of Rhodes. Spurious works Andronicus.

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

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recover tone. Improved diet and hygiene offered the only
successful treatment: drugs were of little or no avail. In normal
infants during health no great difficulty was encountered in
reference to the kind and quantity of food. In feeble and badly
nourished infants, however, the weak action of the stomach,
especially in its muscular power, was the source of much trouble.
With this in mind a series of twenty-one cases were studied with
regard to gastric motility. The ages of the cases were as follows :
two weeks, one; three weeks, one; six weeks, one; two months,
one; three months, six; four months, four; five months, two;
six months, one; seven months, one; twelve months, three.
These infants were taken from the wards of the hospital and
represented all grades of malnutrition from the beginning cases
to those in the last stages of atrophy. It was not possible to
form any definite conclusions as to gastric motility based on
the age of the child from these cases. Of nineteen examined at
the end of three hours, only six could be shown to have approxi-
mately empty stomachs, and these six, with one exception,
were holding their own, and in no case could free hydrochloric
add be determined. In thirteen out of the nineteen it was
absolutely demonstrated that there was a considerable residual
amount of food still remaining in the stomach. Butyric acid
fermentation was marked in six, and in two in which the stomach
was apparently empty there was found a trace of butyric acid.
In seven cases examined at the end of three and one-half to



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1018 TJRANSACTIONS OF THE

four hours five were surely empty; of the remaining two cases
one showed many curds at the end of four and one-half hours,
while the other showed only a few small curds. Few if any of
the children were normal and conclusions drawn from the cases
had value only as a study in the nourishment of a feeble child.
The writer concluded that there could be little doubt that in a
large majority of cases the feeble infant with digestive disturb-
ance has been fed at too frequent intervals; too often a second
feeding being given before the previous meal has passed through
the pylorus, with the result that each successive feeding is con-
taminated ; in the feeble infant gastric[mo tility is greatly decreased,
and it is often necessary to increase the intervals between
feedings. Attention was called to the analogy between this
state in the infant and the condition known as myasthenia
gastrica in the adult, an important element in the treatment of
which is to make certain that the stomach is never overloaded.
Speaking of the form and quantity of food elements, the writer
said that changing the form of the protein has frequently a very
important place in the management of infants and that chang-
ing the form of the carbohydrates also frequently shows a
marked effect in the infant's progress.

In regard to Finkelstein's method of feeding, based upon the
idea that instead of the fat or protein being the usual cause of
trouble, most digestive disturbances are due to the sugar of milk,
and the principle of the new method being cutting down of the
amount of milk-sugar and of the salts, adding in place of this
casein and fat and substituting other forms of carbohydrates
for the milk-sugar. The writer tried this method in a series of
twenty cases. They were all hospital cases and presented the
usual difficulties of infants previously badly fed. The stools
generally became gray, homogeneous, with putty-like consistence;
there was usually then a tendency to constipation. The results
were not very promising in this series of cases. Eight cases
gained slightly in weight, while twelve lost. The writer believes
that when benefits follow this method of feeding the results are
due more to the form in which the protein is given than to the
lessened amount of sugar in the mixture. Judging from the
character of the stools, he thinks it might act well in certain
forms of diarrhea.

DISCUSSION.

Dr. F. S. Meara, New York, said that the papers involved
such careful work that they could scarcely be discussed off hand,
but he desired to ask Dr. Wentworth if he had taken into con-
sideration the relation of the fat to the quantity of hydrochloric
acid, and to ask Dr. Cowie whether he attributed the opening
of the pylorus to the action of the acid on the gastric or duodenal
side.

Dr. a. H. Wentworth, Boston, desired Dr. Veeder to explain



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AMERICAN PEDIATRIC SOCIETY. 1019

whether the periods of feeding were continuous or not and
whether one period ran into another. Also whether the per-
centage of fat per gram was ascertained. It had been his ex-
perience that the greater percentage of all the fats excreted was
in the form of soaps.

Dr. Henry D. Chapin, New York, said that, so far as the
incubators or padded cribs were concerned, he rather preferred the
padded cribs, as he had found that the best incubators were not
as good as the cribs; he preferred a varying temperature to the
steady temperature of the incubators. He had never saved a
premature infant without breast milk.

Dr. Isaac Abt, Chicago, had been impressed with the discrep-
ancy in results and various interpretations of those doing the
chemical research work, though he believed there would be im-
portant definite results ultimately. He thought the dogmatic
methods used in some quarters in making interpretations and
attempting to make clinical deductions based on chemical re-
sults thus far obtained was somewhat premature. He was
impressed with the idea that besides the chemistry of digestion
there is a biology of digestion, and that the ultimate appropriation
of the molecule and its combination with the cell was of more
importance perhaps than the chemical details.

Dr. Samuel L. Bernstein, Cleveland, corroborated what
Dr. Chapin had said in regard to the advantages of the crib over
the incubator and thought the electric heating pad with maternal
feeding had been the means of saving a number of these prema-
ture infants.

Dr. D. M. Cowie, Ann Arbor, said in reply to Dr. Meara's
question that he was inclined to believe that it was the action of
the acidity on the duodenal side that had to do with the retention
of food in the stomach.

Dr. B. S. Veeder, Philadelphia, said in regard to Dr. Went-
worth's question that the experiments extended over seven or
eight weeks вАФ the child being first put on a formula for
three or four days and then placed upon the metabolic bed on
the same formula. They had not tested for soaps separately,
but did compute the percentage of soaps.

Dr. Henry D. Chapin, New York, said that it was of the
utmost importance to have the meals properly spaced, as other-
wise there remained a residuum of food in the stomach to con-
taminate each successive addition of food. This constantly
recurring contamination and overburdening of the stomach
resulted in fermentation and in time gastric dilatation with loss
in?tone of the muscular coats of the stomach, thus explaining
how a chronic digestive disturbance may lead to the condition
known as atrophy.

He was in sympathy with the remarks of Dr. Abt about study-
ing these questions along the broad lines of biology.

Dr. John Howland, New York, thought the biological ques-
tion was largely hypothetical. It could not be expressed in



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1020 TRANSACTIONS OF THE

figures, in charts, and, while very interesting, it led no further
than to saying that in each individual there is an individual
variation. Until the work had been done in terms that could
be expressed in figures there had not been a beginning.



AMYOTONIA CONGENITA.

J. P. Crozer-Griffith, M. D., Philadelphia, said that ten
years ago Oppenheim in Berlin noticed a peculiar symptom com-
plex and reported a few cases but not in detail. They had a con-
dition of flaccid palsy, which appeared to be congenital, varying
up to complete paralysis. No actual atrophy. Oppenheim called
this myotonia congenita. As the symptoms were so similar the
writer called this amyotonia congenita. He has found in all forty-
eight cases besides his own. He reported a case which came to
him in December; a child fifteen months of age; no family history,
except intemperance in both father and mother; diagnosis of mye-
litis had been made. The mother said the child had never been
able to do anything with its hands. The position of the hands
suggested tetany. Electric reactions did not give reaction for
poliomyelitis or tetany, in fact no reactions could be obtained.
Dr. Mills suggested that it was a case of myotonia and further in-
vestigation corroborated that. The child could not turn itself in
bed; when seated in bed it flopped about in any direction; the
head fell forward or backward, anywhere gravity took it. No af-
fection of sensation. Tendon reflexes abolished ; respirations al-
most entirely abdominal, the respiratory muscles being affected.
The child was thought at first to be very weak-minded. In four
and a half months it has improved wonderfully. It can now take
a biscuit in the hand and slowly lift it to the mouth and bite at it.
The author Considers the cause and pathology of the disease so
far as known together with diagnosis and treatment. There
seems to be reason to believe that it is congenital either in its
manifestation or in its origin. It is an affection of the muscles
not controlled by the cranial nerves. As to the pathology, there
have been eight observations more or less complete, but no one
had come to any positive conclusion. There was in almost every
instance loss of striation of muscles or loss of nuclei. In some
there was involvement of the anterior horns of the cord, but this
was as yet not certain, because the changes described were so
slight. Spiller maintained that there was no change in the
nerve centers. The disease has to be distinguished from polio-
myelitis and from hypertonia. Nothing much could be said as to
prognosis. A number have died from respiratory involvement.
Treatment was hygienic, with electricity and massage.

Dr. Henry Heiman, New York, asked if the Wasserman re-
action had been taken in this case to rule out syphilis and Dr.
Griffith replied that no test was made in this case, but so far^as
they could learn there was no history or symptom of syphilis.



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AMERICAN PEDIATRIC SOCIETY. 1021

A STUDY OF THE VALUE OF BRUDZINSKl'S "NECK SIGN*' AND

CONTRALATERAL REFLEX IN THE DIAGNOSIS OF

MENINGITIS IN INFANCY AND CHILDHOOD.

J. LovETT Morse, M. D., Boston, said that Brudzinski in a
paper on **The Contralateral Reflexes in the Legs in Childhood,"
published in 1908, drew attention to a sign which he found in
tubercular and epidemic meningitis, and occasionally in other
conditions, but never in healthy children. This sign was a
concomitant reflex of the leg on one side when passive flexion
of the leg on the other side was made. He concluded that in
connection with other signs, such as Kemig's and Babinski's, it
was useful in the differential diagnosis of meningitis. In a later
paper he stated that further study had confirmed him in his
conviction of the value of this sign. In 1909 Brudzinski had
published another paper in which he stated that in meningitis
passive flexion of the neck forward causes flexion of the legs
at the hips and knees and a marked flexion of the legs on the
pelvis. He found this sign in twenty of twenty-one cases of
tubercular, in all of eleven of cerebrospinal, and in two of pneu-
mococcus meningitis. The writer had examined four-hundred
children, either well, or ill, with diseases other than meningitis^
as to the presence of this sign. Ninety were well; one-hundred
and fifteen suffering from disease of the respiratory tract; ninety-
eight with various diseases of the gastroenteric tract; thirty-one
with diseases of the nervous system other than meningitis; the
remainder with a variety of diseases, typhoid, nephritis, influenza,
heart disease, rickets, purpura, scarlet fever, measles, etc.
Neither the neck sign, nor the contralateral reflex was elicited in
any instance. He concludes from the study of these four-hundred
cases that Brudzinski and his followers are correct in their state-
ments that neither the neck sign nor the contralateral reflex are
present in well children or in those ill with diseases other than of
the nervous system, and that they are very seldom met in
diseases of the nervous system other than meningitis. That their
presence in an acute disease is strong evidence of meningitis;
that their absence does not exclude it. The diagnostic value
of the contralateral reflex is less than that of the neck sign. They
occur in all types of meningitis and so are of no importance in
differentiation.

Dr. Mathias Nicoll, New York, had three weeks ago a case
in which he found the sign positive. When left an hour the child
would give a decided contralateral reflex reaction, but if it was
induced several times in succession there was very much less
marked reaction. He had also had an opportunity of trying it
in a case of cerebrospinal meningitis in which he had been able
to get a very positive response, though it varies in intensity.

{To be contimud,)



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1022 TRANSACTIONS OF THE



TRANSACTIONS OF THE NEW YORK
ACADEMY OF MEDICINE.



SECTION ON PEDIATRICS.

^ Meeting of April 14, 1910.

Eli Long, M. D., in the Chair.

MENINGOCELE.

Dr. Mary Sutton Macy presented a child, fourteen months
old, who was first seen by her at the Gouvemeur Qinic. The
baby was the first bom and was delivered spontaneously. Over
the bridge of the nose was a tumor which had existed since birth.
It pulsated freely and when the child cried became reduced in
size. A tentative diagnosis had been made of hernia of the
frontal sinus, or a meningocele, or a pulsating angioma. She
thought the use of the %-ray would aid much in clearing up the
diagnosis. The tumor was reducible by pressure.

Dr. Ward Bryant Hoag had seen an exactly similar case at
the New York Polyclinic; it occupied a similar situation, had the
same characteristics, could be made to disappear on pressure,
and there was an absence of bone. It appeared in Dr. Kerley's
service and they concluded it was a meningocele.

Dr. L. Pierce Clark said that his experience with these cases
was very limited, he having seen but three, and they were all
older children at the Randall's Island Institution. No one had
undertaken to close the opening between the bones. The results
of surgery in these cases had been unsatisfactory and unfortunate,
because of the danger of infection and because these patients
did not stand operations well. He thought the case presented
by Dr. Macy was very interesting and rare.

Dr. Henry W. Frauenthal believed this to be a case of
meningocele. The %-ray, however, would aid them greatly in
making a diagnosis.

^ Dr. L. Pierce Clark expressed surprise that this meningocele
disappeared in greater part when the child cried, the contrary
was usually the case. The tense muscular action of the py-
ramidalis nasi did not seem to be of sufficient compressive
power to account for the disappearance when the child cried.
The condition here was the same as in spina bifida and similar
operation of laying open the sac and closing the communication
with the cranial cavity might be undertaken; a retaining plate
might be made for the bone defect at the cranial opening. Treat-
ment by injection of these meningoceles with iodine or its com-



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NEW YORK ACADEMY OF MEDICINE. 1023

potrnds was uncertain of good results. One should always bear
in mind that these cases do poorly under any form of surgical
manipulation.

CRETIN SIX MONTHS OLD.

Dr. Ward Bryant Hoag presented this patient. The
family history had no bearing on the case. The child was six
months old and was seen by him March 28. The child was born
at full term; it was a head presentation and a very difficult labor,
not only was the delivery of the head difficult but of the shoulders
as well. Instruments were used. An interesting question arose
in this case as to the influence of the excessive traumatism on the
body, or the force exerted upon the neck, in destroying the
substance of the thyroid gland. When the baby was two or three
months old it began to lose weight. When he saw the child on
March 28, it weighed eleven pounds and six oimces. The child
was seen by a number of men. The mother supposed it was a
hopeless idiot and brought the child to the hospital because of
an umbilical hernia. The child had a shock of coarse hair;
there was a broad slip between the eyes, a broad nose, the mouth
characteristic of a cretin, but the tongue did not protrude.
There was the short condition of the long bones, especially of the
humerus and femur. The skin was cool. There was the broad-
ened hand and shortened fingers and held in the characteristic
fashion. The child apparently had no mentality.

The baby was placed on one-quarter of a grain of Park Davis
Co. thyroid extract, which was equivalent to one and a quarter
grains of the fresh gland, twice a day. At the end of one week
the child nursed better and was warmer, although he lost three-
quarters of a pound in weight. He was then given one-quarter
of a grain of thyroid extract three times a day and during the
next seven days he gained one-half pound. There has been
a slow but gradual improvement in the patient. This was
probably the youngest cretin ever reported, so far as he knew.

Dr. Godfrey R. Pisek said there was no doubt about this case
being a true cretin, for the picture was typical. The interesting
point was the early months in which the diagnosis was made.
It was very difficult to make a diflFerential diagnosis at this early
time of life between a cretin and a Mongolian idiot.

Dr. Eli Long said the youngest cretin he had ever seen was
eleven months old. The child was brought to the clinic because
the mother stated that it never cried. The trouble had not been
suspected. When the photograph was taken, it practically
made the diagnosis. The oldest cretin he ever saw was a man
twenty-three years old. This patient had lived in New York
all his life and was accustomed to sit at the window with his chin
in his hands all the time. He had been to the hospital where
sweat breads were ordered, but he could not afford to get them.
He was very phlegmatic and constipated, and slept nearly all



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1024 TRANSACTIONS OF THE

the time. After taking thyroids he first became very thin, his
teeth dropped out, and he could not sleep. A marvelous change
occurred.

Dr. Charles Herrman recalled a case he had seen recently
in which there were one or two features worthy of note. When
the patient was given thyroid, the hair fell out, but eventually
he got a new crop of hair. The palms of the hands and the soles
of the feet peeled as extensively as though the patient was
desquamating after a severe attack of scarlet fever. Especially
emphasis should be laid upon the institution of early treatment
in these cases, for their results are then so much more favorable.
These patients never attain a normal intelligence.

Dr. L. Pierce Clark said the paramount interest in cretin
therapy was the effort toward successful thyroid body transplan-
tation. Certain experiments upon animals had shown that it
was possible to obtain a fimctionating implanted thyroid. Now
that arterial anastomosis was becoming more practical it seemed
reasonable to look forward to a more hopeful future for these
cretins. It was certainly but a therapeutic aggravation to
rely upon thyroid feeding for a certain number of years, and
then on its withdrawal to see the cretins, not only relapse, but
rapidly become worse than before therapy was undertaken.
It is a fact not sufficiently impressed on the clinical mind that
cretinism per se has but little or nothing to do with idiocy as
ordinarily understood as a permanent defect of mind. No spe-
cial therapy could improve the mental outlook of an idiot.
The type here shown might more properly be called cretinoid in as
much as it occurs as a sporadic case and lacks the intensity of
coarseness and stupidity of the endemic cretinism of Switzerland.

CASES OF HEAD NODDING IN COLORED CHILDREN.

Dr. Charles Herrman presented five children treated in
Dr. La Fetra's service at the Vanderbilt Clinic. One was a boy
four years old; he had the nodding some time ago; it disappeared,
but only to reappear about two months ago. This was rather
tmusual and it was especially unusual to see head nodding in a
child four years old.

A very interesting thing regarding these cases was the etiology.
A great deal had been written upon this question. By some it
was supposed to be a disease associated with rickets. As a
matter of fact nearly all the colored children brought to the
Vanderbilt Clinic had rickets and, therefore, in these cases it
could not be said to play a very important part in the etiology
of the disease; rickets certainly was not essential.

Another interestingfpoint concerned the teeth; the movements
were more marked especially when the teething was difficult,
and Dr. Herrman was inclined to think that the head nodding
was more marked at this time because with difficult dentition
the children were more restless, slept less, and became more
fatigued.



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NEW YORK ACADEMY OF MEDICINE. 1025

With regard to traumatism being a causative agent, few of
the cases gave any history of a fall; if any did give such a history,
the fall was probably secondary to the disease. They had, as a
rule, incoordination as part of the disease already existing and
consequently fell quite easily.

Much stress had been laid upon a theory which was proposed
some years ago by Raudnitz. He investigated a number of
these patients carefully and found that many were living in
dark rooms and the conclusion was reached that darkened rooms
with artificial light played an important r61e in the causation of
the trouble. Some years ago in Dr. Koplik's service at the
Good Samaritan Dispensary, twenty cases were investigated by
Dr. Herrman and it was learned that one-half lived in dark rooms,
while the other one-half in light rooms; Dr. Herrman thought,
therefore, that the influence of darkness as the sole etiological
factor in these cases could be dismissed.

Raudnitz had compared the nystagmus to that occurring in
miners. An article had recently appeared in which it was stated
that darkness as a causative factor was not the sole one; that
nystagmus occurred almost exclusively among coal miners,
therefore something more than darkness was necessary. The
theory was advanced that because the miner used the pick with
the employment of certain long continued rhythmic movements,
that this caused the nystagmus and the condition did not result
solely because the miner worked in the dark. The nystagmus
in these cases was not a disease of the eye, but it was a disease
of the brain. So far as Dr. Herrman had been able to investi-
gate, he believed that the most plausible explanation of the head
nodding with nystagmus was thai: it was a coordination neurosis.
There was an individual predisposition and there was the age
predisposition, a certain stage of development of the nervous
system. A peculiar thing about this nystagmus was that it was
often unilateral; even if the condition was present in both eyes,
it was the more marked in one eye. Another peculiar thing
was that these children held the head to one side and looked out
of the comers of the eyes, "cocking the head," and this was so
characteristic of the disease that it might almost be called
pathognomonic. They probably assumed this position of the
head in order to get the image focused on a certain portion of the
retina.

With regard to the treatment, bromides had but little if any
effect. The children should be kept in the open air as much of the
time as possible.

With regard to errors of refraction and astigmatism, none of
the cases showed any; they all had normal vision.

Dr. L. Pierce Clark said that inasmuch as nodding spasm of
the type shown occurred only in infancy and all cases recovered
we should look for its real cause in a retarded anatomical develop-
ment in the bulb mechanism of coordination of head or eye
movement. It was reasonable to suppose that there is retarded



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1026 TRANSACTIONS OF THE

development, a lock perhaps, of myelinizatioiis of nerve fibers in
the great coordination tract of the posterior longitudinal bundles



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 105 of 109)