of Rhodes. Spurious works Andronicus.

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

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ward. If there ever was a fair field for an epidemic of diphtheria,
this condition of affairs seemed to offer it. These nurses were
instantly isolated in a separate building which we have for that
purpose, with a nurse confined with them and with a physician
who at no time entered any other part of the hospital, and every
technical precaution was taken to make the isolation of these
nurses efficient.

In due course of time we found pure cultures in a child's
throat, and in a day or two another case developed, and so on
until twelve or fifteen of the children in the hospital had pure
diphtheria cultures in their throats. Some of them went so
far that there were physical signs of diphtheritic intoxication.
Our method of procedure was radical. Every child was given
the antitoxin, and as soon as it developed the cultures it was
removed to the isolation building where the nurses had been
previously taken. When a case developed the ward was cleaned
out completely. Every child was bathed and changed and
moved into another ward by nurses under the most rigidly
clean methods. All of the clothing and linens were thoroughly
disinfected before removal to the laundry, and the quarters
were invariably fumigated to the maximum degree. The epi-
demic strung along for nearly a month, but in no case was there
an appreciable illness on the part of the patient, aside from the
light rise of temperature due to the antitoxin; and looking
back upon the epidemic now, we rather like to identify it under



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CHICAGO PEDIATRIC SOCIETY. 335

the name of a laboratory epidemic of diphtheria. It was an
expensive epidemic, however, as every epidemic must be that is
properly handled.

We have had some experience in this institution with the
handling of infant foods, especially milk, and the various formulas
containing milk, and it has been astonishing to us, even to the
attending men in the children's department, what grave results
could come from the minutest errors in the technic of milk
formulation. We pay a very high price for the milk for our
children's department, and obtain it from select cows, raw, and
within twelve hours from the time of drawing.

We use our own design of pasteurizer, in which all the milk
is pasteurized under laboratory conditions; that is, by complete
immersion in water, and the temperature of the water is auto-
matically controlled by approved and proven temperature con-
trolling devices. We try to be mathematical in our exactness
as to the bulk of milk pasteurized in every given laboratory
flask, and we have settled down now to the pasteurization of
milk under the particular laboratory form in use in the labora-
tory of the Agricultural Department at Washington, under
Dr. Rosenau, which provides for 60** centigrade for twenty
minutes after the milk has arrived at the exact temperature
of the water in the pasteurizer. In Dr. Rosenau's experiments
this temperature at this time destroys all pathogenic bacteria,
and we have found that it destroys not only the pathogenic
bacteria, but the so-called lactic acid bacteria as well. And
we have found, moreover, that it does this without fixing the
caseins of the milk and without coagulating the lactalbumen.

I have elaborated somewhat on this method merely to show
that we have a definite and exact system of operation, but
here again comes in the element of human liability to err, and
under even the greatest possible precautions we have on one
or two occasions slipped in our technic, either in pasteurization
or in some step in the formulation of the various milk compounds
or in their predigestion by the use of some one of the rennet
ferments, and these slips have been drawn to our attention
most forcibly at the bedside of some little patient to whom the
milk had been given.

We are finding that it is not sufiicienl that we procure the
best possible form of fresh cows' milk brought to us under the
most favorable conditions, but that the preparation of the
milk for use in the children's department has then but just



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336 TRANSACTIONS OF THE

begun, and that its pasteurization or sterilization and its ad-
mixture with one or other of the ingredients that you gentlemen
of the Pedriatric Society prescribe for your sick children is no
less important a step than the state of the milk itself; and that
an error ever so slight, either under-pasteurization of this milk
or in the over-sterilization of it to the point of solidifying the
caseins and coagulating the lactalbumen can develop gastro-
intestinal disorders of quite as grave a character as those that
we find coming from the slums under slum conditions.

During the past few months, groping as we have been for an
effective reply to the demand for some uniform feeding for sick
children suffering from gastrointestinal disorders or malnu-
trition. Dr. Abt, of our pediatric staff, has undertaken a careftd
study of the milk of goats. The hospital now has its own herd
of goats. The individuals of that herd are identified practically
and in the laboratory. Our records develop the amount of
butter fat, the milk that each contains, the fineness of the fat
globule itself, the bacterial count under those peculiar conditions
which we have in this institution. The milk is drawn under
those ideal conditions prescribed by the technists among dairy-
men; the udder of the goat is washed in sterile water; all the
vessels are sterilized; the hands of the operator are surgically
dean, and the milk reaches the refrigerator in as nearly perfect
a condition as a conscientious respect for these various methods
will permit.

The records of the institution, as Dr. Abt will some day advise
you, demonstrate results that would seem almost out of pro-
portion to the slight change from cows' milk to goats' milk in
the feeding of children; and so well satisfied is the institution
with the results thus far given that we have already imported,
and are to import, other famous breeds of goats to develop the
milking capacity, quality as well as quantity.

If the members of the society are particularly 'interested in
this subject, I should be glad to exhibit before you one of the
members of this imported herd.

Dr. Lackner showed a case of

PLASTIC tubercular PERITONITIS.

In a child two years old in which Schlossman's method of
treatment with tuberculin had been used with apparent success.



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CHICAGO PEDIATRIC SOCIETY. 337

Dr. Mark Jampolis read the report of a case of

DIABETES MELLITUS IN A BOY TWELVE YEARS OLD.

The following case is reported chiefly for its etiologic and
dietetic interest.

The patient, D. R., aged eleven years, of Russian Jewish
parentage, was admitted to the surgical department of the
Michael Reese Hospital, July 2, 1907, with the following history:
While walking in the street, the patient was struck from behind
by an automobile. He fell unconscious and remained so for
about thirty minutes.

On reaching the hospital he had regained consciousness, his
mind was clear and no evidences of head injury were found, but
there was a compound fracture of the right tibia. Under ether
anesthesia, the wound was cleansed and the fracture set by
Dr. L. A. Greensfelder. The recovery was uneventful, and
after five weeks the boy was discharged in good condition.
The urine was normal on the day following the injury.

About eighteen months later, January 19, 1909, he was again
admitted to the Michael Reese Hospital, this time to the medical
service of Dr. Abt, with the following history: Last February
(eleven months ago and seven months after the injury) the boy
began to be troubled with marked diuresis. Nine months ago
he was urinating about twelve times a day, three-quarters of a
quart at a time; six months ago, eight times and a quart at a
time. His. appetite became enormous and his thirst increased
until he has required about fourteen cups of water daily for the
past four months. He has grown progressively weaker and his
eyesight is becoming poorer. Aside from a dryness in the throat
and an occasional headache of late, he has been feeling well. He
had measles seven years ago, but has otherwise enjoyed good
health. The family history is negative, showing no constitu-
tional diseases or neuroses.

Examination. — On physical examination nothing abnormal
was found except diminished patellar reflexes. The blood
picture and blood pressure were normal, and nothing abnormal
was found by Dr. Snydacker in the eye-grounds. One hundred
and six ounces of urine were voided in twenty-four hours, show-
ing 5 . 4 per cent, of sugar and the presence of acetone, but no
diacetic acid.

Treatment and Reaction. — ^He was given an ordinary diabetic
diet until April 21, a period of about three months, the follow-
ing being an average daily diet.

8 A. M. — Orange, ^gg, bacon and coffee with cream.

10 A. M. — Broth, 6 oz.

Noon. — Gluten bread, salad, steak, tea, dessert.

3 p. M. — Orange.

5 p. M. — Steak, chicken or chop, gluten bread, tea with
cream, custard.

In addition, thymus gland, both dry and glycerine extract.



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338 TRANSACTIONS OF THE

was administered for about five weeks and Fowler's solution
for about three weeks, without any noticeable effect. During
this period the urine averaged 35 to 40 oz. in twenty-four hours
and constantly contained from 1.4 to 6.5 per cent, of sugar,
and usually acetone, but no diacetic acid. His weight in the
last month averaged about seventy-two pounds. His appetite
improved and his weakness became less pronounced.

He was then given green vegetables alone for two days, but
the sugar remained high and the weight dropped to seventy-one
pounds. The general diabetic diet was resumed for six days,
but the boy lost two more pounds and the sugar averaged 4
per cent.

On May 5, in spite of the loss in weight, the diet was limited
to the Von Noorden gruel, prepared according to the following
formula:

Oatmeal, 250 gm.

Butter, 250 gm.

White of six eggs,

Salt to flavor.

To be consumed in twenty-four hours.

The sugar promptly disappeared and remained absent, but
acetone was constantly present. After four days, green vege-
tables were added to the diet and sugar remained absent, but the
weight fell to sixty-six and one-half pounds. After a week of the
gruel, the general diet was again resumed and the sugar promptly
rose to 61 per cent., and with it the body- weight increase to
seventy-two pounds.

After ten days of the liberal diet. Von Noorden's gruel was
again given for about a month, a period from May 16 to June 13,
from 200 to 400 grams of green vegetables being added after
the first week. Sugar was absent during this period, but acetone
in various amounts was usually found. The weight fell at first
and then remained fairly constant, averaging 66 to 68 pounds.
The boy felt well, although acetone was constantly present, his
hunger was satisfied and he found the gruel not distasteful. Casts
were found in the urine at times during this period and the total
amount of urine varied from 16 to 40 oz.

Beginning June 13, meats and oranges were gradually added
and the weight rose from 66 to 70 i / 2 pounds. Sugar remained
absent from May 16 until June 25, and from that time until
July 9 varied from zero to 5 per cent. An average diet (June 20)
was as follows:

8 A. M. — Gruel, 155 gm.; coffee, 125 gm.; 1/2 orange.

Noon. — ^Vegetables, 275 gm.; gruel, 190 gm.; beans, 90;
chicken, 140 gm.

3 p. M.-— Gruel, 160 gm.

5 p. M. — Beans, 100 gm.; gruel, 175 gm.; vegetables, 190 gm.

Ten days later, July i, the diet was as follows:

8 A. M. — Bacon, 70 gm.; gruel, 210 gm.; coffee, 210 gm.; 1/2
orange.



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CHICAGO PEDIATRIC SOCIETY. 339

Noon. — Green vegetables, 245 gm.; scraped beef, 60 gm.;
chicken, 100 gm.; gruel, 140 gm.

3 p. M. — Gruel, 240 gm.

5 p. M. — Vegetables, 280 gm.; beef, 90 gm.; gruel, 234 gm.

On Julys a piece of toast was added and the sugar rose to almost
3 per cent . On July 12 the toast was stopped and the sugar fell
to o. 6 per cent. July 15 he left the hospital feeling well, voiding
about a quart of urine daily containing less than 2 per cent, of
sugar, some acetone, but no albumin or casts.

Since leaving the hospital he has been on general diabetic
diet, with gluten bread (no bread, potatoes or sugar). His
weight has increased gradually from 70 pounds to 79 pounds at
present (Oct. 15). A urinalysis once or twice weekly showed
the presence of less than 2 per cent, of sugar, the percentage
averaging less than 0.5 per cent, for the past month. His
general health has been good and he feels no pain or discomfort
in spite of an almost constant acetonuria.

The exact r61e played by the traumatism was the subject of
much controversy in the lawsuit which was started after the
accident but before the diabetes became manifest, and came to
trial when the disease was flourishing.

That trauma to the head and spinal column produces glyco-
suria, both transitory and permanent, has been recognized by
clinicians and physiologists for many years. Griesinger* was
the first to note that severe trauma to other parts of the body,
as the muscles and abdomen, may be followed by diabetes.

In the review of 212 cases of head injuries admitted to the
Boston City Hospital, Higgins and Ogdenf found glycosuria
in twenty cases, five being simple scalp wounds, four deeper
wounds denuding the bone, five fractures of the vault and five
fractures of the base.

According to Naunyn, { although the traumatic glycosurias
are the most favorable as a rule, nevertheless some of the most
severe cases of diabetes are of traumatic origin. He questions
the right of anyone to deny that the frequent ** transitory glyco-
surias" are manifestations of a true "diabetes.** Finding a
hereditary influence in a large number of cases in all types of the
disease, he recognizes only two forms of the disease, the mild and
the severe, the pathogenesis in all cases being a hyperglycemia.
He denies the manifold character of the disease, namely that
etiologic differences correspond with differences in the sympto-
matology and course, and that we should speak of the "various
forms" of the disease rather than the disease ** diabetes mellitus."

Ebstein§ also believes that in all cases of traumatic diabetes,
' ' individual predisposition " is an important factor. He collected
from his own clinic and the literature fifty cases of traumatic

♦ Griesinger. Cited from Kleen (Diabetes and Glycosuria).

t Higgins and Ogden. Bost. Med. and Surg. Jour.f Feb. 28, 1895.

i Na\myn. Mod. Clin. Med., Chap. Diabetes.

} Ebstein. Cited from Osier's Med. Series, Chap, by Futtcher.



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340 TRANSACTIONS OF THE

diabetes, half of which were due to head injuries and half to
trauma elsewhere.

Bemstein-Kohan* found head traumatisms the most fre-
quent, the glycosuria appearing at times long after the injury,
these cases being the most obstinate.

Wegli, t in io8 cases of diabetes collected from the literature,
found trauma the exciting cause in eleven cases. The list com-
prises head injuries for the most part, but in two cases there
was abdominal trauma, in one a back injury and in one an injury
to the hands. Of his own twenty-eight cases, he attributes to
trauma the tmdoubted exciting r61e in four — three head injuries
and one injury to a finger with much hemorrhage. In four
other cases he is doubtful on account of complicating circum-
stances and the long period elapsing between the injury and the
first manifestation of the disease.

In the case reported above, admitting trauma as the exciting
cause, we cannot determine whether the slight concussion or the
more extensive fractures, or both, played the important part.
Other factors must not be overlooked. Thus, in view of the
universally recognized prevalence of the disease among Jews,
the racial predisposition is present, even though some direct
family influence may have been overlooked by the parents.

The accompanying chart shows the reaction to the various
diets.

Dr. a. a. Strauss reported a case of

AMAUROTIC FAMILY IDIOCY.

After a careful history of the case Dr. Strauss summed up the
important points as follows:

1. That it is a family disease, this being the second child
d)ring with this disease.

2. Insidious onset, inability to support the head, gradual
development of muscular weakness going on to spastic and
flaccid paralysis.

3. Gradual development of blindness.

4. Pathognomonic sign in the macula lutea (cherry spot).

5. Constant nystagmus and irregular nystagmus.

6. Alternating absence and presence of reflexes.

7. Hyperacousis or increased motor reaction, throwing child
into convulsions.

8. Impaired deglutition and choking spells.

9. Digestion normal.

10. Constant druling of saliva.

11. Last stage of the disease, marked loss in fat and weight
and marked asthenia.

Practically every symptom that has ever been noted in all
the cases are found in this one case with the exception of the
explosive laughter which was not present in this disease. Nearly

* Bemstein-Kohan. Thesfe de Paris, 1891.

t Wegli. Arch.f. KinderheU.^ B. xix (with references to cases in literature).



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342 TRANSACTIONS OF THE

all the cases reported are found in Hebrews. This child is of
Jewish birth, and highly neurotic parents.

The most important pathological changes to be found in these
cases are marked degeneration of the ganglion cells of the
entire central nervous system, extending to the ganglia of the
retina (cherry spot) and degenerative changes in the pyramidal
tracts.

Meeting of November i6, 1909.
The President, I. A. Abt., M. D., in the Chair,

SYMPOSIUM ON CONGENITAL SYPHILIS.

Dr. W. J. Butler spoke of the ** Value of the Wasserman
Reaction in Congenital Syphilis.''
Dr. Henry G. Anthony discussed the

SKIN manifestations OF CONGENITAL SYPHILIS.

The points of diflFerence between congenital and adult mani-
festations of syphilis are, first, the infiltration is apt to be diffuse;
second, apt to be located on the face, buttocks, and genital
region; third, the epidermis is apt to separate more readily
from the derma; and, fourth, bullous eruptions are more apt to
form. However, all bullous eruptions in these locations are
not s)rphilitic. The most common form is bullous erythema.
The bullae are present at birth, with no erythema of the base,
and not surrounded by redness. In twenty-four or forty-eight
hours the bullae rupture, and the base becomes reddened and
infiltrated. In some cases the bullae disappear and the case
goes on to healing. In other cases the bullae assume a malig-
nant form and appear all over the body. The bullae appear in
the throat and the child has a hoarse cry. Difficulties of feeding
begin; the child loses weight, emaciates rapidly, and dies on the
tenth or twelfth day. No microorganisms are present in the
fluid of such bullae. The disease is probably closely related to
erythema multiforme.

The next bullous eruption is epidermolysis bullosa hereditaria,
usually following a slight traumatism. The disease is not
present at birth, as a rule, but occurs in succeeding generations.

Next eruption is bullous impetigo, which is the same as im-
petigo contagiosa of the adult, from which it differs in the fact
that it assumes the bullous form when it occurs in infants. The
eruption always occurs in warm weather, and there are usually
adult cases of impetigo in other members of the family. In
the beginning it does not resemble a syphilitic eruption, but
after a time, along the outline of the bulla, where the epidermis
lies in shreds, an inflammatory exudate is thrown out forming
circles and segments of a circle which strongly resemble eruptions
of a syphilitic nature.

Another form of bullous eruption is that in which a flat papule
will spring up on [the base of a bullous impetigo. It is almost
indistinguishable from a syphilitic eruption.



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CHICAGO PEDIATRIC SOCIETY. 343



DIAGNOSIS OF SYPHILIS.



Dr. R. a. Krost after calling attention to the impor-
tance of the Wasserman reaction and the finding of the spiro-
chete took up the clinical manifestations in the active
stage and in the stages of remission and of freedom from symp-
toms. He first mentioned the pathological findings in the organs
of the fetus together with the occasional occurrence of the pem-
phigoid eruption before birth. In the first three months of life
the presence of a firm enlarged spleen is almost diagnostic.
The snuffles, rhagades, diffuse infiltration of the skin, the infil-
trated and glossy appearance of the palms and soles, excoria-
tions about the anus, and the various circumscribed skin erup-
tion should receive our earnest attention. In the bones we find
the epiphyseal swellings, pseudoparalysis, the "natiform caput"
of Parrot and hydrocephalus. The enlargement of the cubital
and posterior auricular glands is of much diagnostic value pro-
vided there are no local lesions.

During the interval of remission the yellowish tint to the skin,
the splenic enlargement, the cubital gland hypertrophy, the
sparsely covered scalp with the hydrocephalic head, saddle-
nose and rhagades are important signs. During early childhood
a chorioretinitis or bilateral painful enlargement of the testicle,
condylomata lata, anemia, which at times cannot be differen-



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 35 of 109)