of Rhodes. Spurious works Andronicus.

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

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Replying to the remarks in favor of bilateral laminectomy,
he stated that the method which gave the most convenient
exposure with the least loss of bony structure was certainly to
be preferred, and that unilateral laminectomy fulfilled these



Nasal and Aural Discharge in Children. — Percy Fridenberg,
(Trans, Amer. Ped, Soc,, 1909) calls attention to the form of
middle-ear disease which in children frequently appears as an
acute catarrh tending to diminish or for a time to cease entirely
under conditions, particularly climatic changes, favorable to a
diminution or cessation of the secretion in the posterior nares,
recurring with every cold in the head as well as with any affection
of the respiratory tract or with acute infectious diseases, and oc-
casionally "coming back" again without any evident nasal dis-
charge, at least for the first few days. The tendency to recur-
rence causes an apparent chronicity with more or less extended
intervals of what seems to be a cure. The first symptom is often
the appearance of a stringy, mucoid or slightly muco-purulent
discharge, frequently bilateral, after a variable period of snuffles,
with little or no systemic disturbance, slight fever if any, and no
pain. Aural examination generally shows a large perforation

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with a pale membrane, or at least no inflammatory reddening,
and no canal changes at all. The benign character of the process
is indicated by the absence of all bone involvement and of mas-
toid complication, and of marked local or constitutional reaction.
Secondary infection from the external auditory canal may
change the secretion to a frankly purulent discharge and a true
otitis with danger of bone involvement or mastoid complication
may be engrafted on the original comparatively benign affection.
In some of these cases pain in the ear, headache with occasional
dizziness, diminished hearing and an old fetid discharge from the
ear suggest the advisability of a radical mastoid operation.
They should be promptly and thoroughly treated by conserva-
tive and quite effectual means, viz., removal of the source of in-
fection in the posterior nares or accessory sinuses by appropriate
procedures, whether medicinal or operative.

Use of Antidysenteric Polyvalent Serum in the Treatment of
Infantile Dysentery. — ^P. Coyne and B. Auch6 {Jour, de Mid. de
Bordeaux, August 15 and 22, 1909) report eight additional
cases of infantile dysentery treated by various physicians with
antidysenteric serum of polyvalent form, with excellent results,
which confirm the already published cases. The general condi-
tion is very quickly improved, with a rapid lowering of tempera-
ture, and stopping of tenesmus. The number of stools rapidly
decreases, and after a few days the stools are normally fecal. In
very severe forms of dysentery the improvement is rapid, and a
cure is obtained in much less time than under any other form of
treatment. Many cases are cured which would die under the older
forms of medication.

Septicemia from Bacillus of Eberth and Paratyphoid Bacillus
in the Nursling. — H. Triboulet, L. Ribadeau-Dumas, and Boy^
{Arch, de Mid, des Enfants, August, 1909 J state that infection
by the typhoid bacillus is very seldom typical when it occurs in
a nursing child. The temperature is irregular; rose spots are
often absent; the diarrhea is not typical; while the nervous symp-
toms are pronounced, resembling those of meningitis. There
are stiffness of the neck, convulsions, and marked prostration.
Sero-agglutination and blood cultures allow the diagnosis to|be
established definitely. Pulmonary signs are frequent and symp-
toms of meningitis are the rule. There is often more of the as-
pect of a toxic septicemia than of typhoid. The bacillus in
circulation in the blood determines death, with ecchymotic and
degenerative lesions of the viscera, the lungs, and meninges, not
of the intestine. In the adult intestinal localization is the rule;
in the infant it is the exception. The question is how the nursing
infant becomes infected. It cannot be through the milk unless
the mother has the disease, and even then some authors deny
the presence of the bacilli in the milk.

Diphtheria of Intestine. — R. E. McKechine {Mont. Med. Jour.,
August, 1909^ records an unusual case of dysentery in a girl six
years old. Shortly before leaving Fiji, the child was taken ill

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with what seemed a mild dysentery, and the condition persisted
throughout the trip of two and a half weeks. On arrival at
Vancouver, the child was found emaciated, and very much
exhausted. The dysentery had been fairly well held in check by
treatment, but she was having several small stools daily, stained
with blood and consisting of mucus and pus. Some were of pure
mucus — about half a pint at a time — and contained enormous
quantities of streptococci. These rapidly disappeared under
treatment with streptolytic serum, but the symptoms did not
abate. Finally cultures showed bacilli of the diphtheritic type.
At once anti-diphtheritic serum was used, with immediate im-
provement of the symptoms, and two days later a complete cylin-
drical cast of the bowel, about four inches in length, was passed.
The child made a slow but uninterrupted recovery. The cast
was examined microscopically, and proved to be a true diphtheri-
tic membrane. The patellar reflexes were absent. Later the
patient developed paralysis of the anus for a couple of weeks.

Streptococcic Infection in Diphtheria. — The frequent occurrence
of isolated phenomena about the twelfth or thirteenth day of an
attack of diphtheria was first called attention to by Sevestre and
Martin. The phenomena which they described consist of one or
more of the following: (i) a cutaneous eruption (most frequently
scarlatiniform, but in a few cases a simple erythema); (2) joint
pains; (3) albuminuria; and (4) general constitutional disturbance,
more or less marked. Sevestre and Martin suggested that the
frequency with which these phenomena developed on or about the
thirteenth day seemed to indicate that they were the symptom-
complex of a secondary disease, with an incubation period of
thirteen days, the infection occurring at the time of invasion
of the diphtheria. They further sug:gested that the cause was
organismal and probably streptococcic. Bacteriological exami-
nations of the throat by D. M. Mathiesen {Lancet, November 20,
1909) showed in nine out of eighty cases of diphtheria a marked
streptococcic infection at some period of the disease. Fifty-
five per cent, of the streptococcic cases developed "thirteenth
day" symptoms; and 2.8 per cent, of the nonstreptococcic
cases developed these symptoms.

These results seem to suggest that there is some connection
between the streptococcus infection and the "thirteenth day"

Impossibility of Demonstrating a Specific Protoplasmic Poison
in the DiphAeria Bacillus Differing from that of the Common
Protein Bacteria. — Giulio Funaioli {Rivista di Clin. Ped,, Sept.,
1909) has made experiments on animals with a view to demon-
strating a specific protoplasmic poison in the diphtheria bacilli,
but has not been able to show its existence. He finds that such
poisons are produced by all bacteria, and that the poison from
the diphtheria bacillus differs in no way from that of other
pathogenic microorganisms. There exists in the dry, washed,
.dead, or living bacilli a poison which is common to all pathogenic

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bacteria. It causes elevation of temperature. No immunity to
this poison is acquired as there is to the other toxin of the disease.
Serum prepared by injecting bacteria into animals causes no
immunity to this poison. The action of bactericidal sera results
from the fact that they are bivalent.

Vulvovaginitis and Vulvitis of Children. — Lespinne (Prog, Med,
Beige, Aug., 1909) states that vulvitis or vulvovaginitis may
occur at any period of life, from the day of birth, aside from
gonorrhea, and that it is far more curable than has been generally
supposed. It results in general from a lack of cleanliness which
allows of the inoculation of the vagina and vulva with some of
the ever-present microorganisms. It may result from irritation
of fecal and urinary solids, rectal worms, the propagation of
neighboring dermatoses, or a general malady, such as measles.
There is a form of epidemic vulvitis which is common in institu-
tions. Under proper treatment the affection can be cured in
six to eight weeks. In the contagious forms the affection is
liable to become chronic if the vagina is involved. Treatment
includes three indications: first, absolute cleansing and dis-
infection of everything that is used about the child; second,
local treatment with unirritating antiseptics and later nitrate
of silver; third, improvement of general condition of the child.

Pathology of Thymic Hyperplasia and Status Lymphaticus. —
A. S. Warthin (Arch. Ped., Aug., 1909) gives a brief outline of
41 cases showing thymic hyperplasia at autopsy and sum-
marizes and discusses them. He believes that the status
lymphaticus, or the condition of thymic hyperplasia, has no
specific pathologic entity. It is a collective pathologic complex.
Hyperplasia of the thymus (aside from leukemic, lympho-
cytomatous, tuberculous and other enlargements) is an expression
of a hypoplastic constitution associated with, or dependent upon,
a chronic lymphotoxemia or a congenital hypoplasia of the
lymphoid tissues, or an altered function or disturbed develop-
ment of the thyroid, adrenals, sexual glands, or osseous system
occurring during the period of development. The hyperplasia
of the thymus is compensatory in nature. It constitutes the
most important feature of the conditions grouped under the
complex of status lymphaticus. In young children the hyper-
plasia of the thymus is the most prominent feature. At puberty,
and after, the constitutional hypoplasia that has been styled
the status lymphaticus becomes more prominent. The two
conditions are essentially the same and borderland cases of all
stages and degrees occur. In young children and more rarely
in adults the hyperplastic thymus may cause a mechanical death
from pressure, chiefly upon the trachea, but also upon great
vessels and nerves. This is probably the most common cause of
the so-called thymus death in infants and children. In adults
cardiac death is the rule, as a result most probably of disturbed
correlation of thymus, thyroid, and adrenal function. The
occurrence, however, of thymic stridor, thymic tracheostenosis,

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and mechanical thymic death has been demonstrated beyond
all doubt. The underlying lymphotoxemia and its cause may
also cause death directly or indirectly. The lymphotoxemia
and general hyperplasia create an especial susceptibility and
lowered resistance to infections.

Congenital Dislocation of the Hip. — ^J. J. Clarke (Lancet, Sept.
25, 1909) reports eight ultimate cures in a series of twelve
operations by the following method, one improvement, and three
failures. The operation consists in exposing the joint from
behind, making a small opening in the lowest limit of the posterior
aspect of the capsule, and introducing an elevator to raise the
periosteum and with it the cotyloid ligament for a short distance
at the upper and posterior borders of the acetabulum. Next
three stout silk stitches are passed in turn through the periosteum
thus raised into the joint cavity under the cotyloid ligament,
out of the capsule again and through a fold of the capsule, then
once more through the capsule near its femoral attachment,
where the two ends are tied. These stitches remove the over-
distention of the back of the capsule and hold the cotyloid
ligament over the outer part of the head of the femur. The
limb is put up in plaster.

Infantile Malaria. — ^Jean P. Cardamatis (Ann, de Med. et Chir,
Inf,y September, 1909) has made a careful examination of the
statistical tables of the antimalarial League of Greece to ascer-
tain the morbidity of infant from malaria. He finds that dur-
ing the nursing period the infants is least subject to malaria of
any time of its life. Children under three months are less often
attacked than from that age up to twelve months. All nurslings
show a relative immunity during the first month of life. Morbid-
ity is less during the first year than later, probably on account
of the care taken to protect the infant by mosquito nets. Malaria
is more frequent in the second and third years, and attacks older
children just as it does adults. The author does not believe that
congenital malaria exists, or if it does it is extremely rare. The
examination of the blood of infants under one month, whether
of mothers infected or not with malaria, has not shown the para-
sites to be present. The parasites have been found in the pla-
centa on the maternal side, but very few on the fetal side, and no
anatomical alterations of the placenta were found. It has also
been observed that infants born of mothers having malarial
cachexia have been in florid health when born. The parasites
cannot be transmitted to the fetus through the placenta, proba-
bly because there are antitoxic substances in the placenta which
prevent the transudation of poisons. No organisms^ have been
found in the umbilical cord. Infant malaria is both acute and
chronic. Children have all types of the infection, tertian being
the commonest. Natural immunity is seen in some cases,
while in others the effect is very slight. Malaria is irregular
in infants, some of the stages being absent. Gastro-intestinal
symptoms and meningitic symptoms predominate. The older

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the child, the more typical the attacks. The most important
symptom of chronic malaria is the splenic enlargement which
is immense, the organ occupying sometimes the entire abdomen.
The anemia of m^arial cachexia gives the child's skin the ap-
pearance of wax. The frequency of malarial infection in Greece
is very great.

Tuberculosis in Nurslings. — H. Barbier (Ann. de Mid. et Chir,
Inf., September, 1909) says that in nurslings who have tuberculo-
sis it is usual to find a tuberculous heredity. The effect of
this is dependent on which parent had the disease, and the
extent and evolution of the disease at the time of conception and
during pregnancy. It is certain that tuberculosis is a frequent
cause of abortion, just as syphilis is, the infection of the ovum
at conception causing the death of the fetus, and abortion in
consequence. In hereditary tuberculosis we may have failure
of nutrition without finding any characteristic lesion of tubercu-
losis at autopsy. In other cases the lesions do not vary at
all from the typical tuberculosis of adults. There may be
congestive pulmonary lesions, dyspepsias that are intractable,
degenerations, or other atypical conditions, yet still caused by
tuberculosis. In atypical tuberculosis the toxemic origin of the
troubles from the mother is probable. Degeneration of the liver,
which may be entirely fatty, is common. This is an excellent
reason for the obstinate dyspepsias that are seen in such children,
with intolerance of milk and other foods, that are benefited by no
change of diet, and end in death. Hepatization of the edges or
posterior portions of the lungs may be found. Hypoplasia of
the viscera, liver, kidneys, arteries, and heart may be seen. Such
children are weak, meager, pale, and cachectic; digestion and
assimilation are at fault; oxidation fails; the toxicity of the
urine is increased. They are especially liable to infections, and
the secretions of skin and mucous membranes are lessened.
There are degenerative lesions of the viscera, and at the same time
generalized tubercles throughout the body in the form of caseous
masses, true tubercles, or gray granules are seen in the brain. The
diagnosis of tuberculosis is very diflScult, because no typical
symptoms characterize the condition. The mortality from
tuberculosis during the first year of life is very great. The pul-
monary lesions are small, while .the glandular ones are more
important, many glands being caseous. There may be a tuber-
cular bacilemia with septic fever, or a granular meningitis, or an
acute bronchopneumonia. Chronic cases may be of an ulcerative
type, with large or small cavities, resulting from caseation of
tuberculous deposits of small size or of large masses of broncho-
pneumonic consolidation. They may also be of the sclerotic
type with dilatation of the bronchi, or there may be multiple
cold abscesses.

Cerebrospinal Meningitis in the Nursling. — A. Lesage (Bull.
Mid., September 15, 1909) describes the course of cerebrospinal
meningitis in the nursing child. Here there is danger of mistak-

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ing the disease for other less serious affections, since the symp-
toms are not always typical. The general symptoms are agita-
tion, lack of appetite, refusal of milk, diarrhea, hyperesthesia,
and cries which give evidence of suffering. These symptoms
may indicate gastroenteritis instead of meningitis. But the
patient is stiff, there is Kernig's sign, and the face looks upward
from contraction of the neck. The fontanelle is distended.
Optic atrophy is frequent, as is loss of hearing even when the
symptoms have not seemed to be severe and diagnosis has not
been made. The abnormal forms of the disease are a paralytic
type in which the head falls about like that of a new-born infant ;
a mild type with indefinite symptoms ;-a tetanic type; a convulsive
type, and a cachectic type with oscillations of temperature; a
comatose type and a hyperesthetic form of the disease, with
intense nervousness, nystagmus, and strabismus. Lumbar
puncture with the finding of turbid fluid and meningococci
will make possible a positive diagnosis in these cases.

Relation of Duodenal Ulcers to Atrophic Conditions of Infants.
— H. F. Helmholz (Arch. Ped., Sept., 1909) has previously
reported nine cases of pedatrophy complicated by duodenal
ulcers, and he now adds the notes of seven more. Since all
sixteen cases have been observed within six months, he thinks
it probable that duodenal ulcers are of quite common occurrence
in atrophic infants and that they are frequently overlooked,
especially when attention is not called to them by such features
as hemorrhages, peritonitis, and pyloric stenosis. The difficulty
of seeing the ulcers at autopsy is great unless there are hemor-
rhages in them. A method which has been of service to insure
the finding of all the ulcers is the following: The duodenum is
spread out flat on a piece of blotting-paper and allowed to harden
in formalin. Cross sections, 2 mm. in thickness, are cut of the
entire duodenum and each section in turn is held up against a
light background. In this way the ulcers are readily seen as
small cup-shaped indentations in the otherwise smooth surface
of the mucosa. Sometimes the hardening alone will bring out
ulcers which were not visible in the fresh state. It seems
probable that the ulcers are related to extreme atrophy rather
than to pyloric spasm as suggested by others. A definite
relation between the ulcers and a particular kind of food is
unlikely. The pathology of the ulcers is covered almost entirely
by that of the adult. In only three of the seven cases were
there any symptoms. Hematemesis and melena are practically
the only diagnostic symptoms, though it is not improbable that
chemical tests for blood might point to the presence of ulcers
when the hemorrhage was so slight as to be invisible macro-
scopically. In very acute cases the transfusion of blood, which
has been successfully performed in melena of the new-born, might
be tried. To combat the loss of fluid, physiologic salt solution
may be given per rectum and hypodermically. When the infant
has recovered from acute symptoms, it is very essential that it

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receive breast milk, beginning with very small amount (90 to
100 grams per kilogram of body weight), and only after the child
has ceased losing weight should the amount be slowly increased.

Hirschsprung's Disease. — D. P. D. Wilkie (Edin. Med, Jour.,
Sept., 1909) records five cases of this condition which is known
also as idiopathic dilatation of the colon. As to its causation
he suggests a modification of the anatomical theory. Acknowl-
edging that the anatomical structure of the pelvic colon in new-
bom infants and young children does predispose it to kinking
with obstruction, and that this anatomical factor does play a
considerable part in the causation of many cases, he holds that
a primary overdistention of the pelvic colon with meconium
is an important cause. If overdistention has taken place at
or before birth the pelvic colon may have the same trouble in
emptying itself as an overdistended bladder does. The primary
overdistention results in hypertrophy of the bowel wall and also
in further distention. The relation which the hypertrophy bears
to the dilatation determines the fate of the case. Where the
hypertrophy fails to keep pace with the dilatation we get early
obstructive symptoms with distention and frequently death from
toxemia in infancy or early childhood. Where the hypertrophy
is sufficient to compensate for the dilatation, the child may
reach adult life, suffering only from a slightly swollen abdomen
and a certain degree of constipation. Adult life being reached,
compensation does not usually fail till the degenerative changes
of old age begin to set in; then, from fibrous changes occurring
in the hypertrophied wall, compensation fails, the bowel dilates
further, and leads to the well-known symptoms. * In support of
this, it is worthy of note that it is extremely rare to meet with a
case appearing for treatment between the ages of twenty-two
and forty, although numerous cases have been reported where
the patient was over fifty years of age.

Infection of the Urine and Urinary Tract by Bacillus Coli in
Infancy. — ^J. L. Morse (Amer, Jour. Med. Sci., Sept., 1909) says
that in the majority of cases of infection of the urinary tract
in infancy with the colon bacillus there is nothing about the
symptomatology to direct attention to the urinary tract. When
such symptoms are present they are usually mild and are easily
overlooked. Consequently the urine should be examined in all
diseased conditions with indefinite symptoms in infancy, espe-
cially if febrile, and no physical examination should be considered
complete or diagnosis satisfactory in obscure conditions in
infancy unless the urine has been examined. In fact, in the vast
majority of cases the diagnosis can only be made by the ex-
amination of the urine. The writer favors the use of alkalies
for this condition and has found them more efficient than
hexamethylenamine, which, however, should be used if they
fail. If there is still no, or very little, improvement and the case
is becoming chronic, autogenous vaccines should be tried.

Chorea a Symptom, not a Disease. — G. M. Swift (Amer. Jour.

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Med, Sci., Sept., 1909) states his belief that the normal condition
of childhood is constant muscular activity and that anything
that weakens the child weakens the nervous control and may
permit unrestrained muscular action. He divides all cases of
so-called chorea into five classes: Class I comprises the many
cases which occur in the spring or autumn months, most com-
monly in nervous girls between the ages of seven and fourteen,
who are overstudying and are " run down." Such incoordinated
muscular movements and hysteria of young adults seem entirely
analogous. The treatment is rest in bed in a quiet room with
an excess of plain nutritious food, tonics, and, during the acute
stage, quieting drugs. Removal to the country is often of
great value. Class II consists of cases due to infections, malarial,
pneumococcic, post-typhoidal, and especially rheumatic. The
writer believes the incoordinated movements in these cases are
brought about by the infectious process causing profound anemia
and malnutrition or innutrition of the control centers, motor
and sensory. Rest in bed for an indefinite time, drugs to

Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 19 of 109)