of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

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SILL: DIPHTHERIA IN CHILDREN.

Two other cases were thought to be of diphtheria from exami-
nation of direct smear; culture growth, however, did not show
the Klebs-LoefiBer bacilli. Thus, although five cases were diag-
nosed as diphtheria from direct smear, culture growth only
showed Klebs-Loeflaer to be present in three, leaving six other
cases of clinical tonsillitis, which culture growth showed to be
diphtheria, but which we could not demonstrate as diphtheria
by direct smear.

Of the sixty-seven cases of sore throat without the Klebs-
LoeflSer bacilli, the slides showed forty-eight to be streptococci,
three large diplococci (scarlet fever cases), two diphtheria, seven
staphylococci, five diplococci, two Vincent's bacilli.

It will be seen that we were only able to diagnose 23 per cent,
or less than one-fourth of the thirteen positive cases by means
of direct smears, but our clinical diagnosis corresponded exactly
with the diagnosis from culture growth in the pharyngeal cases.

Of the eight cases of nasal discharge the direct-smear diag-
nosis corresponded with the culture growth, with the exception
that by direct smear one case upon slide examination showed
diphtheria bacilli, while on culture growth from the same case .
diphtheria bacilli were not reported.

Of the laryngeal cases the clinical and bacteriological diagnosis
were both positive diphtheria, but we were only able to demon-
strate diphtheria bacilli in 33 1/3 per cent, of the cases by direct
smear from the throats.

I have not infrequently gotten reports from the bacteriologist
of true diphtheria from cultures taken from an apparently
normal throat and vice versa a negative report from a true
diphtheria.

A case in point: a child nine years old with typical clinical
diphtheria — with membranes on both tonsils and spreading to
pharynx — 10,000 units of antitoxin given and culture taken
from the throat — bacteriological report negative. Child im-
proved rapidly under serum treatment.

A culture was taken next day from the throat of her sister
which appeared normal and the report came back true diphtheria.

I then took a culture from the throat of the first child whose
throat had cleared of the membrane and obtained a report of
true diphtheria. I might cite numerous similar cases.

This shows that one negative throat culture should never
be relied upon if there is a membrane in the' throat, it also shows
that one should never wait for a report from the bacteriologist



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990 SILL: DIPHTHERL\ IN CHILDREN.

before giving antitoxin, but give it at once in all suspicious cases.
If it prove afterward to be a case of Vincent's angina or pseudo-
diphtheria, no harm has been done by giving the antitoxin,
and if true diphtheria the child will be well on the road to
recovery; while if we wait for a positive report from the labor-
atory we are taking grave and unnecessary chances with our
little patient which may result in a prolongation of the disease,
serious complications, and not infrequently death.

If a direct smear shows Klebs-Loeffler bacilli we may be very
sure the case is one of true diphtheria, but absence of the Klebs-
Loeffler bacilli on direct-smear examination does not necessarily
mean the case is not true diphtheria, and I believe it is safer
for one of experience to rely on the clinical diagnosis and appear-
ance of the throat rather than to go entirely by the smear exami-
nation.

One hundred and fifty-five cases of diphtheria were examined
especially with the view of comparing the clinical aspect with
the bacteriological findings. There were sixty-one cases of
clinical pharyngeal diphtheria with membrane. Thirty-six
of which the culture showed Klebs-Loeffler bacilli present. In
twenty-five it was absent. There were seventy-two cases of
clinical nasal diphtheria or a chronic nasal discharge which had
lasted from a week to three months, forty-one of which showed
Klebs-Loeffler bacilli present, and in four they were absent.

Of these 155 cases of clinical diphtheria there were ninety-five
positive Klebs-Loeffler bacilli reports and sixty negative KJebs-
Loeffler bacilli reports from the bacteriologist; or, in other words,
61 1/3 per cent, of these 155 cases of clinical diphtheria were
positive Klebs-Loeffler, while 38 2/3 per cent, were negative.
Some of these latter very likely on second or third cultures
would have shown the Klebs-Loeffler bacilli to be present;
many, however, were probably cases of Vincent's angina or
pseudo-diphtheria. I find this report corresponds closely with
that of Park and Beebe who found 40 per cent, of 5,611 cases
of clinical diphtheria to be diphtheroid. Here again is the
question of second and third cultures to be considered.

It was now decided to take cultures from cases of ordinary**
sore throat to ascertain how many of these harbored the diph-
theria bacillus.

One hundred and twenty-seven cases were chosen of simple
sore throat without membrane; of these fifty-nine showed
positively the diphtheria bacillus with the first culture and in



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sill: diphtheria in children. 991

68 it was not present. Thus 44 3/4 per cent, showed Klebs-
Loefifler bacilli and were therefore classed as true diphtheria.

It is not an infrequent thing to find true diphtheria in the
throats of apparently healthy individuals who have been in
contact with cases of diphtheria, and, according to different
observers, this varies from 40 to 50 per cent, in relatives living in
the house and from 15 to 25 per cent, among physicians and
nurses attending diphtheria cases. Few really healthy persons,
however, harbor the germs according to Holm (Philadelphia).
A peculiar thing about this is that antitoxin does not hasten the
disappearance of the bacilli in these cases, but they are easily
killed by local antiseptics.

It has been shown that about i per cent, of all children are
diphtheria bacilli carriers, most of them being of a nonvirulent
type of bacilli, the mere presence of the bacilli alone not being
sufficient for the development of the disease. Sometimes,
however, these bacilli carriers can communicate the disease in a
virulent form, as has been demonstrated many times by Park
and others and to my own satisfaction. Therefore no physician
has a right to allow such cases to go unquarantined and they
should remain so quarantined until cultures show the throat
to be free from the organism, thus no definite period of quar-
antine can be assigned. Reports from many observers show
that the average length of time in the majority for the Klebs-
Loeffler bacilli to remain in the throat is twenty-one to thirty
days; but this varies greatly, and cases have been reported as
having the organism present all the "way from a few days to
100, 200, 300, 400, 500, the highest being 669 days reported by
Prip in 1901. I have had cases lasting two months.

In general it may be said that very few people are disposed
to take the disease.

According to Trump (Mtmich), one attack confers immunity
in a large proportion of the cases for the rest of the individual's
life, second and third attacks occurring in 9 to 13 per cent.
(Zucker).

The reason that diphtheria is so frequent in early childhood
no doubt is from the fact that children are in the habit of putting
all manner of things in their mouths that may be infected and
are creeping on dust-laden floors and are prone to catarrhal
conditions of the nose and throat.

Diphtheria may be contracted either by direct or indirect
contact. By direct contact may be mentioned those suffering



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992 sill: diphtheria in children.

from the disease, but no doubt a more fruitful source is the so-
called bacilli carriers, as very mild unrecognized cases; persons
who have been in contact with diphtheria cases and have become
infected but have shown no symptoms of this disease, being
immtme to even the virulent forms of bacilli, and cases which
have recovered but where the bacilli are still present.

Indirectly diphtheria may be distributed by means of dust-
soiled clothing, books, toys, eating utensils, sewage, water, and
milk. Pets, such as cats, dogs, chickens, and also rats, as was
conclusively proven by cultures taken from these animals by
Jessie Weston Fisher, M. D., in a recent epidemic at the Connecti
cut Hospital for the Insane.

Dr. Fisher found 2.08 per cent, of the apparently healthy
individual bacillus carriers in this epidemic, and after the epi-
demic was over, i per cent, bacillus carriers.

The diagnosis of diphtheria is, therefore, both clinical and
bacteriological, but finding the IQebs-Loeffler bacilli in the
throat establishes the diagnosis.

The clinical picture of diphtheria varies greatly, depending
on the location of the disease, its severity, and complications.

We see all degrees of severity from a mild catarrhal angina
to the most severe inflammation with profuse membrane. Be-
tween these extremes, we have the catarrhal cases with no
membrane, the bacilli not being of suflScient intensity to cause a
membrane; cases with small amount of membrane limited to' the
tonsils or nose, and with few constitutional symptoms; pseudo-
membrane, or diphtheroid cases; cases with small patches of
membrane distributed over the tonsil resembling follicular
tonsillitis.

Severe cases with marked constitutional symptoms, large
amotmt of membrane in the throat; and laryngeal stenosis cases.

Then we have cases of mixed infection or the so-called septic
cases, which give marked symptoms of septicemia. This is
a streptococcus infection along with the diphtheria, and not in-
frequently the glands of the neck become involved together with
the surrounding cellular tissue and suppuration and sloughing
result. Another not infrequent complication is broncho-
pneumonia, the prognosis of which in young children is grave.
Besides these we have the membranous angina in some cases of
scarlet fever and the membrane following removal of the tonsils,
both resembling diphtheria and which have not infrequently
been mistaken for it.



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sill: diphtheru in children. 993

Those of us who have seen many cases of diphtheria are
familiar with the variable but usually low fever which attends
diphtheria in general, ranging as it does from 99 to 103° F.,
rarely above. It may not be out of place to speak more par-
ticularly with regard to this point in nasal diphtheria.

In nasal diphtheria it is extremely rare to have a temperature
of more than 99 or 100° F. unless the phar)mx is also involved,
and most cases of nasal diphtheria have no fever whatsoever
and very slight constitutional symptoms, but if examined
closely the patient will present a pallid, unhealthy, or septic
look, quite characteristic.

The treatment of diphtheria in detail is too well known to
requirecomment.

Antitoxin has revolutionized the treatment and is a specific
for the disease.

In the giving of antitoxin a few points should be mentioned
in regard to the dosage and time of administration.

My experience has proven that it should be given in large
doses. My rule for a number of years has been to give an initial
dose of 8,000 to 10,000 tmits, irrespective of the age, for cases
of ordinary pharjrngeal diphtheria; 5,000 to 10,000 units in
nasal cases, and from 10,000 to 15,000 units in laryngeal diph-
theria; and in septic cases or those seen late.

These doses are repeated in eight, twelve, or twenty-four
hours if there is no improvement in the case.

The antitoxin should be given in sufficient doses to neutralize
or antidote the toxin of the disease, since we now know that
death is due to the toxin, not to the bacteria, they are only
found at the seat of the lesion.

The danger lies not so much in administering too much, but
in administering too little, since in a given case we are never
able to know just the extent of toxemia. Enough antitoxin
should be given to produce a marked change for the better.
By giving a large initial dose early in the disease we overcome
the toxemia almost immediately, the temperature drops, some-
times in twenty-four hours almost to normal, the pulse im-
proves, the patient feels better, and the membrane begins to
loosen and shrivel. I have rarely had to give a second dose, and
complications and sequelae are of extremely rare occurrence.

The antitoxin should be given as early in the disease as pos-
sible. A physician is never justified in waiting for the bacterio-
logical examination of a culture, but should alwa3rs administer
9



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994 goodhart: education of the atypical child.

antitoxin in a clinical or suspicious case of diphtheria at once.
When in doubt administer antitoxin, and if the case later prove
to be diphtheroid no harm will have been done by the antitoxin.

The mortality in this series of over 800 cases has been less
than I per cent, and none of those that died were over two
years of age. There were five laryngeal stenosis cases, two
were moribund when seen and died of suffocation; three were
intubated, one of these latter died a week after recovery of
cardiac failure; one seen on third day of the disease died of sep-
ticemia and suffocation, and the third had involvement of the
nose, tonsils, pharynx, and larynx, and died of cardiac failure,
septicemia, and laryngeal stenosis. There was one case of
pharyngeal diphtheria that developed bronchopneumonia and

died.

142 West Seventy-eighth Street.



THE EDUCATION OF THE ATYPICAL CHILD— THE
UNUSUAL CHILD,

BY
S. PHILIP GOODHART, M. D.,

Consulting Neurologist to the NationalAssociation for the Study of Atypical Children;

Chief of Neurological Clinic. Mt. Sinai Hospital, CD J*.; Visiting Physician

to New York Red Cross Hospital,

New York.

The classification of the children who are different from the
accepted standard intellectually is a various and uncertain
one. The terms "imbecile/* "idiot/' "defective/' "atypical/'
etc., have been so variously used that we have at present no
universally recognized classification.

I think the term "atypical" is one that has a distinct repre-
sentation, and although not generally recognized, represents
a large class of children who have not received the attention
that their importance to society warrants. There are ele-
mosynary institutions in abundance that care for the purely
defective children from the dullard down to the imbecile. There
are institutions that safeguard the educational interests of the
deaf, dumb, and blind; but that child who differs from his fellow
beings essentially in that he does not conform to the so-called
normal, the accepted standard of the usual child, and who, by
the way, is a valuable asset to the arts and in intellectual posses-
sions, has been steadily overlooked.

These children are not well poised ; they are very often lacking
in certain elementary faculties; are not social instinctively, very



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GOODHART: EDUCATION OF THE ATYPICAL CHILD. 995

often self-absorbed, and by reason of their conduct are more or
less isolated from the rest of their playmates.

Among these atypical children are frequently found those who
later on in life show unusual intellectual attainment. They are
possessed often of unusual endowment in the arts and along the
lines of special pursuit.

The future of these children is to a large degree determined
by their education and environment.

To this class belongs that great mass of humanity, the " mis-
understood." And through a want of proper adjustment to
what the child needs, many a bud which should have blossomed
in later life and added fragrance to this sad world of ours has
been doomed to wither early owing to a misconception or indif-
ference as to what that particular child needed in the way of
training. These children, many of them, in fact most of them
we may say, born of neurotic stock, are possessed of unusually
vivid imagination, and one attendant feature of their mental life
is this fanciful play of ideas. If this is allowed unrestrained
development, these children become day dreamers, and, further,
there is usually a tendency within them to perverse sexual
instincts. And, again, in others weakness of will and the
allurements of the easier and more fascinating way eventually
lead through criminal paths.

I do not doubt but that the so-called high-class criminals,
men who have shown a want of moral stability, in high so-
cial, financial and political stations, had their early instinctive
faculties been properly bent, might have been saved from the
misfortune of their later misdeeds. We have a good example of
want of proper training in early life in the enactment of the
tragedy of recent date in which a deluded youth slew his victim;
also an illustration of sexual perversion, admixed with genius,
who is now learning the lesson of reeducation in a criminal in-
stitution for the insane. A perusal of the life of the young
murderer is a lesson to all who are interested in the subject of
children with astigmatic minds.

Although the home and the school environment are important
in the development of these children, there really should be
schools, or rather institutions, which can deal directly with the
unusual, the atypical child. It is an accepted principle of civic
life that every person has a right to be educated to a certain
extent at least; and again that normal children should not be
hindered by others in attendance whose mental or moral qualifi-



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996 goodhart: education of the atypical child.

cations differ from the standard. That most successful results
can be obtained by the proper application of scientific instruc-
tion and proper environment is beyond question. There is but
one institution that I know of that makes a specialty of caring
for the strictly atypical child. This means that no epileptics
and none of the large class of true defectives are admitted. As
consulting neurologist to this institution I have had occasionally
to examine many of the children as to their physical and mental
deficiencies. In contrast to what we find in examining a large
class of defectives, I do not observe marked degrees of physical
defect. The usually recognized stigmata of degeneration which
accompany the cranial defects are conspicuously absent in these
children. I do not observe the cranial and facial asymmetry,
palatal deformities, abnormalities of the ears, unusual length of
limb and various malformations so common to the inferior types
of children. On the contrary, in stature and physical symmetry,
cranial measurement and appearance generally, these children
did not suggest intellectual inferiority.

There is, however, to be observed a marked anemia and a
general appearance of malnutrition; especially upon admission,
it was most instructive in looking over the histories, family and
personal, to observe that the mild degrees of neuroses prevailed
as a family element, various degrees of psychoses, history of
epilepsy, alcoholism, or tuberculosis, were originally present.

Under the care of special teachers it was manifest that various
intellectual endownments, very often precocity showed itself
within six months or a year. It was necessary to analyze care-
fully, to study daily, the tendencies of the child in order to bring
out special faculties, which with proper development will usually
enable the child to find a suitable place in his social sphere.

It was easy to see, also, that if these children were allowed to
drift along, and only the usual methods of mental stimulation
applied, they would soon fall further and further behind the
ordinary child.

A study of the ancestry in this class of children is a great help,
and a study of the child likewise brought out the fact that
hereditary tendencies are strong factors in the life of these
children. A study of the results of special education points
strongly to the very potent influence of environment and
education.

A study of the daily experience of the children's court in this
city is strongly convincing of the great value from a social and



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goodhart: education of the atypical child. 997

economic standpoint of the recognition of the atypical child in
early life. Here almost daily are illustrations of children
possessed of strong intellectual force and who are allowed, by
reason of faulty adjustment to their environment, and since the
best within them has not been properly developed, to fall into
paths that lead to criminality, and the result is that they become
the most expert of criminals; as expert forgers, counterfeiters,
leaders of so-called juvenile " gangs." Their imperfectly guided
intellectual powers become a menace to society, whereas, if
there had been early recognition of the unfortunate defects,
these youths might have been lifted to a really high plane in
social life. It is not diflScult to recognize this class of children,
who are plentiful enough I am sure, in the classes of our public
schools. There should be a means adopted for scientific investi-
gation so that this type of child may be early recognized. It is
out of the ranks of these children, I believe, that come the idols of
later life, whose moral shattering every now and then startles
the community.

Of course, there are those strong adherents in the belief of
inexorable laws of heredity, who will not see the potent influence
that education and environment exert; they would say, and
perhaps with justice, that if our laws of heredity were reasonably
recognized and the mating of the unfit individual prevented, we
should have less need of institutions for defectives generally.
I am heartily in accord with any means that will regulate pro-
creation by the physically and mentally weak. As the aspect
of our social status now exists, any such regulation in any satis-
factory way, is almost Utopian. The old laws in existence in
Plato's time, especially the destruction of the weaklings, in-
dependent of the sentiment of the day, would probably be
disastrous to our race. Intellectual superiority by no means
goes hand in hand with physical excellence. Had the Spartan
laws continued to exist we should have lost many an intellectual
genius of modem times.

34 West Eighty-seventb Street.



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998 CLAIBORNE: TYPES OF CONGENITAL SYMBOL AMBLYOPIA.



TYPES OF CONGENITAL SYMBOL AMBLYOPIA.*

BY

J. HERBERT CLAIBORNE, M. D.,

New York City.

On February 19, 1906, I read a paper at the New York Acad-
emy of Medicine, entitled "Types of Congenital Symbol Ambly-
opia." Later I read the same paper before the section on
diseases of children of the American Medical Association at the
fifty-seventh annual session, June, 1906. In them I described
in detail two cases of so-called congenital word-blindness, and
presented reflections and ideas which had been suggested to me
by study, which ideas I take pleasure in setting before you to-day,
though in a slightly abbreviated form.

I will briefly review the two cases. One was that of a boy ten
years of age, who was unable to recognize the letters of the
alphabet, and, consequently, could not recognize the words
composed of the letters. He was fairly bright in every other
respect and knew the meaning of spoken words; recognized
objects and their uses; was talkative, communicative, and even
garrulous at times; played and acted in a normal manner, and
in all other respects was like other children of his age. His
spontaneous writing exhibited to some extent the ear marks of
a classical motor aphasia. He was able to recognize figures
easily and had no difficulty in his mathematics at school. He
was very backward according to his teacher, and she was inclined
to call him a fool. The temptation was strong for me to do the •
same until I had studied his case thoroughly when his defects
became evident; it was a case of letter-blindness, consequently
word-blindness.

The second case was that of a boy of nine, in the higher walks
of life, who was brought to me by his father because he could not
be taught to read at school. This boy knew his letters perfectly,
missed none of them, but when it came to recognizing words

* Read before the National Association for the Study and Education of Excep-
tional Children, April 21, 1910.



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CLAIBORNE: TYPES OF CONGENITAL SYMBOL AMBLYOPIA. 999

showed himself decidedly word-blind. My own name, Herbert, he
wrote from dictation, letter by letter, "Herbdred" and called
it ** purram." There were a few words like rat, cat, and all, which
he spelled accurately because, his father said, he had been drilled



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 102 of 109)