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Wis., (/. A. M, A,, 1912, LIX, p. 690) and
Bell of Cincinnati {Lancet Clinic, 1912,
CVIII, p. 234).

In Europe the matter has been curious-
ly ignored though a prophet never has
honor in his own country. The only one
who has tested it out is Dr. J. D. Rolles-
ton, assistant medical official of the Grove
Fever Hospital in London. He permits
me to quote from his article which is to
appear in their next annual report. He
was impressed by the "simplicity, efficacy
and apparent harmlessness of the method"
and tried it on eight advanced convales-
cents of whom three were adults. In two
the nose alone was involved.

"A pure culture of staphylococcus pyogenes
aureus having been obtained from the Central
Laboratory a broth tube was inoculated with
two or three loopfuls of the culture and in-
cubated for 18 to 24 hours. The palate and
fauces and in nasal cases the nostrils as well
were sprayed three or four times a day. The
spraying was followed by applying swabs dipped
in the culture to the tonsils and surrounding
parts.

In every case but one a mild form of sore
throat was produced within 2 to 3 days of
starting the treatment — an occurrence not re-
ported in any of the cases hitherto published —
and was accompanied by more or less con-
stitutional disturbance. A striking feature was
the considerable degree of malaise quite out of
proportion to the temperature which as a rule
was but slightly raised. The ssrmptoms, how-
ever, when general and local were of short
duration and were not followed by otitis or
any other complication. The full issue of case
8 cannot fairly be attributed to the treat-
ment.

As the process entails some degree of dis-
comfort it is well not to employ it until other
methods have been tried, and it is for this
reason that I did not make use of it in a larger
number of cases, but confined it to the treat-
ment of chronic carriers in all of whom the
bacilli had existed for more than 6 weeks. The
earliest date on which the spray was used was
the 46th day and the latest the 70th.

In any case it is advisable not to employ
the method except at a late stage of convales-
cence for the following reasons. First, in the
early stage before the mucous membrane has
completely regenerated there is a danger of
infection of the deeper tissues by the pyogenic



organisms. So far no serious complications
have resulted in man, but De Witt's experiments
on rabbits and guinea-pigs show that the clini-
cal symptoms of diphtheria are often more
severe under staphylococcus treatment than
otherwise. Secondly, the excess of mucus and
detritus present in the throat during the acute
stage prevwits free access of the staphylococci
to the parts and affords a temporary shelter
to the diphtheria bacilli. Thirdly, in hospitals
where patients owing to the possibility of com-
plications, especially subsequent paralysis, are
detained from 4 to 6 weeks. There is no need
to use the method at an early stage when the
chance of the bacilli being present is much
greater than late in convalescence.

In this connection De Witt's investigations
as to the persistence of Klebs-Loefi9er bacilli in
the throat of diphtheria patients are of in-
terest. In 175 cases examined their duration
was less than 30 days in 63 per cent., between
15 and 35 days in 87 per cent, under 15 days
in only 12 per cent, and over 40 days in 12
per cent.

In view of the futility of most other methods
in ridding the throat of diphtheria bacilli the
application of staphylococcus cultures is worthy
of trial. It is superior to the endotoxin treat-
ment recently advocated by Hewlett and Nan-
kivell {Lancet, 1911, ii., p. 143), in that the
culture is easily prepared and that no injec-
tions are required."

"E)ight chronic diphtheria bacillus carriers
were treated by spraying and swabbing the
throat and nose with a bouillon culture of
staphylococcus pyogenes aureus. In 6 faucial
cases the findings became negative within 2 to
7 days after starting the treatment. In the 2
nasal cases the treatment was ineffective. In
about every case a mild form of sore throat
was produced, but no complications ensued."

Case 8, to which he refers is as follows :

"Girl, aged 3 months. Admitted August 19th,
1912, with nsBal diphtheria and congenital
syphilis. 4,000 units given.

October 1st (44th day). — Nasal culture posi-
tive.

October 3l8t (74th day). Virulent diphtheria
bacilli in nasal culture. Nostrils sprayed twice
daily with staphylococcus culture.

November 1st. — Nasal discharge increased.
Fauces clear. Morning temperature 101°. eve-
ning temperature 104**. Spraying omitted.

November 2nd. — Still much nasal discharge.
Fauces clear. Temperature 100-102°. Culture
positive, but much fewer bacilli present.

November 5th-9th. — Temperature normal.

November 8th. — Nasal discharge still profuse.
More diphtheria bacilli in culture.

November 9th. — 4,000 units of antitoxin given.

November 10th. — Erythema and edema of
skin of abdomen at injection site. Tempera-
ture 102-99°.

November 17th. — Broncho-pneumonia.

November 19th. — Death.

Although the application of the spray was
followed by a febrile reaction lasting for 4
days, the temperature became normal, and sub-



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sequently remained so until after the re-Injec-
tion. The terminal broncho-pneumonia to
which the child was pre-dispoeed by Its chronic
rhinitis, developed nearly three weeks after the
use of the spray, which cannot therefore be
regarded as responsible for the fatal issue. It
is more reasonable to incriminate the combina-
tion of congenital syphilis, diphtheria and ana-
phylaxis."

Probably the applications to the nasal
cavities were not made as vigorously as
by Schiotz and others who have been suc-
cessful in such cases. Perhaps also an
aggressive use of the culture might have
prevented the death.

The only complications mentioned by
others are those noted by Lorenz and
Ravenel— -coryza, very mild laryngitis and
nasal furuncles in one case. It is under-
stood that since the publication of Rav-
enel's article he has continued the treat-
ment in many other cases with uniform
success. It seems that we have at last a
cure for chronic carriers who are largely
if not entirely responsible for keeping up
this disease. Apparently the method is less
beneficial in the early period of convales-
cence than in the carriers of long duration.

The explanation of the remarkable re-
sults is not known. De Witt has shown
that in vitreo there is no antagonism be-
tween staphylococcus pyogenes aureus and
bacillus diphtheria, and thinks that the ef-
fect is due to the restoration of the normal
flora of the mouth as originally suggested
by Page. If so there is an antagonism
which is not shown in vitreo. Our bac-
terial guests are not true parasites but are
rendering return services, and this may
be the reason for their presence. It is at
least one more instance of the great dis-
covery by Metschnikoff that benign bac-
teria may prevent the growth of malig-
nant ones — ^particularly in the intestines
where the bacillus bulgarius will drive out



those responsible for intestinal intoxica-
tion.

It might be well to find out whether a
dead vaccine of staphylococci or an emul-
sion of their crushed bodies or an extract
of them, would not accomplish similar re-
sults either locally applied or internally.
This would prevent all danger of even
their mild complications and overcome the
reluctance of some physicians to the use
of living pus organisms.



THE VALX7E OF EARLY DIAGNOSIS
OF MENTAL DEFICIENCY.

BY

ISABBLLB THOMPSON SMART, M. D..
Medical Examiner of Mentally Defective Chil-
dren to Department of Ejducation, City of
New York.

Ten years ago few specialists were giv-
ing any thought to the early diagnosis of
mental defect. Then it was sufficient to
recognize the marked cases as they came
before one, and that there were latent pos-
sibilities of such defect being evident in
the infant and in any child under seven
years of age was little thought of. With
other recent advances in medical science,
there has come a very marked advance in
the methods of diagnosing, as well as in
the scientific treatment of mental deficiency.
This condition has assumed huge propor-
tions and mental deficiency per se has been
becoming more and more a social question.
Some of the factors which have helped to
bring about the present status of this con-
dition, and which have helped in a very
large measure to place it in such a prom-
inent place among thinking people, are ( i )
the influx of hordes of defective im-
migrants; (2) the presence of these im-



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migrant children in our public schools; (3)
their absolute failure to compete with other
children; (4) their signal failure to ac-
quire the English language as taught in
what are known as the special classes, i. e.
those in which the newly arrived im-
migrant of school age is placed in order
to gain a working vocabulary of English
before he may enter the regular grades.
These are among the most potent causes
for stirring the pedagogue and the phy-
sician to a better understanding of the
needs of this class of children.

In a large cosmopolitan city, such as
New York, which is the port of entry from
the Occident, there is naturally a greater
opportunity for the detailed study of such
cases, and it is a fact that by far the gpreat-
er number of mentally defective children
are discovered by the class teacher, and
are then referred to the proper channel for
diagnosis as to the type of defect, and for
treatment. But there are also a very large
number of such children born in the United
States every year, mostly of foreign par-
ents, and here is where the value of early
diagnosis comes in. It must be evident
that the early diagnosis of mental de-
ficiency is vastly important, but by no
means is it easy to demonstrate, for the
very reason that mentally defective or
feeble-minded children, vary markedly in
their degree of defect. Those who belong
to the lowest type of feeble-minded are
closely akin to the imbecile, while those who
are only slightly afflicted are, on the other
hand, only little different from the group
of children said to be dull or backward.
The most difficult case to diagnose is the
border-line case, and with this type, it is
only by the most careful watching and
the most earnest efforts to remedy, in so
far as possible, any and all existing phy-



sical defects, that a definite diagnosis can
be made: But while this period of proba-
tion is going on the safest and sanest
method of treatment is to give the suspect
all the advantages that are provided for
the case who has been positively diagnosed,
1. e. a place in the special class, the ad-
vantage of the expert teacher, the op-
portunity to establish new muscular co-
ordination by means of the special manual
and physical training which the more un-
fortunate case is given; also the frequent
rest periods and the additional nourish-
ment. Then, if the child proves to be only
on the border-line and can be reclaimed in
this way, the reward is great, for surely
there can be no greater work, next to the
saving of human life, than the saving of
human intellect from becoming doomed to
the fog and mist of possible feeble-mind-
edness.

If these children can be diagnosed by
the family physician as positive cases or
as suspects, much valuable time could be
saved for the child, by having it properly
placed when entering upon its school career.
All too frequently the boy or girl is tried
out first in the kindergarten, then in the
grades, term after term, year after year,
whereas a careful study by the family
physician, or by the specialist whose ad-
vice may be sought, and a recommenda-
tion that the child, upon entering school
be given the advantages of the special class,
and if the case is really improvable, when
the child is placed at once under the proper
kind of scientific training, there is much
hope for him, for, all things being equal,
there will be only right habits and right
coordinations established from the start
and no time lost in unlearning bad or
faulty habits. Even if the case is only
slightly trainable, the best years will be



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utilized at once and no time wasted, as is
too often true at present.

The statement has been made, that not
all physicians are alive to this serious prob-
lem, and thus are not keen in observing
and diagnosing this condition. What then
should he or she look out for in the young
patient ?

First, and of paramount importance, is
the family history. Wherever there is a
history of epilepsy, insanity or tuberculosis,
the physician cannot be too vigilant in
watching the developmental processes of
the child. Alcoholism and syphilis fre-
quently render the offspring deficient, both
mentally and physically.

The knowledge of the physical condi-
tion of the parents at the time of concep-
tion is an aid in keeping the lime light on
the suspect, while, of course, the mental
and physical condition of the mother dur-
ing her pregnancy is of much importance
to the well-being of the child in utero.
Certainly it cannot be disputed that any
disease or ill health of the expectant mother
during the development and growth of the
fetus, which is nourished and entirely de-
pendent on the mother's blood for its nu-
triment, would, with little doubt, be con-
tributing in its effect in the cause of ab-
normal development.

Where the physician has been the one
to bring the child into the world, he will
know exactly how great may be the in-
jury from prolonged labor and pressure of
the head in its passage through the birth
canal. If the case comes under his care
later, these points must be carefully con-
sidered. It has been estimated that about
ten per cent, of cases of feeble-mindedness
are due to these secondary causes of dif-
ficult labor, illness or accident.



Following these considerations, the next
important points for observation are the
proper development of the child's co-or-
dinations and the time when these co-
ordinated movements first appear.

A normal child is usually able to sit up
by the ninth month, and should begin to
walk and talk from the ninth to the fifteenth
month. Many feeble-minded children do
not attempt these acts until three, four and
five years or even later. Two very im-
portant coordinations, i. e. the control of
bowels and blader, should be fairly well de-
veloped at the end of the second year, in
the child who has been properly trained.
These are usually very late in developing
in the child of mental defect, for several
reasons, chief among them being the dif-
ficulties in muscular co-ordination, defec-
tive sensation, and the slowness in acquir-
ing any habit. The most interesting point
of normal development about the sixth
post natal month is the dawning con-
sciousness of self, and of great importance
in laying the foundation for this develop-
ment is the sense of touch. At the eighth,
ninth and tenth months we find the normal
infant maturing rapidly; his latent abilities
become realities; there is evident a certain
judgment of distance, which is shown in
more accurate use of the hands; there is
more purpose in the grasping movements;
the child seems intellectually more alert
and shows marked interest and pleasure
in accomplishing his desires, and evidences
marked astonishment when they fail, and
there is a remarkable eagerness to seize
and handle every article within reach.
Walking, which is an intricate and highly
co-ordinated movement, now begins to
come under control. The usual normal
child of ten months is not satisfied to sit



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Still ; he must be up and doing. He begins
first to creep, then to stand. At first these
eflforts are very crude, but after he has
gained some confidence and has sensed the
new experience, walking becomes possible.
Forsyth says that "the psychological im-
portance of the ability to walk cannot be
over-estimated. The child is now able to
concern himself with a wider area and dis-
covers a thousand and one novel delights
that urge forward hi^ mental development
at great speed. New experiences are of
frequent occurrence and the eager intel-
ligence of the child absorbs them like a
sponge in water."

The opposite is, of course, true of the
child of defective mentality. If he de-
velops these traits at all, they are very late
in appearing and very inert in their ex-
pression.

In the second year the vocabulary of
the normal child, which has been wholly
acquired through imitation of sounds
heard, begins to assume decided propor-
tions. First he stores up an ever increas-
ing vocabulary, and in the second half of
this second year he begins to form crude
short sentences. The intellectual growth
during this year is very marked, augmented
as it is by the understanding of speech and
his ability to use words and short sentences.

At the end of the second year most of
the principal faculties have been acquired,
though used in a very elementary manner.
Large muscular co-ordinations are fairly
under control; the child can run and skip,
and some of the finer co-ordinations of the
hands are in evidence. Color sense is
also developing. Emotions become more
complex. The child begins to evidence
timidity and even fear. "Tears, which
earlier marked periods of anger, now come
at the call of sympathy and grief." The



child displays real aflfection and is deeply
swayed both by his fears and his aflfections,
as occasion calls them forth. Imagination
also becomes active; powers of observa-
tion become more accurate, and with the
dawn of the fourth year, we find the little
one ready to enter the kindergarten, where
all these intellectual powers will come under
wise guidance, and -from now on co-ordina-
tion of the physical, mental and intellectual
will actively increase. Here again we meet
with decided contrast between the normal
child and the child of true mental defect.
The spontaneity, curiosity and interest
which are characteristic of the normal child
are either entirely absent or so lacking in
force as to be negligible in the mentally
defective child.

A very important detail in the diagnos-
ing of mental defect is the close study of
the physical and bodily characteristics of
the child.

The circumference of the head is of
moment, i. e. whether the child is micro-
cephalic or hydrocephalic. Of course
many physical abnormalities may be in
evidence and the child not present mental
defect, yet in the major number of cases
these conditions play an important part.
Stigmata in general do not positively di-
agnose a case as one of enfeebled men-
tality, yet they are very important factors
in evidence, and if present with the psy-
chological and nervous abnormalities al-
ready noted, are diagnostic. Among those
which bear weight in the consideration of
almost any case are — any deformity or
asymmetry of the cranium, the epicanthic
folds, which appear at the inner canthi;
abnormalities in contour and size of the
external ear, bent or curved little fingers.
Abnormalities of the palate, tongue and
dental arches, the character and texture of



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ETIOLOGY AND DIAGNOSIS



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449



skin and hair, defects of speech and sight,
ability or inability to recognize and name
the cardinal colors, the gait, when the child
walks, must be observed, as well as the
posture and the general poise and balance
of the suspect. The ears should be care-
fully examined to detect deafness, due to
impacted cerumen or diseased condition,
and all the other senses should be tested
for possible deficiencies. Symptoms of ab-
normalities in glandular development should
also be looked for, especially those of thy-
roid, thymus and pituitary bodies.

From the foregoing statements the de-
duction is apparent that the early diagnosis
of true mental deficiency is possible and
should be made, because whatever of plas-
ticity there may be in the human mechanism,
is present to its maximum extent in early
childhood, and the earlier the diagnosis the
more hopeful is the prognosis under ef-
ficient medical control, and too, the pos-
sibilities for practical training are capable
of being developed to their maximum.

The so called border-line case is not al-
ways evident until school age has been at-
tained, and in fact sometimes appears to be
an outgrowth of the lack of individual
adaptation of school hygiene to the "ail-
ing child." The early diagnosis of such
cases in the schools, and the institution of
the proper medical, hygienic, and pedag'og-
ical care, will result most favorably in the
alleviation of such conditions, and help
to a hopeful prognosis,
loi West 8oth Street.



ETIOLOGY AND DIAGNOSIS.



Iodine forms a harmless soluble com-
pound with phenols, and its affinity for phe-
nol is very much greater than that for liv-
ing protoplasm, hence its unique value for
all forms of carbolic acid poisoning. — Med,
Summary,



Chancre of the Scalp.— Ricord used to deny
the possibility of chancre of the scalp and be-
lieved the latter to be immune to the first
lesion of syphilis. Journal dea praticiens,
however, for March 15, 1913, states that such
chancre is not uncommon from an infected
comb, brush or razor. A kiss might transmit
infection despite the supposed protection af-
forded by the hair, and as a matter of fact
a scalp chancre is most common in infants
and has been communicated even by the par-
ents themselves. The vertex is the commonest
location of a scalp chancre, then the parietal
regions, the forehead, and last the occipital
area. The attendant adenopathy is difficult to
find in this latter case, although in the others
it is distinguished without difficulty. It is
possible, now that attention has been
drawn to the possibility of chancre of the
scalp, it may be discovered more frequently
than formerly.



Acute Abdominal Conditions of Children.

From the Surgical Standpoint. — EHdred Comer
points out in an address given at the Hawaiian
Society, London, and published in the Prac-
titioner, May. 1913, that in this connection,
there are two points which must be mentioned.
Children from their superlative physiological
activities usually show great and even exag-
gerated signs and symptoms, rapid pulse, high
temperature, etc. Thus, if anything pathologic
happens to them their warnings are generally
too obvious to be overlooked. Indeed, they
may be so emphatic as to obscure the clinical
picture. Therefore with a child there is no
great hurry to make a diagnosis, in spite of
the importunities of relatives, it should be
seen again in an hour or two and perhaps
again. Then it is time to act. Secondly, a
rectal examination should never be omitted be-
fore deciding against operation. It may be
omitted if operation is decided upon, for the
evidence derived from it may there be merely
"coals to Newcastle"; but never when opera-
tion is decided against Corner has repeatedly
seen this form of examination make a world
of difference. The two points he leaves for
consideration are: multiple examinations at
short intervals, and a rectal examination be-
fore deciding against operation.

F. Warren Low remarks In the discussion
which followed the address that what every
surgeon wants to avoid is the overlooking of
an early case of appendicitis and one can for-
give a few mistakes in the other direction if
no case of appendicitis is missed in its earliest
and therefore safest stages. There is one
warning to emphasize, nearly all abdominal
conditions in children start with pain which
could generally be regarded as colicky in na-
ture. Most parents and nearly all matrons of



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TRBATMBNT



J JUMK. 1918.

\ New Series, Vol. VIII, No. 6.



Online LibraryNew York (State). Board of Railroad CommissionersAmerican medicine → online text (page 65 of 131)