj^es of cases, as in constipation, by so called
irregular practitioners who resort to manipulative procedure. The
ultimate outcome of those children with gross intestinal abnor-
malities is not particularly favorable, they probably will belong to
that class of individuals who have to keep a proper intestinal
elimination constantly in mind.
CASE NO. 3. Female; age Zy2 months, weight 12 pounds.
Family History. Negative. Father and mother are well.
Complaints. Originally the child came to us for advice re-
garding feeding. Later impetigo, purpura, hydrocephalus and
staphylococcus aureus infection developed in the course of 11
weeks.
Personal History. First child, full term, forceps delivery,
birth weight 6 pounds, 9 ounces. The child had pneumonia when
3 months old. She had been breast fed for 3 months, when
weaning was necessary. For 2 weeks various feeding methods
had been tried without finding one which was suitable.
Inspection. Fairly well nourished child with development
corresponding to that of a child of her age. Expression was
bright, skin was clear, abdomen slightly distended. Eyes, nose
and lips appeared to be normal.
Physical Examination. Heart, lungs, liver and spleen were
740 Clinical Department — Cases by Kerley & Lorense, Jr.
normal. Muscles were rather soft and flabby. No rachitis.
Fontanel one inch by one inch. Mouth and throat were normal.
Management and Further Personal History. The feeding
history is unimportant. She was put on a milk and malt soup
formula suitable for a child of her age, and gained 15 ounces
in the next 10 days.
Impetigo. During this time an impetigo developed involving
particularly the scalp, chest and legs. The disease responded
to boracic acid baths and the application of an ointment of boracic
acid and ichthyol, 10 per cent, of each being used.
Purpura. While recovering from the impetigo, which lasted
14 days, purpuric spots varying in size from ^ to 1 inch in diam-
eter appeared on the left knee, chest and arms.
Convulsion. One week after the appearance of the impetigo
and 3 days following the first appearance of the purpuric spots,
the child had a general convulsion. She was unconscious for
one-half hour. At this time she came under the immediate care
of one of us (Lorenze) at the home.
Hematoma. At the time of the convulsion a large hematoma
3 inches in diameter appeared on the side of the head immediately
above the left ear. There had never been an elevation of tem-
perature or prostration and food was taken very well. A di-
gestive disturbance could not account for the convulsion.
Second Convulsion. Again 2 days after the first convulsion
there followed another which lasted 1 hour. The child rested in a
semi-comatose state for one-half hour following the convulsion.
Second Hematoma. Coincident with this convulsion, a second
hematoma appeared which was smaller than the first and in-
volved a considerable area about the left eye. There was no
involvement of the mucous membrane and no blood in stools or
urine.
Physical Examination. At this time, 7 days after the ap-
pearance of the purpura, a considerable change had taken place
in the patient. The uninvolved portion of the skin had a blue
greenish tint. There was now a general purpura with areas of
hemorrhage varying in size from J^^ to 1 inch in diameter scat-
tered over the legs, abdomen and chest. These, in addition to the
hematoma above mentioned, comprised the skin lesion, the mu-
cous membranes were very pale, there was internal strabismus.
Clinical Department — Cases by Kerlcy & Loreuse, Jr. 741
the pupils reacted to both hght and accommodation. The heart,
liings, Hver and spleen were negative. The skin over the hema-
toma had now taken a black bluish color; from the nose there
was a profuse mucopurulent discharge slightly tinged with blood.
The cervical glands were not enlarged. There was no rigidity of
the neck, Kernig and Babinski were not present. The mentality
apparently was normal, the urine was negative.
Blood Examination. An examination of the blood by Dr. L.
J. Unger was reported as follows :
Bleeding time, 8 minutes,
Coagulation time, capillary pipette method, 4^ minutes,
Schick reaction, not done,
Capillary resistance test, positive.
Blood platelets, 120,000.
The above findings proved the existence of a purpuric condi-
tion. In addition the child had an intense secondary anemia.
Transfusion. Laboratory diagnosis and clinical findings were
such that we considered transfusion imperative. The father was
found to be a suitable donor. By Unger's direct method, 250 c.c.
of the father's blood was transferred to the infant. Following
the transfusion there was an immediate favorable response. A
rosy pink color replaced the greenish tinge of the skin, the pulse
was less rapid and the heart sounds became clearer. The pur-
puric areas rapidly disappeared so that at the fifth day there were
but a few remaining.
Staphylococcus Infection. With the disappearance of the
purpura there suddenly appeared a crop of pustules most abund-
ant on the skin over the head and neck. The pustules rapidly
developed into large abscesses. For 7 days the abscesses were
treated by incision and other local measures. At this time, on
the 22nd day of illness. Dr. L. E. Holt acquiesced at the sug-
gestion of vaccine therapy. Autogenous vaccines were made by
Dr. F. Sondern and 2 injections of 250,000,000 and 500,000,000
staphylococcus aureus bacilli were given at 48 hour intervals.
Acute Hydrocephalus. At the time of the consultation. Dr.
L. E. Holt remarked at the size of the child's head, which then
measured 17 inches in its largest circumference. In 2 weeks the
head was again measured and found to have increased 1 inch in
circumference, the fontanel was now bulging, which had not
742 Clinfcal Department — Cases by Kerley & Lorenze, Jr.
been the case previously. During the next 6 weeks the head in-
creased in size, measuring 19 inches and showed the typical pic-
ture of internal hydrocephalus. There was marked bulging of
the fontanel and lateral strabismus. During the development of
the hydrocephalus there had been decided improvement in the
nutrition of the child, the weight had increased to 16 pounds, 4
ounces, a gain of 4 pounds and 4 ounces during a very stormy
period in her career.
Dr. Alfred Taylor now saw the child in consultation and re-
ported as follows : June 24, 1920 : Puncture through the an-
terior fontanel drew a considerable quantity of fluid which was
slightly blood stained, probably from the puncture, the flowing"
occurring when the needle was in about 2-2.5 cm. After a smaller
amount had been evacuated an ampule of neutral phenolsul-
phonephthalein was injected and the needle was withdrawn.
Lumbar puncture was then done, the needle was pushed in
through the dura in 2 separate places, the 4th and 5th lumbar
spaces, and no fluid whatever was withdrawn. These punctures
were lateral punctures. A mid-line puncture was then done be-
tween lumbar 4 and 5 and when the needle entered the dura no
spinal fluid came but there were a few drops of pure blood. This
rendered the investigation useless from the standpoint of color
effect, but the presence of the dry tap of the spine was definite
indication of the case being one of obstructive hydrocephalus.
A catheter was passed into the bladder and left there to see
how soon the phenolsulphonephthalein would appear in the urine.
Phenolsulphonephthalein appeared in the urine first after 2^
hours. The parents were advised to have a puncture of the
corpus callosum made.
June 25, 1920. Operation. An incision was made just to the
right of the mid-line in the fontanel. When the dura was punc-
tured there was an outflow of bloody cerebrospinal fluid, evidently
having occurred through the puncture wound of yesterday, the
brain cortex being very thin. The canula was passed down along
the falx cerebri and was then passed through the corpus callosum
into the third ventricle, from which a small amount of fluid was
recovered. The hole through the corpus callosum was then
slightly enlarged by manipulation of the canula. The wound
was closed by layer sutures and the baby was returned in good
condition, the operation having lasted about 20 minutes.
Clinical Department — Cases by Kerley & Lorenze, Jr. 743
Post-Operative Course. The post-operative course was un-
eventful. The child was fussy for the first few days and did not
take her feeding well. On June 29 the sutures were removed
and there was good primary union. On June 30 she left the hos-
pital with no other dressing except a layer of collodion over the
wound, the head had been shaved all over and when she left the
hospital measured 19^ inches in circumference. The eyes showed
rather less' tendency to squint and were more freely movable.
The child was playing with her feet much of the time and seemed
to be quite happy and was much less troublesome and worried.
She was now taking her food well.
In this case, from the failure to get spinal fluid from the spinal
canal and the failure of the phenolsulphonephthalein to appear
in the urine for 2^ hours, it was evident that the blocking had
occurred so that the spinal fluid could not escape from the ven-
tricles. Blocking occurred either in the Aqueduct of Sylvius or
at the outlets of the fourth ventricle.
The fact that the neutral phenolsulphonephthalein did not ap-
pear in the urine until 2^ hours after injecting, showed that the
rate of absorption was very materially delayed. The intention
was to make artificial communication between the ventricular sys-
tem and the surfaces of the hemispheres so as to open up the
entire absorbing field. This was done by means of puncture
through the corpus callosum into the third ventricle. This per-
mitted the ventricular fluid to come up between the hemispheres
and to spread out upon their convex surfaces which form the
major part of the area which absorbs the cerebrospinal fluid
normally.
On October 18, 1920, at the age of lOj^ months, our findings
are as follows: General condition, excellent. Weight, 21 pounds.
Head 19^^ inches in circumference. Eyes are normal. She has
7 teeth. The skin and all the organs are normal. She creeps
and tries to stand. Muscles are firm and color good, recognizes
her parents and apparently is a perfectly normal child. The head
has not increased in size since June 24, an interval of over 4
months.
Remarks. It is our belief that the convulsions indicate the
beginning of the hydrocephalus. The enlargement of the child's
head was noted about 10 days after the first convulsion.
Contributed by Philip S. Potter, M.D., and A. Clement
Silverman, M.D.,
Syracuse, N. Y.
HOSPITAL CASE No. 48326.* V.M.E., female infant, ad-
mitted to Hospital of the Good Shepherd, May 17, 1920.
Family History. Father, 21 ; mother, 17. Both in good
health. Wassermann on mother negative. Paternal and mater-
nal grandparents alive and well. No history of any chronic dis-
eases in either family.
Past History. Born March 30, 1920; first, illegitimate, full
term, normal delivery. Said to have weighed 6 pounds and 3
ounces at birth. Not breast fed at all. Was started on a simple
milk dilution and about 10 days after birth was placed in a pri-
vate maternity and infants' home. Baby admitted to hospital
from this institution.
Present Illness. Baby did not gain on its feedings and soon
began to appear undernourished. Early in May, it is said, both
hands and feet began to look blue and felt cold, and the baby
appeared to cry when these were handled. At first the extremities
were pale and the blueness would pass ofif after a while or change
to a reddish discoloration, but for about a week before admission
the extremities were almost constantly purplish.
A few days before admission the tip of the right ear turned
black. At the same time the child began to take its feedings
poorly. The child had no fever at any time. Its temperature ap-
peared to be almost constantly subnormal.
Physical Examination. Fairly well developed but marantic
female infant, looking pale and very feeble. Weight, 6 pounds, 2
ounces. Rectal temperature 96.8 degrees. Head negative. Pu-
pils react to light ; sclerae pearly blue and clear. Nose and throat
negative. Heart and lungs negative. Abdomen soft. Liver edge
palpable 1 cm. below costal margin ; spleen not felt. Genitals
negative. Extremities: both hands from wrists down and both
feet below the ankles are cyanotic, purplish blue, cold. The anemic
pressure trace disappears slowly. On the pad of the left great
toe is a small black area about 3 mm. in diameter. The tip of
the right ear shows a black area of 1 x 0.5 cm., surrounded by
*Case of Raynaud's Disease in an infant of six weeks, from the Pediatric Ser-
vice, Hospital of the Good Shepherd, Syracuse University, Syracuse, N. Y.
744
Clinical Department — Case by Potter & Silverman 745
a larger area of black-blue cyanosis. The tip of left ear is
markedly cyanotic. Skin is otherwise pale, clear, somewhat blu-
ish or rather ashen gray.
Laboratory Findings. Roentgenogram of chest negative.
Blood Wassermann negative. Blood was obtained from the su-
perior longitudinal sinus a few hours before death for the blood
chemistry findings : blood sugar, 72 mgm. per 100 c.c. ; non-pro-
tein nitrogen, 65.7 mgm. per 100 c.c. No urine was obtained for
examination, but the appearance of the diapers was not suggestive
of hemoglobinuria. Blood examination was not done until the
infant was moribund, and at that time the red blood count was
5,250,000; white blood count 24,200; polymorphonuclears 53 per
cent. ; lymphocytes 42 per cent. ; large mononuclears 5 per cent.
Course of Disease. The child began to look moribund shortly
after admission despite efforts at treatment, and died on the third
day. During this time the extremities remained purplish, chang-
ing at times to a slightly brighter or darker hue. Before death
the skin in front of the right ear also became cyanotic.
Necropsy. Body length 48 cm., weight 2.5 kg. Mesenteric
lymph nodes not enlarged. Heart weight 14 gms., right lung 19
gms., left lung 14 gms., spleen 9 gms., liver 30 gms., kidneys 18
gms. Blood fluid. No gross lesions were found aside from the
gangrene. Microscopic sections of the tissues were examined
especially for the blood vessels, and long strips from the dorsalis
pedis artery and vein were carefully examined. The gross and
microscopic appearance of the vessel walls was found normal.*
Comment. This case, though under observation for too short
a time for any extended study, appears, nevertheless, worthy of
record. The available literature would seem to indicate that this
is the youngest case of Raynaud's disease on record. Beck^ men-
tions a case reported by Reiss in 1902, in which symmetrical gan-
grene of the extremities occurred at 7 weeks, but that child re-
covered. Beck himself reports a case at 6 months with necropsy.
In his case, however, the vessels of the extremities and of the
other tissues showed sclerotic changes when examined micro-
scopically. In our case no changes in the vessels were detected
in gross or microscopic examinations ; nor is there any history or
*We are indebted to Profs. Steeiisland and Weiskotten of the Department of
Pathology for the examination of the sections.
1. Beck, Carl: Raynaudsche Krankheit beim Saugling, Tahrb. f. Kinderheitk. 72: 84,
1910.
746 Clinical Department — Case by Potter & Silverman
postmortem changes suggestive of any infection.^ One of us has
recently seen gangrene of the nose develop 2 days after the onset
of an apparently mild erysipelatous infection of the face in a
premature infant 45 days old. In the case herewth reported, Ray-
naud's disease appears to be the only logical diagnosis. The
question comes to mind: If anemia and diminution of blood vol-
ume are etiological factors in this disease, why is it not more
often found associated with infantile atrophy?
2. Michael. May: Case of Purpura with Symmetrical Gangrene of the Fingers. Am.
Jour. Dis. Ch. 20: 124, 1920.
Bacteriologic Findings in Epidemic Encephalitis (Ri-
forma Medica, Naples, Jan. 31, 1920). Maggiora and his co-
workers report that they isolated from the blood in three cases of
severe lethargic encephalitis a gram-positive diplococcus which
reproduced in guinea-pigs a fatal disease with torpor, paresis and
jerking of muscles, and punctiform hemorrhages in the gray mat-
ter of the brain. The diplococcus is a facultative anaerobe and
passage through animals seemed to enhance its virulence. Bocco-
lari and Panini report the finding of a gram-negative diplococcus
in the blood of patients with lethargic encephalitis and from the
blood from the heart in one fatal case. Guinea-pigs inoculated
with it developed a diffuse diplococcemia. — Journal A. M. A.
Eczema in Infants (Archivos Espaiioles de Pediatria, Mad-
rid, Dec, 1919). E. de Oyarzabal remarks that as the skin is so
sensitive in children with eczema, it may be advisable to refrain
from washing the eczematous regions with soap and water, and
use olive oil, cold cream, a benzoin or a hot 3 per cent, solution
of boric acid. The region in children should be covered with a
bandage to protect against scratching. If in the face, and if it
itches much, it is better to give small doses of bromid or chloral to
insure the child's sleeping. Eczema of the scalp, he says, readily
improves under a 2 per cent, salicylated yellow petrolatum or oil
containing 1 to 5 per cent, anthrasol, cleansing once a day with
olive oil and occasionally washing with an infusion of chamomile
Eczema, rebellious to all other measures, may yield to roentgen-
ray exposures. "With these, admirable results are obtained." —
Journal A. M. A.
MISCELLANY
INTERESTING CASES*
SiNUS-TlIROMBUSIS FOLLOWING MeASLES
J. W., male, aged 18 months, was admitted Ai)ril 24, 1920.
case showed coryza, conjunctivitis, marked photophobia, and a
general maculo-papular rash. Temperature, 104° ; pulse, 102 ;
respirations, 36.
Rash was well marked on April 25. child doing nicely. At 8
J), ni., on April 26, temperature was 104° ; pulse, 160; respirations.
52. On morning of April 27, child had a frank bronchopneu-
monia, both l)ases. On April 28, temperature was 105.4° ; pulse,
180; respirations, 58. Edema of the right ear, and over tip of
mastoid, obliterating the posterior auricular folds, was observed.
The left drum, which was bulging, was incised and pus obtained.
On May 5, left ear drum was again bulging, was opened and
pus obtained. In the afternoon, there was bleeding from right
ear, and this kept up for 3 days, until operation on May 9.
Child was operated on for right mastoiditis, on May 9. On
opening, pus with a marked odor was discovered. There was a
thrombosis of the right jugular vein, and about 5 inches of it was
resected. Child died about one-half hour after the operation.
CiiiCKENPox Complicating Scarlet Fever
E. S., male, aged 6^/2 years. This patient was admitted to
Willard-Parker Hospital on May 1, 1920, with a diagnosis of
scarlet fever. On admission, temperature was 101°; pulse, 130;
respirations, 28. Fine, erythematous, punctate rash was general,
and patient had a strawberry tongue. Before admission, on April
28, patient had had both tonsils removed; and, on admission,
there was a marked exudate in both tonsillar spaces.
Temperature dropped to normal, and remained so until May 7,
when it rose to 101°. On May 9, it went to 102.4°, and several
vesicles appeared on face and neck of patient. He was then
transferred to an observation room, with a tentative diagnosis of
chickenpox. Within 24 hours, the vesicles had attained a size
*Recorded by Department of Health Hospitals, City of New York, in the Weekly
Bulletin of the Department, November 20, 1920.
747
748 Miscellany: Interesting Cases
of about 34 i"^h i" diameter, and had become pustular, so that the
probabiHty of a general infection, with multiple abscesses, was
considered.
On May 11, the temperature had begun to come down, and
numerous new pustules appeared over patient's trunk and ex-
tremities. These pustules all began as vesicles, quickly becoming
pustular. The skin surrounding the pustules was in all instances
red, but not infiltrated or painful. Within 3 days the pustules on
the face began to scab over, and disappeared without leaving a
scar. New pustules kept coming until May 21, at which time the
face had entirely cleared up and, a few days later, nothing but
a few scabs were left of the entire eruption.
The absence of a septic curve in the temperature, the drying
up of the pustules, and their healing without incision or scarring
all pointed to the case as being one of varicella, superimposed on
scarlet fever, although at the beginning of the eruption the ques-
tion of pyemia was considered. Since this case, several more
cases of varicella have been seen in scarlet fever patients, but none
of them of the extent or severity of the one detailed.
Meningismus From Severe Throat Infection
L. H., female, aged 22 months, ill 2 days, was admitted on
June 22, 1920, with a diagnosis of pharyngeal diphtheria. On
admission, there was a profuse, slightly sanguineous nasal dis-
charge. A dirty grayish, non-adherent exudate covered tonsils,
pillars and margin of soft palate. There was moderate ulceration
of the underlying tissues. The cervical glands were only slightly
enlarged. The child appeared very toxic. A smear from the
throat showed numerous cocci, but no fusiform bacilli or spirilla,
and no diphtheria bacilli. The rectal temperature was 103°.
Although the process in the throat did not seem diphtheritic
in character, 5,000 units of diphtheria antitoxin were injected,
intravenously.
During the next day the temperature fell slightly, but there
was no change in the general condition of the patient. Ex-
amination of the lungs and ears was negative. Leucocyte count
was 14,000.
On th6 following day there was marked opisthotonus ; the
patellar reflexes were normal, and Kernig's sign was absent.
A lumbar puncture was done, and about 20 c.c of clear fluid
Miscellany: Interesting Cases 749
obtained, under slightly increased pressure. (Examination of
fluid was negative.) The following day the neck was still rigid,
and Kernig's sign positive. There were no pupillary changes.
For the next 5 days the patient ran a temperature varying
between 100° and 105°, which, from that period on, fell steadily
to normal.; Meningismus lasted, in all, 4 days. The nasal dis-
charge lasted about 2 weeks, the throat cleared up in about a
week.
Repeated cultures from the nose for diphtheria bacilli were
negative.
This is one of several cases of severe throat infections seen,
where meningismus, to a greater or less degree, has been present.
The spinal fluid has been uniformly clear, and under but slightly
increased pressure. Cultures and smears for the diphtheria bacil-
lus, and for Vincent's angina, negative.
Physical Signs of Foreign Bodies in Bronchi (American
Journal of Medical Sciences, March, 1920). Decreased expansion
on the affected side, the presence of very fine rales and the "asth-
matoid wheeze," T. McCrae regards as signs of value in the
diagnosis of foreign body in a bronchus. Some foreign bodies,
such as a peanut, set up a very acute general process which is
fairly distinctive. Other structures, such as metallic objects, cause
permanent changes, usually in a lower lobe. The chief errors in
diagnosis are to mistake the signs for those of pneumonia in the
early stages and in the acute cases, and for tuberculosis after the
body has been present for some time. — Journal A. M. A.
Subarachnoid Meningeal Hemorrhage (Journal de Mede-
cine de Bordeaux, March 10, 1920). In one of three cases de-
scribed by P. Mauriac and E. Ferre — all in young men — no cause
for the sudden meningeal hemorrhage could be discovered, and
after blood had been released by lumbar puncture, recovery was
complete in two weeks. In the second case the hemorrhage fol-
lowed the pulling of several teeth. The third case was diagnosed
as uremia with convulsions, as the urine contained albumin. But
lumbar puncture revealed the hemorrhage. Complete recovery
followed in each case. The writers warn that too niucii fluid must
not.be released at one time by lumbar puncture, or the hemorrhage
may be started anew. — Journul A. M. A.
DEPARTMENT OF ABSTRACTS
Ross, Fred E. : Acute General Peritonitfs in Infants.
(The Pennsylvania Medical Journal, March 20, 1920, p. 323.)
When acute pyogenic infections of the new born occur, peri-
tonitis is perhaps the most common lesion found at necropsy. It
is due to a direct infection through the umbilical wound and is
accompanied by an umbilical arteritis and often with erysipelas.
After the neonatal period and before the fifth year, peritonitis
is a very rare disease. After the fifth year, peritonitis is rela-
tively more common. In infants, when the disease occurs, it
is probably a local manifestation of a general septicemia. The
author states that there is one symptom, which is absolutely char-
acteristic and diagnostic, namely, distention of the abdomen with
marked general abdominal tenderness. Four cases are reported
varying in age from four weeks to four months. All had some
elevation of temperature, high at the onset. Neither diarrhea
nor constipation were prominent features ; one had persistent
vomiting and in another cyanosis was present. Common to all
was marked distention of the abdomen with general abdominal
tenderness. L. L. Shapiro.
Hill, Lewis Webb : A Critical Discussion of Certain
Phases in the Development of Modern Infant Feeding:
Their Influence Upon Present Teachings. (The Boston
Medical and Surgical Journal, March 25, 1920, p. 311.)
To Biedert we owe the first really important scientific investi-
gations in infant feeding, and the proving that human milk and
cow's milk are very dissimilar in composition, especially as re-
gards their casein content. To Meigs we owe a more accurate
analysis of human milk, and the widespread diffusion of his own
and of Biedert's ideas in America. To Rotch we owe the great
principles of individualization, and the new conception that it is
not the food as a whole, but its elements that must be consid-
ered. These three men may be regarded as the great pioneers
of infant feeding especially on the study of what to feed the
baby. To Widerhofer we owe the first pathological classification
of gastrointestinal diseases in infants. It was Escherich who
750
Department of Abstracts 751
first studied the bacteriology of the infant's intestine, and showed
that bacterial processes in the intestine, and their relationship to
the food supply can never be separated from questions of practi-
cal infant feeding, either normal or abnormal. To Czerny we
owe the first really adequate study of the "nutritional distur-
bances," and their most comprehensive classification, Finkel-
stein's teachings, which are the most popular to-day, came into
prominence about 1907. His chief contributions may be summed
up in four phrases : sugar, salts, clinical classification and protein
milk. These four men studied the baby primarily and his food
secondarily, contributing especmlly the study of physiological,
bacterial and chemical processes within the baby's body. Refer-
ring to the subject as the "tools of the trade," Dr. Hill urges
that we know our food elements, and be able to trace them in
their progress through the digestive tract, and that we have
several methods of milk modification at our command so that
they may be combined and modified to meet special indications,
L. L. Shapiro.
Epstein^ J. W. : Intussusception in Infants with a Re-
port OF Five Cases. (Ohio State Medical Journal, June 1, 1920,
p. 429.)
Four of the cases reported occurred during the summer
months when every physician is called to treat children for
various gastric disorders. The season of the year and the acute
onset resembling that of gastrointestinal disorders are prone to
distract the physician's mind from the possibility of an intussus-
ception. In all the author's cases, the alarming symptoms that
induced the mother to seek medical advice was the hemorrhage
from the rectum, a symptom of sufficiently grave importance to
warrant the elimination of a possible intussusception. The dif-
ferential diagnosis from a follicular enteritis, the only form of
gastroenteritis where blood is present in the stools, should present
no difficulty. The presence of shock, a normal or subnormal
temperature, absence of stools, a palpable tumor, and a mass on
rectal examination will establish the diagnosis of intussusception
with certainty, while in follicular enteritis the blood is scarce,
there is no shock, no tumor mass palpable, high fever is present
and the stools on microscopic examination reveal the presence
of pus cells. It would seem that in every case with a history of
752 Department of Ahstracls
blood in the stools, a rectal examination should be made for the
purpose of either establishing- or eliminating a diagnosis of
intussusception, and further, it would seem necessary that the
napkin should be examined by the physician to determine whether
there are stools present with blood or pure blood only. The state-
ment of the mother is not always reliable. L. L. Shapiro.
Stern, Arthur: The Umbilical Colic of Friedjung in
Older Children. (Journal of the Medical Society of New
Jersey, XVII, No. 8, August, 1920, p. 279.)
Stern calls attention to a typical form of hysteria in children
from 3 to 10 years, described by Friedjung- in 1904, and char-
acterized by sudden attacks of abdominal pain in the region of
the umbilicus. The attacks of pain are usually sudden in onset
and last only from 15 to 30 minutes; they occur at irregular in-
tervals, occasionally through a period of years, and are usually
without other gastrointestinal disturbances such as vomiting and
diarrhea. Psychopathological signs, such as nail-biting, may be
present, and all cases show a hyperesthesia, especially of the
cervical and thoracic vertebrae, and of the skin of the abdomen.
The differential diagnosis from such conditions as acute appendi-
citis must, of course, be made most carefully. Stern considers the
disease undoubtedly a disturbance of the nervous system, and one
probably to be classified among the hysterical group.
Philip Moen Stimson.
Hand, Alfred: The Diagnosis of Empyema in Children.
(Pennsylvania Medical Journal, XXII, No. 12, September, 1920,
p. 697.)
Hand, in this speech before the Pediatric Section of the Medi-
cal Society of the State of Pennsylvania, noted the rarity of
empyema in infants under a year old and also in the colored
race, both being in contrast to the frequency with which the
disease may follow any variety of pneumonia in other children.
He described the usual clinical picture of empyema in children,
but noted that there was no one pathognomic sign. He called
attention, however, to the differences in the physics of the child's
chest as compared with that of the adult, viz., the greater re-
siliency of the walls, the greater mobility of the heart, and the
Department of Abstracts 753
greater ease which the vocal and respiratory sounds may be
transmitted through effusions. In cases of indefinite cHnical
signs and where the x-ray failed to give conclusive evidence,
such as when the pneumonic consolidation was still present, he
advocated aspiration, and his site of choice for the puncture, he
said, was the sixth interspace in the midaxillary line, preferably
with the help of general anesthesia, in turn exploring inwards,
backwards, and forwards, with only one insertion of the needle
through the chest wall. Philip Mgen Stimson.
Morse, John Lovett: A Study of the Relationship of
Convulsions in Infancy and Childhood to Epilepsy. (Ameri-
can Journal of Diseases of Children, August, 1919, p. 72>.)
Morse recalls in his article the discussion of 20 or 25 years
ago as to the connection between convulsions in early life and
epilepsy. Since that time he has followed the condition of babies
and children he has seen with convulsions in consultation and
private practice. He includes only those cases in which the con-
vulsions were the primary cause for medical attendance and not
those in which there were any evidences of acute or chronic
cerebral disease. He wished to determine in the first place, what
proportion of the children, otherwise apparently normal, having
convulsions have epilepsy or develop it later, and second, to find
out, if possible, whether there is anything in the history or in the
manner of the development of the convulsions to show whether or
not they are manifestations of epilepsy, or whether they will be
followed by or develop into epilepsy later. He obtained satisfac-
tory reports regarding 107 children. The time elapsed varied
between 2 and 20 years. In order to study these cases better and
to avoid confusion they were divided into 4 classes (1) those in
which the convulsions were associated with evidences of spasmo-
philia, (2) those in which the convulsions occurred in the course
of whooping-cough, (3) those in which there was a single con-
vulsion or a series of convulsions at the onset of some acute dis-
ease or with an attack of acute indigestion, (4) those in which
there had been repeated convulsions during a considerable period
or in which there had been repeated attacks suggesting petit mal.
The results of this study were very unsatisfactory and very few
conclusions could be drawn from it. His conclusions are as fol-
lows: Convulsions which are a manifestation of spasmophilia are
754 Department of Abstracts
likely to eventuate in epilepsy. Convulsions which occur in the
course of whooping-cough must always be regarded seriously,
as they are quite likely to be followed by epilepsy later. Single
convulsions or a series of convulsions occurring at the onset of
an acute disease or with an attack of acute indigestion are less
likely to be followed by epilepsy than are repeated convulsions
during a considerable period or repeated attacks suggesting petit
mal. Repeated attacks which would be classified as petit mal, or
which suggested it, are just as likely to eventuate in epilepsy as
repeated attacks of general convulsions. Nothing can be told
from the nature of the early attacks as to the nature of the attacks
when epilepsy develops later. When an injury to the head has
directly preceded the onset of the attacks or there is no apparent
cause for the attacks, epilepsy is more probable than when there is
an apparent cause, such as indigestion, for each attack. The pres-
ence of an apparent cause for the attack does not, however, ex-
clude epilepsy. The longer the attacks have persisted, the more
probable is the diagnosis of epilepsy. General impressions, which
cannot be explained, have a certain value in diagnosis. Finally
and most positively, there is no way to determine immediately
when a baby or child has a convulsion, or has had repeated con-
vulsions or repeated attacks suggesting petit mal, whether it has
epilepsy or whether it will develop later. C. A. Lang.
RoDDA, F. C. : The Coagulation Time of Blood in the
New-Born. (The Journal of the American Medical Association,
August 14, 1920, p. 452.)
By a short review of the literature, Rodda shows that the
most frequent cause of death in the new-born is cerebral hem-
orrhage. He gives short histories of 4 cases with the necropsy
findings and concludes that there are other factors than instru-
mentation and trauma concerned in cerebral hemorrhage. He
summarizes as follows: 1. Cerebral hemorrhage is a frequent
occurrence in the new-born, and the most frequent cause of
death in the first days of life. 2. Cerebral hemorrhage is not
always caused by obstetric operations; it may follow normal
labors when least expected. 3. Severe trauma results in massive
hemorrhages and early death. 4. A more frequent cause of
cerebral hemorrhage is mild trauma plus hemorrhagic disease of
the new-born, accompanied by findings of delayed, coagulation
Department of Abstracts 755
time and prolonged bleeding time. 5. A delayed coagulation
time and prolonged bleeding time can be controlled by the sub-
cutaneous injection of whole blood. This is a rational therapy
in cerebral hemorrhage. 6. In severe cases, surgery should be
employed early; operation should be controlled by blood studies
and the injection of blood, if indicated. 7. The coagulation
time and bleeding time should be determined in every new-born
presenting unusual symptoms, or better, as a matter of routine.
If reactions are delayed, blood should be administered.
C. A. Lang.
Clendening^ Logan : The Cause of Abscess of the Lung
After Tonsillectomy. (The Journal of the American Medical
Association, April 3, 1920, p. 94L)
The author gives a short review of the literature, cites 2 cases,
and concludes as follows: L Lung abscess is at present a fre-
quent sequel to tonsillectomy. 2. It occurs in all classes of
cases — in private as well as in free services. 3. It is sometimes
fatal, always serious and often very crippling. 4. It is due in
some cases to inspiration of infected material. 5. Motor-driven
anesthesia apparatus, by creating a positive pressure in the
pharynx, may operate as a cause. At any rate, the danger is
sufficiently great to justify the discontinuance of their employ-
ment until comparative data can be secured. 6. It is due in some
instances to metastatic infection through the lymphatics. 7.
Swabbing or tampering with the throat, after enucleation has
been accomplished, is the cause of one group of cases.
C. A. Lang.
Newton, McGuire: Chronic Appendicitis in Children.
(Southern Medical Journal, March, 1920, p. 166.)
Four cases are illustrated here in which after medical treat-
ment the x-ray was resorted to in an attempt to diagnose ap-
pendicitis. In all these cases appendicitis was diagnosed which
was proven by subsequent operation. These children made an
uneventful recovery, their symptoms entirely clearing up. The
first, a difficult feeding case, for 9 years suffered from an increas-
ing tendency to headache and constipation. The second case
suffered from frequent attacks of cyclic vomiting who, at 5
756 Department of . Il>slraels
years, had her tonsils removed with no benefit and at 7 diagnosed
appendicitis; operated upon and made an uneventful recovery.
The next case for 5 years suffered from vomiting alternating
with bronchial asthma; this case elicited tenderness on deep
palpation at the umbilicus. The last case at 5 suffered from vio-
lent attacks of urticaria with no abdominal tenderness which also
cleared up after operation. The author thus shows how prone
we are in losing sight of the frequency with which chronic ap-
pendicitis occurs in the young and lays special stress on the aid
of radiography. A. Bret Ratner.
Halsted, W. S.: The Upturned Edge of the Liver over
Acutely Distended Empyematous Gall-Bladders. A Diag-
nostic Sign of Some Value. (Johns Hopkins Hospital Bul-
letin, January, 1920, p. 14.)
The author directs attention to this manifestation on account
of its occasional value as a confirmatory diagnostic sign. It is
better to feel for the edge of the liver in the flat rather than the
everted position. A. Bret Ratner.
Myers, E. Lee : Adenoid Diphtheria — Report of a Case.
(The Journal of the Missouri State Medical Association, Janu-
ary, 1920, p. 20.)
Myers reports an unusual case of adenoid diphtheria in a
girl 9 years old. When seen by the author the child had been
sick 3 days and presented distinct pallor, great muscular weak-
ness, listlessness, lustreless eyes, a temperature of 97.6°, very
weak and compressible pulse of 160. The examination of the
tonsils, larynx and nose was negative. Post-nasal examination
of the nasopharynx showed the vault of the nasopharynx filled
with a yellowish-white, thin membrane, apparently covering the
adenoid growth, of immense proportions. The child was imme-
diately given 10,000 units of diphtheria antitoxin. Twelve hours
later a post-nasal examination showed the post-nasal space to be
clear of any membrane, although the child had a temperature of
104°, and a pulse of 120. Unfortunately no cultures were taken
at this time. The child had an uneventful convalescence, during
which time the cultures from the nasopharynx were persistently
Department of Abstracts 757
negative for Klebs-Loeffler bacilli. The author based his diag-
nosis on the clinical picture, and prompt recovery after diphtheria
antitoxin. William London.
Reid, Mont R., and Montgomery, J. C. : Acute Cholecys-
titis IN Children as a Complication of Typhoid Fever.
(Johns Hopkins Hospital Bulletin, January, 1920, p. 7.)
The authors have collected 18 cases of typhoid fever in children
under the age of 15, v^^ho either died from, or were operated
upon for, complications arising in the gall-bladder. In one case
acute cholecystitis did not develop until 8 months after recovery
from the disease. In all the other cases, the complications came
on during the course of the disease. The good results in recent
years are due mainly to the fact that the operations have been
performed before rupture of the gall-bladder and partly also to
better surgical treatment. Slight pain and tenderness in the
region of the right rectus muscle are not so very unusual during
the course of typhoid fever. The vast majority of these patients
get well. The points to bear in mind are acute pain in the right
side of the abdomen, large gall-bladder or signs of acute peri-
tonitis. There is a rise in temperature and a leucocytosis that
varies between 10,000 and 33,000. They believe the best treat-
ment cholecystectomy and advise immediate surgical treatment,
for in such cases rupture of the gall-bladder may occur and thus
lessen many times the chance of recovery. A. Bret Ratner.
Brown, Alan, MacLachlan, Ida F., and Simpson, Roy:
The Effect of Intravenous Injections of Calcium in Te-
tany and the Influence of Cod Liver Oil and Phosphorus
in the Retention of Calcium in the Blood. (American
Journal of Diseases of Children, June, 1920, p. 413.)
The authors give a short resume of the literature and the
results of their observations conducted on 14 cases of frank
tetany, all of which showed varying degrees of rickets. Their
conclusions are as follows: 1. Constitutional reactions are pro-
duced following intravenous injection of calcium lactate in 1.25
gram doses. The degree of reaction varied from a slight drowsi-
ness to almost complete collapse accompanied by dyspnea. The
signs of reaction disappeared usually between 1 and 7 hours ; the
758 Department of Abstracts
more severe the reaction the longer it took the patient to recover.
2. Intravenous injection of calcium lactate in 1.25 gram doses
produces a temporary absence of both electrical and mechanical
signs of tetany, usually lasting from 7 to 10 hours. 3. Calcium
lactate, injected intravenously, apparently exerts no beneficial
therapeutic efifect unless supplemented by the administration of
cod liver oil and phosphorus, and in this instance the reduction
of the tetanoid symptoms is a little more rapid than with the
employment of cod liver oil and phosphorus alone. 4. Cod liver
oil and phosphorus produce an increase in the blood calcium \vith
a corresponding reduction in the mechanical and electrical signs,
within a period of from 10 to 17 days. C. A. Lang.
Mattill, p. M., Mayer, K. M., and Sauer, L. W. : Dex-
trose Tolerance in Atrophic Infants. (American Journal of
Diseases of Children, January, 1920, p. 42.)
Mattill, Mayer and Sauer recall to our minds the fact that
by the Woodyatt method it has been shown that the tolerance
of adults is from 0.8 to 0.9 gm. per kilogram per hour. In the.
present study they describe the apparatus and technique and
gave dextrose solution intravenously to 4 nonatrophic infants.
These infants ranged in age from 5 to 15 months and were
more nearly normal than any of the others. In these cases,
the tolerance was found to be 0.8 to 0.9 gm. per kilogram of
body weight per hour. Seven atrophic infants were studied and
showed emaciation, tendency to subnormal temperature, lack of
turgor and grayish color of the skin. Their weights were sta-
tionary or nearly so; the stools were good. In no case was the
tolerance below 1.4 or 1.5 gm. per kilogram of body weight per
hour. Other authors found that the metabolism of the atrophic
infant proceeded at a higher level than that of the normal infant.
Observations of McClure and Sauer have shown that atrophic
infants have a higher surface temperature than normal infants
and that there is an increased insensible perspiration. An
increased sugar tolerance would seem to fit in very well with such
observations. In cases in which the injections were repeated a
number of times, it was found that the sugar tolerance was
quite constant. C. A. Lang.
ARCHIVES OF PEDIATRICS AU\ FRTISER
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The g atifying results obtained with COW'S MILK, WATER,
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ACCOMPANY TRADE PACKAGES INFORMATION REGARD
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The concentrated nutriment of full-cream cow's milk, wheat
extract and barley malt are contained in Horlick's, the original
malted milk, constituents which contain a rich proportion
of both the Fat Soluble A and Water Soluble B harmones —
as amplified by the research findings of these and of other
foods, by such prominent and recognized men as Funk, Mc-
Collum, Simmons, Hess, Unger, and many other investigators.
Literature in this regard furnished upon application to Hor-
lick's Malted Milk Company, Racine, Wisconsin.
American medical men are showing great interest in the
-British infant and invalid food known as Virol. This prepara-
tion has been used as a staple in hundreds of hospitals, san-
itoria and infant welfare societies abroad for many years,
and its use appears to be spreading rapidly. It is interesting
to note that Virol was one of the first articles of infant dietary
to contain, as an essential ingredient, the important fat prin-
ciple. Until Virol came along there was on the market no
body-building food for infants which showed in its composition
a recognition of the importance of animal fat as a factor in
infant dietary. The presence of fat-soluble vitamines in bone
marrow was unknown at the time Virol was introduced, but
in the light of recent discoveries in the field of bio-chemistry,
there is little doubt that these complex accessory food factors
have played an important part in rendering it of such value
as a nutrient. It is to the credit of its originators that, from
the first, they insisted on the value of the fat content in their
preparation, and their faith has been justified subsequently by
scientific corroboration. Virol is manufactured in England,
under ideal conditions. While the manufacture is carried on
by an organization devoted exclusively to the making of Virol,
the company is closely associated with the firm engaged in
producing Bovril, the most widely sold concentrated beef
preparation in the world, which is used in nearly every home
in Great Britain and colonies. Virol, too, has become very
firmly established. The extent of the Virol output today may
be gauged from the fact that the company is the largest buyer
in the United Kingdom of extract of malt; a substance which,
with bone marrow extract from the Bovril cattle herds in
Argentina, South America, plays an important role in the
composition of Virol. In order to make it an easy matter
for the physician to put Virol to practical test under his own
observation, the American agents, Geo. C. Cook and Company,
Inc., 59 Bank Street, New York, state that they will be pleased
to send liberal samples on request.
Delayed Recovery from Influenza. — The respiratory and circu-
latory disorders, left as legacies of influenza, persist in most
instances as the direct consequence of the general bodily de-
bility that so many people are suffering from. It is common
knowledge that conditions of worry and anxiety are respon-
sible for widespread nervous depression. This in turn leads
to disturbances of digestion and nutrition, with a correspond-
ing decline in bodily vitality and strength. Niaturally, with
this state of aflfairs existing, many a person lacks the requisite
powers of resistance and recuperation to combat successfully
the conditions left by influenza or pneumonia, and undergo
ARCHIVES OF PEDIATRICS ADVERTISER
ZA Edition
CONSUMPTION
ITS
PREVENTION AND CURE
WITHOUT MEDICINE
With Chapter-; on Sanitation and Prevention
of other Diseases
By CHAS. H. S. DAVIS, M.D.
Member of the New Haven County Medical .Society,
Connecticut Medical Society, American Health League.
While SO many works on tuberculosis
theorize upon the subject, this one shows
how it can be treated, and in the large
majority of cases cured, without the use
of drugs and largely through the patient' s
own efforts. The author emphasizes the
vital necessity of an open-air life and a
rational system of diet. It is a practical
treatise and leaves nothing to be desired.
CONTENTS BY CHAPTERS
I. Consumption and its Fatality.
II. What Causes Consumption.
III. Heredity.
IV. Symptoms and Diagnosis.
V. Drug Treatment of Consumption.
VI. How Consumption can be Cured.
VII. Open-Air Treatment of Consumption.
VIII. How to Breathe Properly.
IX. Proper Diet for Consumptives.
X. Exercise for Consumptives.
XL Change of Climate.
XII. Sanatorium Treatment.
XIII. Hygienic and Prophylactic.
XIV. The Cough of Consumptives.
XV. The Hemorrhage of Consumption.
XVI. Bovine Tuberculosis.
XVII. The Use of Milk.
XVIII. General Tuberculosis.
XIX. Marriage and the Offspring.
APPENDIX
I. The Prevention of Consumption and
other Diseases.
II. Nutritive Value of Animal and Vege^
table Food.
III. List of Sanatoriums in the United States
for the Treatment of Tuberculor.is.
Second Edition. Revised and Enlarged
12mo. 216 Pages. Cloth. Postpaid, $1.50.
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Quaker Oats forms almost
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To make Quaker Oats the
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a full restoration to health. Obviously the keystone of any
effective treatment of post-influenzal complications must be
the use of measures capable of restoring the vitality and
strength of the body. Good food, good air and careful atten-
tion to bathing, exercise and so forth are essential, but these
will accomplish little without effective tonic medication. For
this latter purpose, a remedy that has long enjoyed the regard
of many physicians is Gray's Glycerine Tonic. Administered
in two to four teaspoonful doses, this dependable tonic prompt-
ly stimulates functional activity throughout the body. The
appetite shows a gratifying increase after a few doses, and
there is a pronounced improvement in the digestion and as-
similation of the food taken. The nutritional gain is soon
reflected in a marked increase in bodily strength and energy.
The patient's nervous and mental condition shows a decided
change for the better and instead of being morbid, irritable
and spiritless, he becomes happy, hopeful and energetic. His
whole outlook on life changes for the better. Through its
tonic, restorative action Gray's Tonic Comp. has thus supplied
in many a case of delayed or incomplete recovery from in-
fluenza just the stimulation and reenforcement of the natural
recuperative powers of the body to assure a prompt and satis-
factory restoration to health.
The Best Guaranty of Excellence Lies in the Personal Pride
Which the Workman Takes in the Product of His Skill—The
manufacturers of Listerine are proud of Listerine— because
it has proved one of the most successful formulae of modern
pharmacy. This measure of success has been largely due to
the happy thought of securing a two-fold antiseptic effect in
the one preparation — i. e., the antiseptic effect of the volatile
oils and ethers, and that of the mild, non-irritating boric acid
radical of Listerine. Plharmacal elegance, strict uniformity in
its constituents and the methods of manufacture, together with
a certain superiority in the production of the most important
volatile components, enable Listerine to easily excel all that
legion of preparations said to be "something like Listerine."
Listerine is known and procurable in any reputable pharmacy,
anywhere. It advertises itself by its own good quahties; in-
deed, the best advertisement of Listerine is — Listerine.
Protection Against Winter Coughs. — One of the disadvantages
of the cold season, which persons of reduced vitality must
suffer, is their increased susceptibility to colds and coughs.
Old people, especially, are unusually prone to bronchial! in-
flammations during the winter season. Many physicians insist
upon the older and weaker members of their clientele, who
have this susceptibility to bronchial', conditions, anticipating
this season of coughs, by beginning the regular and continued
use of Cord. Ext. Ol. Morrhuae Comp. (Hagee). This agent
not only has a general reconstructive power as a result of which
the resisting powers of the entire body are improved, but
further than this it seems to exert a selective influence upon
bronchial tissue, further fortifying it against inflammations
and infections. The use of Cord. Ext. Ol. Morrhuae Comp.
(Hagee), as a protection against colds, in the aged and v^eak
person in general, has proven of high advantage and is a
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Just Ready
Second Revised Edition
Diseases of Nutrition
and Infant Feeding
JOHN LOVETT MORSE, M. D.
Professor of Pediatrics, Harvard Medical
School, etc.
BY
and
FRITZ B. TALBOT, M.D.
Instructor in Pediatrics, Harvard Medi-
cal School, etc.
The new^ edition has been entirely reset and brought up to date. The work
is no doubt the most outstanding authority on the subject that we have in America
and it contains many features not to be found elsewhere. There has been no
book in English presenting in detail the physiology of digestion and metabolism
in infancy, which must form the basis of all scientific and rational infant feeding.
Of particular importance will be found the chapters on "Physiology and
Metabolism," both of which have been thoroughly rewritten, as has most of the
book. Two new chapters have also been added on "Spasmophilia" and "Acidosis."
By skilful coordination, the authors first present the scientific facts on which
each condition is based and then apply these facts in detail for practical use.
TABLE OF CONTENTS
Physiology and Metabolism.
I. Physiology of Digestion.
II. The Digestion and Metabolism
of Fat.
III. The Digestion and Metabolism
of Carbohydrates.
IV. The Digestion and Metabolism
of Protein.
V. The Metabolism of the Mineral
Salts.
VI. The Energy Metabolism of
Infants.
VII. The Bacteriology of the Gas-
trointestinal Canal.
VIII. The Stools in Infancy.
Breast Feeding.
IX. General Considerations.
X. Human Milk: Chemistry and
Biology.
XI. Clinical Considerations and
Technique.
XII. Wet Nurses.
Artificial Feeding.
XIII. Cow's Milk: Chemistry and
Biology.
XIV. Cow's Milk: Bacteriology and
Chemical Tests.
XV. Sterilization, Boiling and Pas-
teurization, of Milk.
XVI. Certified Milk.
XVII. General Principles of Artificial
Feeding.
XVIII. The Prescribing of Modified
Milk.
XIX. The Feeding of Premature
Infants.
Diseases of the Gastrointestinal Canal
XX. Spasm of the Pylorus.
XXI. Hypertrophic Stenosis of the
Pylorus.
XXII. Nervous Disturbances of the
Digestive Tract.
XXIII. Disturbances of Digestion.
XXIV. Indigestion with Fermentation.
XXV. Infectious Diarrhea.
XXVI. Constipation.
Diseases of Nutrition.
XXVII. Rickets.
XXVIII. Infantile Scurvy.
XXIX. Spasmophilia.
XXX. Acidosis.
Second Revised Edition, Crown 8vo, xii -j- 384 pages. Cloth, $4.50
E. B. TREAT and COMPANY, 45 East 17th Street, New York
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AUTOINTOXICATION
{Man and His Poisons)
A PRACTICAL EXPOSITION OF THE CAUSES, SYMPTOMS AND TREATMENT
By ALBERT ABRAMS, A.M., M.D. (Heidelberg) F.R.M.S.
The author presents, in a concise form, the fundamental principles of the subject, and
its relation to psycho-therapy, the mind being an important factor in influencing the body
for weal or woe. The remedies employed and common sense methods suggested are
practical and scientific, born of the author's large experience in the treatment of these and
allied conditions.
8vo, 272 Pages, Illustrated, Cloth, Prepaid, $2.00.
Bacterial Food Poisoning
A Concise Exposition of the Etiology. Bacteriology, Symptomatology, Prophylaxis, and
Treatment of so-cailed Ptomaine Poisoning.
By PROF. DR. A. DIEUDONNt, Munich. Authorized Translation edited with ad-
ditions, by DR. CHARLES FREDERICK BOLDUAN
CONTENTS BY CHAPTERS
I. Poisoning Through Diseased Meat. VI. Poisoning Through Ice Cream, etc.
II. Poisoning Through Decayed Meat. VII. Potato Poisoning.
III. Sausage Poisoning. VIII. Poisoning Through Canned Goods.
IV, Poisoning Through Fish and Molluscs. IX. MetalHc Poisons.
V. Poisoning Through Cheese. X. Bibliography.
8vo, 128 Pages, Cloth, Prepaid, $1.50.
NUTRITION
A GUIDE TO FOOD AND DIETING
By CHARLES E. SOHN, F.I.C., F.C.S. Member of the Society of
Public Analysts
Dietetics are quite generally compilations and dry as dust. This text is actually enter-
taining. It is concise yet gives enough for the average needs and the information is
immediately available without wading through useless verbosity and inane statistical tables
of results in some foreign land and under conditions one never confronts. — Medical World.
12mo, 272 Pages, Illustrated, Cloth, Prepaid, $1.50.
CONSUMPTION
Its Prevention and Cure without Medicine — with Chapters on Sanita-
tion and Prevention of other Diseases
By CHAS. H. S. DAVIS. M.D.
While so many works on tuberculosis theorize upon the subject, this one shows how it can
be treated, and in the large majority of cases cured, without the use of drugs and largely
through the patient's own efforts. The author emphasizes the vital necessity of an open
air life and a rational system of diet, holding the belief that, until nutrition is improved,
little can be hoped for.
Second Edition, Revised and Enlarged, 12mo, 217 pages, Cloth, Prepaid, $1.50. ..
E. B. TREAT and COMPANY, 45 East 17th Street, New York
ARCHIVES OF PEDIATRICS ADVERTISER
4 — Treatment of Hemorrhage
IN the control of all kinds of
hemorrhage, with the excep-
tion of that following chloro-
form narcosis, Adrenalin is an
efficient aid. The object of
hemostatic treatment is to con-
strict the lumen of the bleeding
vessels, thereby retarding the
flow of blood and facilitating
the formation of a clot which
acts «s a plug and arrests the
hemorrhage.
Adrenalin is effective not only
by virtue of its obvious vasocon-
strictor action, but also because
it shortens the coagulation time.
This has been demonstrated by
Cannon and his co-workers to
be true particularly when small
doses are injected intravenously
or even subcutaneously.
In severe hemorrhages one
drachm of AdrenaHn 1:1000 in a
pint of hot salt solution may be
given by hypodermoclysis in the
subcutaneous tissue under the
breast or by infusion directly
into a vein. This is not a large
dose of Adrenalin if the hypo-
dermoclysis or the infusion is
given slowly.
Adrenalin is oxidized in the
circulation so rapidly that the
result of this injection is not the
tumultuous effect that
would be expected of
one drachm of Adren-
alin; it is rather the
evenly sustained effect of a few
minims. Adrenalin restores and
maintains the arterial tension,
and the volume of fluid intro-
duced into the almost exsanguin-
ated vessels gives the heart some-
thing upon which to contract.
Superficial hemorrhages and
others which, because of their
location, are readily accessible
may be treated by the topical
application of previously moist-
ened compresses to which are
added a few drops of Adrenalin
1 : 1000. In the category of hemor-
rhages which are amenable to
this local measure are those of
the nose, mouth, throat, ear,
vagina, uterus, and rectum.
In hematemesis give by mouth
about one drachm of the 1:1000
solution. The ingestion of the
remedy in this case brings it
into immediate contact with the
bleeding vessels. In hematuria
the injection into the bladder of
an ounce or two of a solution of
Adrenalin 1:5000 or 1:10,000 is
frequently effective.
Because of its vasoconstrictor
action, Adrenalin is utilized also
as an application to mucous
membranes which are the sites
of vascular engorgement or in-
flammation. Dilution
inr^ to 1:5000 is proper
t Cflr^^wSlv K when Adrenalin is used
for this purpose.
PARKE, DAVIS & COMPANY
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EXCESSIVE VENERY
Masturbation and Continence
Their Etiology, Pathology and Treatment, also Resultant Diseases
By JOSEPH W. HOWE, M.D.
Late Professor of Clinical Surgery, Bellevite Hospital;
Visiting Surgeon, St. Francis Hospital, New York
This volume contains, in addition to the results of the author's experience
obtained in hospitals and private practice, the substance of a course of lectures
delivered in the Medical Department of the University of New York, to which
is added the peculiar methods of treatment employed by other authorities
in Europe and America. The causes, diagnosis and treatment of the various
disorders that marshal themselves under the general term of excessive venery
are clearly presented, and many curious experiences detailed bearing upon
the mental influences connected with the use and abuse of the sexual act.
The volume is complete as a book of reference for the student and practitioner
of medicine.
Medical Bulletin says: — "Every topic is carefully, Medical Record says: — "This is a judiciously writ-
judiciously, and legitimately handled." ten book from the standpoint of a practical surgeon
Medical Times says: — "The treatment of the sub- of large experience. The author shows himself a
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Second Edition, Revised. 8vo. 300 Pages. Cloth, Prepaid, $3.00
Nervous Exhaustion
Its Symptoms, Nature, Sequences and Treatment
By GEORGE M. BEARD, A.M. M.D.
Edited, with notes and additions, by A. D. ROCKWELL, A.M., M.D.
Neurologist and Electro-Therapeutist, Flushing Hospital, formerly Professor of
Electro-Therapeutics, New York Post-Graduate Medical School and Hospital
Neurasthenia is now almost a household word and, equally with the term
malaria, affords to the profession a convenient refuge when perplexed at the
recital of a multitude of symptoms seemingly without logical connection or
adequate cause. In spite of its frequency and importance, although long
recognized in a vague way among the people and the profession under such
terms as "general debility," "nervous prostration," "nervous debility," it is
the most frequent, most interesting and most neglected nervous disease of
modern times. Among specialists and general practitioners alike, there has
been, on the whole subject, a fearful and wondrous confusion of ideas. The
present work is the result of the experience and study of my entire profes-
sional life in the subject to which it relates. — From Author's Preface.
Fifth Edition, Revised and Enlarged, 8vo, 288 Pages, Cloth, Prepaid, $3.00
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DISEASES OF CHILDREN
By SAMUEL W. KELLEY, M.D., LL.D.
Pediatrist and Orthopedist, St. Luke's Hospital, Cleveland; Formerly
Professor of Diseases of Children, Cleveland College of Physicians and '
Surgeons, Ohio Wesleyan University.
"The author's tone is judicious, personal and not unduly authoritative, for no one
man can be authority for such a long range of subjects. ' Jour. A. M. A.
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gical affections as they are manifested in children." Therapeutic Gazette
"Compares favorably with any work on the subject, and is more complete than
many prior efforts on this line." Medical World.
"The essential facts of pediatric surgery have been presented in a clear and inter-
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general practitioner." Archives of Pediatrics.
1 U* Jlt.1 _ thoroughly revised and enlarged
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Diseases and Deformities t1 Foot
By JOHN JOSEPH NUTT, B.L.. M.D.
Surgeon-in-Chief, New York State Hospital (or the Care of Crippled and Deformed
Children; Surgeon, Sea Breeze Hospital; Assistant Attending Surgeon in charge of Or*
thopedic Cases, Willard Parker Hospital; Member of the American Orthopedic Association
' I ^HIS handbook is prepared for the use of physicians who have not had iht
•*' time or the opportunity for thorough study of this often neglected subject and
who feel keenly their inability to prescribe scientifically and successfully for the
many who consult them regarding their pedal conditions. Text-books on orthopedic
surgery are rarely consulted by the general practitioner, as most of the diseases
and deformities of the frame-work of the body demand such treatment as only
orthopedic surgeons are prepared to give.
With regard to the feet, however, much of the treatment is so simple that
the general practitioner can and should assume the responsibility of preventing
deformities, correcting abuses and those conditions which have already occurred
and treating minor diseases of the bones and joints. Many painful and disagree-
able conditions, such as chilblains, corns, ingrowing toe-nail, painful heel, excessive
sweating of the feet, etc., may be cured by simple measures, and these, as well
as the operations for severer complications, are herein fully described and j.mplj
illustrated. — From Author's Preface.
CONTENTS BY CHAPTERS
Chapter I. Anatomy.
II. Physiology,
lit. Examination.
IV. Shaffer's Fool. Weak-Foot. Fiat-Foot
V. Congenital Club- Foot.
VI. Treatment of Congenital Club-Fool.
VII. Pott's Paraplegia. Cerebral Paralysis.
" VIII. Infantile Paralysis.
IX. Tuberculous and Gonorrheal Diseases.
** X. Other Ailments, including Painful Heel — Chilblain*
— Excessive Sweating^Ingrowing Toe-nail — etc., etc.
XI. Foot Apparel.
Svo.y 300 pages, 105 illustrations and plates, cloth, $3.50
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INSTINCT
BY JAMES POSTER SCOTT, B.A. (Yale University); M.D., CM. (Edinburgh University)
late Obstetrician to Columbia Hospital for Women, Washington, D.C.
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8vo, 436 pag:e8.
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Cloth, $3 Postpaid.
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AKCHlVES OF PEDIATRICS? ADVERTISKR
THE, BLUE,S
(NERVE EXHAUSTION)
CAUSES AND CURE
By ALBERT ABRAMS, A.M., M. D., (Heidelberg), F.R.M.S.
CONSULTING PHYSICIAN, DENVER NATIONAL HOSPITAL FOR CONSUMPTIVES,
THE MOUNT ZION AND THE FRENCH HOSPITALS, SAN FRANCISCO;
PRESIDENT OF THE EMANUEL SISTERHOOD POLYCLINIC;
FORMERLY PROFESSOR OF PATHOLOGY AND DIRECTOR
OF THE MEDICAL CLINIC, COOPER MEDICAL
COLLEGE, SAN FRANCISCO.
The object of this volume is to direct attention to a new and heretofore
undescribed variety of nerve exhaustion, which the author designates Splanchnic
Neurasthenia. This special form of nerve weakness, characterized by par-
oxysms of depression of varying duration, is popularly known as "the blues."
its recognition is of more than theoretic interest. A mere theory may be of
interest to the rhedical profession, but the layman asks science for results.
From the author's vast experience with neurasthenics, he knows of no
variety of neurasthenia which is more amenable to treatment than this
splanchnic form. A perusal of the subject matter of this volume will show that
he has referred its origin, in brief, to a congestion of the intra-abdominal veins.
"It is a long time since we have read a
medical book with such interest and real en-
joyment as we have this work. Dr. Abrams
writes entertainingly on a novel subject, and
whether his theory is fundamentally sound or
not his book is suggestive, and will at least do
good in directing attention to the neglected
set of muscles which constitute the abdominal
wall. However, it is not merely in the novelty
of the theory and the seeming ease of cure
that the charm of the book lies, but rather in
the author's evident sincerity and the easy,
pleasant way in which he has developed his
theme.' ' — Medical Record.
"This book is a most valuable addition to
the literature on the subject, as it contains
many excellent methods of treatment which
the patient can carry out without the aid of a
nurse or masseur." — Cleveland Medical and
Surgical Reporter,
"Treatment is considered at length. The
author's theories are not only plausible, but
as his results show, correct." — The Medical
Standard.
" Abrams is a ready and interesting writer
and an original investigator. His statements
will always bear perusal for the practical good
there is in them." — Denver Medical Times.
" The book is very clearly written, and is
an addition to the literature on the protean
disease, neurasthenia, that is worthy of a care-
ful perusal." — American Medicine.
" There are a number of very practical
points with regard to the varying phases of
the disease, and the various chapters arr
summarized very interestingly. The book is
worth reading, especially for those who have
much to do with the idle rich, with so much
time on their hands that ' the blues' become
a frequent source of annoyance." — Medical
News.
"In this book we find much that is original
in thought and investigation. The author
elaborates his theory in a thoroughly scieniific
spirit and adduces much experimental and
clinical evidence to support it. The practical
value of the book is also great as the methods
of cure, mainly through appropriate exercises,
are completely and clearly detailed." — North-
west Medicine.
"Dr. Abrams always has something to say,
and usually something new, and this is no
exception. The author is a graceful writer,
and yet a practical man.'' — The Alkaloidal
Clinic.
Fourth Edition, Revised & Enlarged, 8vo, 304 pages. Illustrated. Cloth, $2.00
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ORIGINAL ARTICLES FOR THE PAST TWELVE MONTHS
(Continued from second page of cover)
JULY, 1920
Special Detailed Report of the Thirty-second Annual Meeting of the American Pediatric
Society, held at Highland Park, 111., May 31, June 1 and 2, 1920, with full ab-
stracts of all papers read.
AUGUST, 1920
The Effort Syndrome in Children By Charles Gilmore Kerley, M.D.
The Dietetic Treatment of Summer Diarrhea — .By J. P. Crozer Griffith, M.D.
The Bacteriology of Summer Diarrhea By D. H. Bergey, M.D
Weight and Height in Relation to
Malnutrition By William R. P. Emerson, M.D., and Frank A. Manny
Further Studies in Thick Cereal Feeding in Malnutrition
in Infancy By Harold R. Mixsell, M.D.
Some Experiences with Malaria Among Children in Palestine. .. .By Sophie Rabinoff, M.D.
SEPTEMBER, 1920
Acrodynia By William Weston, M.D.
A Clinical Classification of the Diarrheas of Infancy and Child-
hood By Lawrence T. Royster, M.D.
Meningitis, Caused by Lead Poisoning, in a Child of Nineteen
Months By Robert A. Strong, M.D.
Focal Hemorrhagic Encephalitis By Aldert Smedes Root, M.D.
The Importance of Lumbar Puncture in Intracranial Hemorrhage of the New
Born. Report of a Case with Recovery By J. Buren Sidbury, M.D.
The Prophylaxis of Ileocolitis By J. Ross Snyder, M.D.
The Diphtheria Carrier By W. L. Funkhouser, M.D.
OCTOBER, 1920
Some Peculiarities in the Symptomatology of Childhood By Herbert B. Wilcox, M.D.
Report of a Case of Diaphragmatic Hernia By John E. Greiwe, M.D.
Lambotte-Handley Drainage in a Case of Chylous Ascites By Francis Huber, M.D.
An Unusual Instance of Multiple Infections By Archibald L. Hoyne, M.D.
Butter Fat and the Child's Weight .By J. H. Larson
NOVEMBER, 1920
A Method of Determining the Appropriate Dose of Tuberculin for the Individual
Tuberculous Child By Myer Solis-Cohen, M.D.
Epidemic Acid Intoxication By B. K. Rachford, M.D.
Intraperitoneal Administration of Sodium Bicarbonate Solutions. .. .By J. P. Epstein, M.D.
Cyanosis of the New Born By Frank Cohen, M.D.
Congenital Atresia of the Esophagus By Alfred L. Kastner, M.D.
A Case of Bacteriemia Treated by Repeated Transfusions By Jesse F. Sammis, M.O.
The Organization of a Modern Pediatric Service By Henry Heiman, M.D.
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