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fremitus along the sides of the vertebral coliunn at the level of the
scapulae ; transmission of the nasal quality in the whispered voice as
heard over the vertebrae below the first dorsal, and roentgenograms.
Certain other signs, such as dilatation of the superficial veins of the
front of the chest and dulness over the manubrium, occur in excep-
tional instances. Other rare signs are due to pressure on the laryngeal
nerves. One of our patients had only one complaint, hoarseness, com-
ing, on gradually, but well marked when first seen. He showed para-
vertebral dulness, D'Espine's sign and a positive roentgenogram. The
von Pirquet reaction was negative and there was no other indication
that he had a tuberculous infection. Under observation his hoarseness
has gradually improved and coincident with this the D'Espine sign has
decreased from the fifth to the third dorsal vertebra, and the roent-
genogram has shown the shrinking of the glands. In the 100 cases,
20 showed dulness with or without change in breathing at the lung
roots and in every instance the D'Espine sign was positive and the
Roentgen ray revealed bronchial glands or thickening of the lung roots
except in 2 cases in which the D'Espine sign was not recorded, but
the roentgenogram was positive. Seventy out of the 100 cases had a
positive D'Espine sign down to or below the second dorsal vertebra.
Of these, 65, or 92.85 per cent., had positive roentgenograms, 3 had
negative roentgenograms and in 2 no roentgenograms were taken.
Two of the cases in which roentgenoscopy was negative showed
D'Espine's sign to the fifth, the other to the second dorsal vertebra.
There is no explanation for these discrepancies, but it would seem,
except in rare instances, that a positive D'Espine sign means enlarged



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232 AMERICAN JOURNAL OF DISEASES OF CHILDREN

bronchial glands. The only case which we were able to follow to post-
mortem examination showed paravertebral dulness, a positive D'Espfne
and a positive roentgenogram, and at necropsy there was marked
enlargement of the bronchial glands. In 16 instances the roentgeno-
gram was the only evidence of enlarged bronchial glands, and the plate
often showed in these instances a marked enlargement. Presumably
these glands were so situated as to cause no pressure and thus escaped
detection. The 70 cases with positive D'Espine's sign shown a positive
von Pirquet reaction in 41 instances, or 58.57 per cent., a negative
reaction in 27, or 38.57 per cent., and in 2 the test was not done. The
one instance of enlarged bronchial glands examined post mortem had
a negative von Pirquet, and no tuberculous focus was found at
necropsy. The glands in this case were due to an acute endocarditis.
These figures emphasize the importance of remembering that a diag-
nosis of enlarged bronchial glands does not mean necessarily tuber-
culous glands. In several instances it was possible to observe by the
D'Espine sign and the Roentgen ray the appearance and disappearance
of the bronchial glands during the course of an acute bronchitis or
endocarditis. Any infection in any part of the body drained by these
glands may give rise to their enlargement.

VON PIRQUET REACTION

There were 62 positive and 35 negative von Pirquet reactions, and
in 3 patients the test was not done. Of the 62 positive cases, 24, or
38.7 per cent., had a known exposure to tuberculosis, 45 had a positive
D'Espine sign and 56 showed signs in the lungs by Roentgen examina-
tion. Only 7 of the positive reactions were in patients having an active
tuberculosis; the others had without doubt a healed process in many
instances shown by some physical sign. None of the cases with nega-
tive reaction had tuberculosis proved by other means, but many of
them showed physical signs of disease in the lungs.

Case 1 (5). — This patient was 11 years old and came to us complaining of
a cough which had lasted for several years. It was especially severe during the
winter and accompanied by a considerable amount of sputum. The examina-
tion of the lungs was negative except for a few scattered rales. Repeated
examinations of the sputum showed no tubercle bacilli. D'Espine's sign was
negative. Roentgenoscopy revealed the lung markings matted together and
abnormally dense especially on the right, more marked at the base; the apices
normal. The von Pirquet reaction was negative. This case was considered
to be one of chronic bronchitis.

Case 2 (11). — This patient, 12 years old, complained of cough lasting for
several months with profuse expectoration. The examination of the lungs
showed many small areas of dulness over both bases without change in breath-
ing and many scattered coarse rales. Repeated examinations of the sputum
showed no tubercle or influenza bacilli. The D'Espine sign was negative.
Roentgenoscopy revealed enlarged glands at both roots, especially the right,
with slight thickening of the linear markings, right apex slightly dull. A sec-



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SMITH AND SWEET— CHEST EXAMINATION 233

ond roentgenogram several months later showed some pathologic process at
the root of the right lung. Fluoroscopic examination showed that the diaphragm
on the left did not move so well as on the right, and that there was a dull
spot at the root of the right lung. Several von Pirquet reactions were done and
were negative. This patient had been at a state sanatorium for tuberculosis
and the case was recorded in the classification of that institution as "not
determined." It was considered by us to be one of chronic infection of the
lung roots with some organism not the tubercle bacillus.

Case 3 (39). — A child of 5 years, who three years ago had pneumonia, since
when about every two months, she had had attacks of coughing lasting from
two to three days accompanied by pain in the side, fever and profuse yellow
expectoration. The cough did not entirely disappear between attacks. On
examination the lungs showed increased paravertebral dulness and slightly
impaired resonance over the right base. The sputum showed no tubercle bacilli
and no influenza bacilli, but many other organisms. D'Espine's sign was posi-
tive to the fifth thoracic vertebra. The Roentgen ray showed enlarged bron-
chial glands and a pathologic process involving both lungs. The von Pirquet
reaction was negative. This was considered to be a case of chronic bronchitis,
quite possibly bronchiectasis.

Case 4 (53).— A child, 4 years old, who complained of attacks of coughing
coming once or twice a month lasting two or three days and accompanied by
fever and thick yellow sputum. On examination the lungs showed dulness
with distant breathing and moist rales at the right base. D'Espine's sign was
positive to the fourth thoracic vertebra. The Roentgen ray showed enlarged
bronchial glands and some pathologic process at the root of the right lung
with a dull area in the region of the right bronchus. The von Pirquet reaction
was negative. It is fair to say that the Roentgen interpretation said "bronchiec-
tasis or bronchopneumonia, no evidence of tuberculosis." It was considered to
be a case of bronchiectasis.

Case 5 (65).— A child, 10 years old, who came to us with the statement that
three years ago she had had pneumonia and since then she had caught cold
easily. She had attacks of fever and recently a considerable amount of sputum.
She had had no night sweats. Examination of the lungs showed slight dul-
ness at the right apex without change in breathing except during the time
when she had a cold; then there were a few scattered rales. Repeated exami-
nations of the sputum failed to show any tubercle bacilli or influenza bacilli.
D'Espine's sign was positive to the fifth thoracic vertebra. The Roentgen ray
revealed enlarged bronchial glands and a pathologic process involving both
lungs. Repeated von Pirquet reactions were negative. This was believed to
be a case of bronchiectasis.

Case 6 (66).— A child, 10 years old, who for two months had had pain in
the back and recently had begun to have a considerable amount of thick yel-
low sputum. On examination the lungs showed at the right apex dulness with-
out other changes and dulness in the middle of the left lung and toward the
left base with slight change in breathing and medium and fine crepitant rales.
Many examinations of the sputum showed no tubercle bacilli or influenza bacilli.
D*Espine's sign was positive to the fourth thoracic vertebra. Roentgenoscopy
revealed enlarged bronchial glands and mottling of both lungs, more marked
about the roots but extending to the apices. The von Pirquet reactions were
negative. This was considered to be a case of bronchiectasis.

The analysis of these cases has shown that only 9 out of 1(X)
suspected cases had active tuberculosis ; that 63 had evidence of tuber-
culous infection., now in a quiescent state, and that 39 had no evidence
of tuberculosis of any kind. It is important to find the cases of active
tuberculosis and give them the proper care. It is equally important to



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234 AMERICAN JOURNAL OF DISEASES OF CHILDREN

be sure that this diagnosis is correct. Patients with old inactive scars
of tuberculous infection should not be treated as cases of active tuber-
culosis. A considerable number of children suspected of having tuber-
culosis will be proved to have an infection with some other organism
than the tubercle bacillus. These patients need proper treatment. A
part of this treatment consists in keeping them away from exposure
to tuberculosis either outside or in a tuberculosis sanatorium. These
patients deserve and should receive the most careful consideration.

329 Beacon Street.— Griffith-McKenzie Building.



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THE ABSORPTION OF FAT FROM THE INTESTINAL
TRACT OF THE ACTIVELY TUBERCULOUS CHILD*

FREDERIC W. SCHLUTZ, A.B., M.D.
Assistant Professor of Pediatrics, University of Minnesota.

MINNEAPOLIS

The question of fat absorption from the intestinal tract of the
actively tuberculous child is one of considerable importance. This is
particularly true in view of the fact that it is almost a universal custom
to feed the tuberculous child on a diet especially rich in fat.

Two things are considered advantageous to the tuberculous child :
(1) to bring about as rapidly as possible a pronounced increase in
weight ; (2) to have this gain represented as much as possible by the
deposit of fat in the tissues. While both of these considerations were
purely empirical, the extensive studies on food metabolism carried
out in recent years have shed much light on the factors which should
influence the choice of diet for this affection.

It has been shown that diet may not only affect the chemistry of
the tissues of an organism to a very marked degree but also play
an important role in influencing the resistance of the tissue to disease
process.

Weigert^ has shown by experiments on animals that both the fat
metabolism and the water metabolism of the tissues are important
factors. He has shown that the age of the animal and the manner
of feeding determine the water retention. The amount of water con-
tent in the tissue depends not only on an increase or decrease of fat
substance in the tissue but also on variations of the fat-free residual
substance in them.

The tissues of the animal fed on protein and fat-rich food show
the largest amount of fat- free residual substance and are low in water
content, while conversely those fed on food low in protein and fat,
but rich in carbohydrate, show a small per cent, of fat-free residual
content but retain much fluid. He has further demonstrated by
experiments on pigs infected with tuberculosis that animals fed on



* Read before the Section on Diseases of Children at the Sixty-Fifth Annual
Session of the American Medical Association, Atlantic City, N. J., June, 1914.

♦From the Minneapolis City Hospital and the Department of Medicine of
the University of Minnesota.

1. Weigert, R.: Ueber dem Einfluss der Ernahrung auf die chemische
Zusammensetzung des Organismus, Jahrb. f. Kinderh., 1905, Ixi, 178; Ueber
dem Einfluss der Ernahrung auf die Tuberkulose, Berl. klin. Wchnschr., 1907,
xliv, 1209.



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236 AMERICAN JOURNAL OF DISEASES OF CHILDREN

carbohydrates and with pronounced water retention in their tissues
are the least resistant to this infection, whereas those fed on fat-rich
mixtures, resulting in low water retention and high specific gravity
of the tissues, succumbed much less readily to the inroads of this dis-
ease. Fattening the animals rapidly by forced feeding did not seem
to hinder in any particular way the destructive influence of the infec-
tion. Weigert's experiments seem to emphasize the important rela-
tionship of fat metabolism and water retention of the tissues to the
production of immunity.

The importance of diet in its relationship to tissue metabolism is
further emphasized by Czerny's* important studies and publications
on the exudative diathesis or the scrofulous manifestations of the
older writers. He calls attention to the extremely intimate connection
existing between these manifestations and the diet. This is shown
by the reaction of individuals affected with the exudative diathesis to
certain kinds of food. With few exceptions, such as are cited by
Finkelstein,'* overfeeding or attempts to bring about forced gain in
weight results in the prompt appearance of these manifestations or in
their aggravation, if already present. The reaction seems particu-
larly prompt and pronounced if milk, cream, eggs or large quantities
of concentrated sugars form the chief ingredients of the diet.

There is still much difference of opinion whether many of the
scrofulous or exudative manifestations are tuberculous in their nature
or not. This fact has been clearly shown, that the selection of a diet
which is not especially rich in fat and which does not favor retention
of fluid in the tissues influences favorably the scrofulous or exudative
manifestations in the tuberculous child.

Just what particular part of the metabolism of the scrofulous or
exudative child is abnormal is not definitely known. Both fat and
salt metabolism have been suspected. That the fat absorption in
children with this condition differs very little from the normal was
shown by experiments of Birk* and L. F. Meyer.*^

The importance of the fat metabolism for the tuberculous child
brings up the question of the fat absorption from its intestinal tract.



2. Czerny, A.: Die exudative Diathese, Jahrb. f. Kinderh., 1905, Ixi, 199;
Exudative Diathese Skrofulose und Tuberloilose, Jahrb. f. Kinderh., 1909, Ixx,
529; Erfahrungen iiber den Verlauf der Tuberkulose im Kindesalter, Arch,
f. Kinderh., 1913, Ix, 242; Zur Kenntis der ecudativer Diathese, Monatschr. f.
Kinderh., 1907, vi, 1; Ueber die Beziehung zwischen Mastung und scrofulosen
Hautaffectionen, Monatschr. f. Kinderh., 1904, ii, 57.

3. Finkelstein, H. : Ztschr. f. Kinderh., 1913, viii, 1.

4. Birk, W. : Ueber den Magnesium-Umsatz des Sauglings, Jahrb. f.
Kinderh., 1907, bcvi, 300.

5. Meyer, L. F. : Zur Kenntis des Mineral-Stoffwechsels im Sauglings-Alter,
Biochem. Ztschr., 1908, xii, 422. '



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SCHLUTZ—FAT IN TUBERCULOSIS



237



Talbot* in an interesting series of cases reported before this Section
two years ago showed that in peritoneal tuberculosis, fat absorption
was markedly diminished. This, he believes, is explained by blocking
of the lymphatic channels leading from the intestinal tract by the
inflammatory reaction to the tuberculous infection. Whether decreased
power of fat absorption exists in other of the common forms of
tuberculosis has (with the exception of a single case reported by
Freund^) not been determined. This study is concerned with this
particular phase.

The amount of material presented is not large but was carefully
selected with special reference to patients in definitely active stages
of the disease. The ages of the children ranged between 2}^ and
10 years.

TABLE 1. — Results in Series A, Children Fed on Fat-Rich Diet (Butter
Cream, Milk, Eggs) with Small Amount of Carbohydrate (Bread)



Cases


Fat Intake
in gm.


Fat Excreted
gm.



Loss of Fat
Per Cent.


Type of Tuberculosis


1


450.5


26.9


5.9


r

Pulmonary.


2


429.0


7.5


1.6


Pulmonary.


3


473.2


22.6


4.5


Pulmonary.


4


422.1


18.6


4.4


Pulmonary and glandular.


5


382.4


46.8


12.2


Pulmonary


6


298.3


30.0


10.7


Pulmonary and glandular.


7


4732


18.1


3.8


Pulmonary and glandular.


8


4042


10.6


2.6


Pulmonary and glandular.


9


391.7


42.6


10.9


Glandular.


10


430.0


40.5


10.7


Glandular.


11


410.3


30.8


7.5


Glandular.


12


455.1


20.3


4.2


Bone.


13


423.9


15.4


3.6


Bone.


14


361.5


59.3


16.6


Pulmonary, bone and

glandular.
Pulmonary and peritoneal.


15


457.1


21.3


4.6



It is an interesting coincidence that eleven out of the fifteen cases
reported were distinctly of the exudative or scrofulous type, showing
how frequently this condition and tuberculosis are associated. In
several of the cases manifestations had existed since infancy; in
others they had become particularly pronounced during the stay at
the hospital. An exclusively fat-rich diet consisting of cream, milk;



6. Talbot, Fritz B.: Tuberculosis of the Mesenteric Glands in Infants and
Young Children, Its Effect on Absorption, Am. Jour. Dis. Child., July, 1912,
xi, p. 49; Physiology and Pathology of the Digestion of Fat in Infancy, Am.
Jour. Dis. Child., March, 1911, p. 173.

7. Freund, Walther: Physiologie und Pathologic des Fettstoffwechsels im
Kindesalter, Ergebn. d. inn. Med. u. Kinderheilk., 1909, iii, 139.



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238 AMERICAN JOURNAL OF DISEASES OF CHILDREN

butter and eggs with a small addition of carbohydrate, in the form
of bread, was given in the larger series, A, consisting of fifteen cases
and the same diet with larger addition of carbohydrate in the form
of sugar, bread and vegetables given in a smaller series, B, con-
sisting of five cases. The diet in each case was given for a period of
several days. The fat determinations in both the food and the feces
were carried out according to the methods described by Talbot and
also one described by Folin and Wentworth.® Both methods gave
good results and seemed sufficiently accurate for a clinical study of
this kind.

The series of cases reported comprises all the common forms of
tuberculosis and includes four cases with pulmonary involvement
alone, four with pulmonary glandular involvement, three with pro-
nounced glandular involvement only, three cases of bone tuberculosis,
in one of which there was also marked glandular involvement and one

TABLE 2. — Results in Series B, Children Fed on Fat-Rich Diet with the
Addition of Large Amounts of Carbohydrate (Butter, Bread, Milk
Cereals, Eggs, Vegetables)



Cases


Fat Intake


Fat Excreted
gni.


Loss of Fat
Per Cent.


Type of Tuberculosis


1

2

8

14

15


472.5
476.5
424.9
474.3

393.8


14.4
10.5
11.9
45.9

20.5


3.0
2.1
2.7
9.6

52


Pulmonary.
Pulmonary.

Pulmonary, bone and

glandular.
Pulmonary and peritoneal.



in which there was pulmonary and suspected peritoneal involvement.
The fat absorption is distinctly diminished only in the glandular type
of tuberculosis. The stools in three of the cases showed both macro-
scopic and microscopic evidence of fat, considerably in excess of the
normal. The same was shown by the quantitative determinations.
In all the other forms of tuberculosis the fat absorption very nearly
approached the normal.

The one case suspected as peritoneal showed good fat absorption.
Series B brought out the interesting fact that the fat absorption was
if anything improved by the addition of certain amounts of carbo-
hydrate to the diet.

The results of so small a series of cases are probably not sufficient
to warrant extensive conclusions. They do seem to show, however,



8. Folin, O., and Wentworth, A. H.: A New Method for the Determina-
tion of Fat and Fatty Acids in the Feces, Jour. Biol. Chem., 1909, vii, 421.



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SCHLUTZ^FAT IN TUBERCULOSIS 239

that fat absorption in most of the common forms of tuberculosis
is practically normal and is likely to be diminished only in those cases
in which there is extensive glandular and lymphatic involvement.

If it were a question of fat absorption only, high fat feeding would
not be contra-indicated in most forms of tuberculosis.

To what extent scrofulous or exudative manifestations, apparently
unfavorably influenced by fat-rich food, should influence the diet of
the tuberculous child is a question which the individual case must
determine. The presence of the exudative cpndition apparently does
not influence fat absorption.

Experimental and clinical evidence both seem to show that a diet
which insures the largest amount of fat deposit in the tissue, with
the least retention of water, is the one most beneficial to the tuber-
culous child.

CASE REPORTS

Case 1.— Dorothy F., aged 10, schoolgirl. Admitted to the City Hospital
Tuberculosis Pavilion in March. An outside physician had diagnosed pulmon-
ary tuberculosis. She has not been well for some time and has had night
sweats, afternoon rise of temperature, considerable cough and expectoration.
Tubercle bacilli were found in the sputum. Her bowels are regular and not
loose. The appetite is fair. She has been fed on fat-rich diet, especially cream,
eggs and cocoa, on account of suspected lung trouble. Her father is living and
well. The mother died four years ago of tuberculosis. Two brothers died of
tuberculosis. She has had mumps, measles and pertussis two years ago and
has not been well since the attack of pertussis. Some eczema was present dur-
ing early childhood.

Physical examination shows a fairly well-nourished child with flabby muscu-
lar tone, dry skin, evidences of eczematous eruption back of the ears, and
general glandular enlargement, especially of the cervical glands of the neck.
The head is negative. The teeth are carious. There is some hypertrophy of
the tonsils, also adenoid tissue. The chest is flat; the intercostal glands are
slightly enlarged. Dulness is pronounced on the right side. Dry, crepitant
rales are heard over that side and some over both lungs posteriorly. The
abdominal walls are flabby. The liver is half an inch below the costal margin.
The spleen is not palpable. No masses are felt in the abdomen. The extremi-
ties are quite emaciated. All reflexes are present. The tuberculin reaction is
very pronounced.

Case 2. — Amanda B., aged 8 years. Admitted to the City Hospital Tubercu-
losis Pavilion in February. The child was sent to the "fresh-air camp" two
years ago with a diagnosis of incipient tuberculosis, one sister having just died
of the disease. The patient has not been well since that time. She coughs a
good deal and expectorates. Tubercle bacilli were found. There is afternoon
rise of temperature. Anorexia is pronounced and she has not been gaining.
Her father died of diphtheria. The mother is rheumatic and has a chronic
cough. Two sisters died of tuberculosis within the last two years. The patient
has had pertussis, diphtheria, measles, and scarlet fever. She has never had
diarrhea and has been on a fat-rich diet, especially cocoa, eggs and cream, for
the last two years.

Physical examination shows an undernourished child with pronounced pallor.
The color of the skin is sallow and the skin is dry and rough. There are some
eczematous patches on the legs and dry crusting on the scalp. Glandular
enlargement is general. The glands of the neck and inguinal region are especi-



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240 AMERICAN JOURNAL OF DISEASES OF CHILDREN

ally large. The throat shows general hypertrophy, both of the tonsils and of
the tissue, in the posterior pharyngeal wall. The chest is fairly well formed.
There is some dulness over the left lower lobe posteriorly. Crepitant rales
are heard throughout both lungs. The abdomen is not prominent. The liver
and spleen are not palpable. No masses are felt in the abdomen. The extremi-
ties are negative. The von Pirquet reaction is pronouncedly positive.

Case 3. — Alexander B., aged 5. Admitted to the City Hospital Tuberculosis
Pavilion in May. The complaint is a chronic cough with expectoration and
night sweats. Tubercle bacilli had been found. The child has had measles



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