of Rhodes. Spurious works Andronicus.

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well authenticated cases of same on record.

The fundus lesions of inherited syphilis are apt to be very
misleading. There is no condition in the fundus that is path-
ognomonic of inherited s)rphilis. The principal characteristic
fundus lesion is the powder grain fundus which in time may be
due also to consanguinity, and not alone to syphilis. So far
as the sight of these children is concerned, involvement of the
meninges, as mentioned by the previous speaker, may produce
a partial optic atrophy. Again these children are bom with a
congenital optic atrophy, are usually puny, and have marked
defects of vision which cannot be improved by glasses. Nystag-
mus is frequently observed and this, in conjunction with polar
cataract and some optic atrophy is not uncommon in inherited
syphilis. A moderately white disk, atrophic type, with nystag-
mus and otitis media in a child are as conclusive of inherited
syphilis as is Hutchinson's triad. These children also frequently
have a reduced patellar reflex on either one or both sides. An-
other important point, so far as the eye is concerned, is the
peculiar appearance of the iris. It loses its characteristic dia-
phragm appearance because the pigment layer is largely absorbed
and hangs like a straight curtain without any folds. By trans-
illumination the iris often shows marked areas of thinness.

So far as the treatment is concerned, I have obtained very
good results from the feeding of fats and oils without any specific
treatment, until the keratitis has practically subsided, and then
I give mercury and iodide but only in moderate doses — the
younger the child the more careful with mercury. Build up
your patient and the eye will get along better then when you
tamper with it and look upon it as only a local manifestation
to be combated only by local measures.

So far as vision is concerned in interstitial keratitis, some
eyes almost as white as paper may clear up very nicely provided
the general health of the child is built up. Time is an important
element, and we must not be discouraged. The opacities in
the cornea are very deep, but seldom go on to ulceration.

Chorioretinal lesions are not as prone to appear in the con-
genital as in the acquired type of syphilis. Besides, the anterior
portion of the globe is more apt to be involved in the congenital
type than in the acquired type, e.g.^ polar cataract, interstitial
keratitis, etc. In the latter, the posterior portions are more
apt to be involved, retinitis, chorioiditis, optic atrophy, etc.
The younger the patient the greater the tendency for the in-
volvement of the anterior portion of the globe. One may see a
retinitis pigmentosa as the result of syphilis, the same though
being often a consequence of consanguinity.

Dr. Julius Grinker. — There are a few things which have
not been mentioned and which neurologists see occasionally.
I think that many cases of backwardness in children are due to



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CHICAGO PEDIATRIC SOCIETY. 353

syphilis in the parent, and to congenital syphilis, which has
been very mild, not causing any gross lesions, but preventing the
brain from developing normally. This, in turn, causes an under-
development of the cerebral centers, particularly those in the
frontal lobe. These cases of mental retardation may be either
slight in degree, such as the so-called high degree of inbecility,
the most intelligent imbecile, or of the lowest types of idiocy.
Close inquiry will often reveal s)rphilis in the parents and stig-
mata in the children. Another class of cases in which we have
learned to inquire into the history for syphilis are the epileptics.
We have idiopathic and symptomatic epilepsy, the latter, the so-
called Jacksonian type, which undoubtedly points to gross
organic disease in the cerebrum. I have reference particularly
to the so-called idiopathic epilepsy — generalized fits without
any cause. This disease is caused by a certain something about
which we know nothing, and we are justified in searching care-
fully for evidences of syphilis both in the parents and in the child
in order to find a tangible cause which admits of more successful
therapy than the ordinary epilepsies.

I have come to rely mostly on the radiating scars about the
mouth, Hutchinson's teeth, and chorioretinitis. These help
me considerably in many cases. In cases of epilepsy with a
hopeless prognosis, all we can do is to give bromides for years.
I have found in both the acquired and congenital types that
when bromides fail to produce any eflfect, the iodides diminish
the attacks and prove otherwise beneficial. I would not say,
however, that I have cured epilepsy even of the luetic variety.

Another class of patients with which neurologists are familiar
and which are undoubtedly caused by syphilis, are the cases of
juvenile tabes and paresis. They differ somewhat in their
symptomatology from the ordinary tabes. In such children
we find either the ordinary stigmata, or some definite symptom
pointing to the previous existance of syphilis. But the tabes
does not begin as in the adult. One of the first things to develop
in these children is urinary incontinence or retention. At the
age of nine or ten when habits of cleanliness have long been
established it is noticed that these children begin to wet them-
selves. In a great many instances optic atrophy appears early,
and may be the only sign. It is rather difficult to say whether
the optic atrophy is the result of syphilis, or a beginning tabes.
However, the lancinating pains do not seem to be a very conspicu-
ous symptom. These patients also become somewhat unsteady
on their feet. The optic atrophy, the slight paralysis of the
spincters, the beginning ataxia, with loss of reflexes, and the
Argyll- Robertson pupil are exceedingly characteristic of these
as well as ordinary cases of tabes. In the juvenile types tabes
sometimes runs a benign course, but these children do not often
reach old age.

Juvenile paresis due to congenital syphilis, either acquired in
early infancy or prenatally, also appears slightly different from



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354 TRANSACTIONS OF THE

the ordinary general paresis. The disease makes its appearance
when the patient is in perfect health, and usually when he has
reached maturity or the acme of success. These children,
brilliant in school up to this time, suddenly develop paretic
speech, delusions of grandeur, and the other phenomena of general
paresis, which last disease usually runs a rapid caurse.

Another peculiarity of juvenile paresis is that it often presents
many of the phenomena common to dementia precox. In
the latter condition we see the so-called mutism and stereotyped
mannerisms. I have seen cases in which the existence of these
symptoms made it exceedingly difficult to differentiate them
from dementia precox. In every care of so-called dementia
precox, with a suspicion of lues, we must bear in mind that we
may have a case of juvenile paresis, and not one of dementia
precox. Look for the Argyll-Robertson pupil, the exaggeration
of the reflexes, the tremor, and the peculiar paretic speech.

As regards the nervous manifestations of congenital S)rphilis,
I wish to cite one case in which there were undoubted evidences of
congenital lues and in which, at the age of nineteen, a hemiplegia
developed, as in an acquired syphilis, due to thrombosis. There
were three different attacks culminating in aphasia and hemi-
plegia. The patient went along as an ordinary hemiplegic until
a gummatous meningitis set in. Postmortem we found a throm-
bosis in the internal capsule leaving a scar, and a gelatinous,
gummy coat covering the cortex, a so-called gummatous menin-
gitis. These cases usually respond well to mixed treatment.
Congenital cases of brain syphilis should be treated very ener-
getically, and we often get brilliant results, just as in the ac-
quired form.

Some of the muscular dystrophies are also ascribed to congeni-
tal lues, but there is still great uncertainty in the entire j&eld of
the muscular atrophies.

Dr. F. S. Churchill. — Dr. Krost seems to attach more impor-
tance to enlargement of the spleen as a diagnostic feature of
syphilis than seems warrantable. He quoted Finkelstein to the
effect that if rickets and tuberculosis could be excluded, it would
be an important diagnostic sign of syphilis. I do not believe
that to be the case.

He also stated that syphilis can be confused with leukemia.
I do not see how that can be possible if a careful examination of
the blood is made. The differential count gives an absolutely
typical picture in leukemia, which is not the case in syphilis.

Dr. Krost. — I meant particularly the spleen in children under
three months old, when anemias are not common. In some cases
of syphilis the blood picture is that of a leukemia, except that the
white count is not high ; almost all the cells are lymphocjrtes.

Dr. Churchill. — With which variety of leukemia would you
confuse it?

Dr. Krost. — ^Lymphatic leukemia, which at some periods has
a very low count.



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CHICAGO PEDIATRIC SOCIETY. 355

Dr. Churchill. — Just before death.

Dr. Krost. — ^I have seen it also in the splenomedullary type.

Dr. Churchill. — The total count is of no importance, but the
differential count is. It is on that count that I would base my
diagnosis. As to the anemias of infancy, before three months,
not being common, they are exceedingly common.

Dr. B. C. Corbus. — The diagnosis of congenital and acquired
syphilis may be made by one of two ways: First, by finding the
spirochete pallida in the lesions; second, by the Wassermann
reaction. We found spirochete pallida in one case eight and
one-half years after the primary lesion, in another four and one-
half years afterward, and in a third, three and one-half years
afterward. The latter occurs quite commonly. In one case of
congenital syphilis we found the spirochete pallida in moist
papules between the toes at three months. These children teem
with spirochete pallida. It is from the livers of these children
that we get the antigen for the Wassermann.

The more we work with the Wassermann the more we realize
its value in diagnosis and in treatment. Neisser says, "that the
Wassermann test reveals syphilis with such surety that he can
now no longer be without it. A positive Wassermann is an
absolute surety that syphilis is present. Negative tests are
valuable as diagnostic aids, but not always infallible.'*

So far as the treatment of congenital syphilis is concerned, it
should be instituted before conception occurs. No man or
woman should be permitted to marry who does not show a negative
Wassermann at least a year and a half previous to marriage.
They should be kept negative for that time. The modern treat-
ment of syphilis is chronic and energetic, not chronic and inter-
mittent, as it used to be. Make your diagnosis early by finding
the spirochete pallida and getting a positive Wassermann, and
then keep the reaction negative for all time.

Dr. I. A. Abt. — The clinical description of these cases in text-
books is frequently inadequate. The symptoms do not always
occur in the sequence which is stated. Not sufiicient importance
is laid on some of the unusual symptoms. The classical case with
snuffles, maculopapular eruption, does not always present itself
in this form. Very frequently an infant who is born of known
syphilitic parents shows no symptoms at all or only obscure
signs later in childhood. Or another child presents no symptoms
for the first six months of life, when it may show febrile reactions,
furuncles, arthritis, visceral lesions, or some other sign which is
not readily interpreted as of syphilitic origin.

With reference to syphilis and leukemia, I agree with Dr.
Krost. I believe that the blood picture in syphilis very fre-
quently resembles that of lymphatic leukemia. There are nu-
merous reports in the literature showing lymphocytosis of 80 per
cent, and over in cases of congenital syphilis.

Another point which may be referred to is that it is not so easy
to treat these cases. After treatment is begun, the child very



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356 rudisch: diabetes in children.

often develops a diarrhea, colic, and restlessness, and fails to
pick up if mercury is given by mouth. If given by inunction,
dermatitis or severe constitutional symptoms may result.
While the adult bears mercurialization, as a rule, without much
difficulty, the child is easily intoxicated.

There are many exceptions to the text-book rule. I have seen
cases of multiple gummata during the first year and also gumma
of the larynx, proved on autopsy, in a child less than eighteen
months old. Therefore, one of the important things that might
be brought out in this connection is that text-book descriptions
are for the most part inadequate, and not always borne out by
clinical experience.

Dr. W. J. Butler (closing). — ^It is often difficult to push
mercury in syphilitic infants. The discussion has shown the
great value of the Wassermann test because of the absence of
characteristic symptoms in many of these cases. We certainly
are not doing justice to our patients if we fail to control the
interruption of their treatment by the Wassermann test. For
ten years I have been looking for progressive paresis of the
insane and tabes in children. I saw one case in my own clinic
and one in Vienna, so that I am rather surprised to learn of the
frequency of these cases in the practice of others.

Dr. S. J. Walker (closing). — ^I said that I had seen several of
these cases — about three, I think.



ORIGINAL COMMUNICATION&



DIABETES IN CHILDREN.*

BY

JULIUS RUDISCH, M. D.,

Attending Physician to Mt. Sinai Hospital, New York City.

The subjects of etiology, pathology, and treatment of diabetes
in children have been gone over so thoroughly and exhaustively
by my predecessors that I need only dwell upon the peculiari-
ties of diabetes in children as compared with that in adults.

Etiology. — ^In most of the cases in children no tangible cause
could be found. They seemed to have more of the pure diabetes
in the sense in which Naunyn uses it than diabetes due to
organic diseases, such as aflfections of the liver, arteriosclerosis,
obesity, diseases of the nervous system, etc.

Heredity plays just as large a r61e in children as in grown
persons. In some families where one or both parents or some
other members of the family had been afflicted, the disease
showed itself in one, two, or three of the children.

* Read before the Williams burgh Medical Society, December 13, 1909.



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rudisch: diabetes in children. 357

An eruptive disease, such as measles, scarlatina, etc., often
preceded the outbreak of diabetes.

Where syphilis has been the causative factor in some of
these cases, an antisyphilitic treatment cured the patients of
their trouble.

In some cases the etiology shows an abuse of sweets just as
in grown people.

Van Norden questions very much if diabetes is as rare in
children as is popularly supposed. He thinks that if the urines
were examined as often as in adults many a case dying from
some chronic indefinable disease would be found to be diabetes.

Prognosis, — The prognosis in children is much more unfavor-
able than in adults. According to the statistics of Bogeraz,
which embrace some six hundred cases, the fatalities are over
90 per cent., and the duration of the disease rarely extends over
more than two or three years. More often the unfavorable
progress is extremely acute.

On the other hand, children, if cured, are usually cured perma-
nently; that means that in after-life they no not differ from
nondiabetics in their power of assimilating the carbohydrates,
^ condition which is unhappily very rare in the adult.

Incidentally I may mention the history of two cases of dia-
betes in children observed both by Drs. A. Jacobi and Kerley.

Dr. Jacobi has seen these two boys at the ages of three and five
years, with a daily output of from two to four ounces of glucose.
I will continue to cite their further history in the words of
Dr. Kerley:

**The two boys have not had less than 6 per cent, of sugar in
the last eight years. Including those two, I have seen eight
undoubted cases of diabetes in children. The other six cases
were rapidly fatal. One patient was nineteen months old and
died within three months. The boys, eleven and fifteen years of
age, are clinically perfectly well. Diabetes in children is asso-
ciated with much thirst and the passage of large quantities of
urine. These boys have good appetities and sleep well. There
is no excess in the passage of uritie and no excessive thirst. They
have been a puzzle to two continents. The older boy, six feet
in height and weighing 170 pounds, took three gold medals and
three silver medals this year for long jump, high jump, and other
athletic feats. The younger brother is of exactly the same type.
They excrete sugar on a very strict diabetic diet, and though the
excretion of sugar continues, they continue to thrive and grow.



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358 rxtdisch: diabetes in children.

They are living on a proteid diet and what the outcome will be
we do not know. They are not ill, do not feel badly, and never
have. The fact that sugar was found occurred through the
desire of the mother to know that her four children were all
well, as mothers will. She sent me a specimen of the urine of
all four and I found the sugar in the two cases. The sugar was
only discovered because the mother wanted the urine examined
on general principles."

These two cases are unique. With these two exceptions.
Dr. Jacobi's fifteen cases of children under twelve, all died in
a comparatively short time. Few lived more than a few months
after the diagnosis was made.

Treatment. — ^Now it remains for us to see in what respects the
treatment of children differs from that of adults. First of all,
it is the opinion of all practitioners that one of the reasons for
their unfavorable course is the fact that children cannot be kept
on as strict a diet as is necessary, nor can they be watched as
thoroughly. I have myself had experience with children who,
under the watchful eyes of the nurses, stole bread and sugar,
so that I had to keep the patients in bed, and even then they
contrived to get from the other patients forbidden foods. I do
not doubt and I have had the experience to corroborate me
that a strict surveillance of the patient, especially in institu-
tions, will make it possible to obviate this diflSculty, as every
transgression will show itself immediately in an increased out-
put of sugar. Diabetic children suffer from a voracious appe-
tite. They get into the habit of eating large quantities, and
in the beginning it is necessary to fill their stomachs with foods
that will not overfeed, that will not give them too much carbo-
hydrate or even too much protein and still satisfy their craving.
I have found that cabbage and cauliflower, also spinach, water-
cress, if cooked for a couple of hours, with water poured off and
a little beef or chicken broth added, will answer the above re-
quirements. Green salads in large quantities, as much as they
will eat, are also beneficial.

Cut down as much as possible proteids, meat, eggs, and cheese,
as a superabundance is as detrimental as an excess of carbo
hydrates.

In regard to the quantity you will have to be guided by the
condition of the patient, loss or increase of weight, and by the
excretion of sugar.



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jrudisch: diabetes in children. 359

Relishes like pickles, olives, tomatoes, are allowable in older
children.

Nuts like walnuts, peanuts, almonds, in moderate quantity
will benefit the patient.

Of the greatest importance in the feeding of these children
s the use of fat. Of the fats I prefer codliver oil, or olive oil, if
the patient can stand them, the more the better. Butter,
especially fresh butter, is of great value, though in cases of
acetonemia it is questionable whether the butyric acid does not
too easily become converted into beta-oxybutyric acid.

The question arises whether these strenuous measures should
be taken in every case of diabetes. A great many authors
think that a certain amount of carbohydrates should be given to
children where there is a large amount of diacetic acid in the
urine. On this subject I can refer to my article on the treat-
ment of diabetes mellitus as follows:

**The question arises as to whether or not we shall continue
our attempt to reduce the glycosuria by the withdrawal of carbo-
hydrates in the presence of large quantities of acetone and diacetic
acid. This is the problem the practitioner is asked to face in
all severer cases. He finds in the text-books that when acetone
bodies appear in the urine he is immediately to add carbo-
hydrates to the patient's diet to ward oflF the onset of coma.
The results of my observations have led me to the conclusion
that this dictum must not be applied indiscriminately, and that
in very many cases of acidosis a strict protein diet is not merely
not harmful, but even distinctly beneficial.

"The carbohydrates in severe diabetes do not enter into the
patient's economy. They increase the hyperglycemia, are ex-
creted as glucose in the urine, and often prevent but little, if
at all, the formation of the acetone bodies.

"When a healthy person is suddenly deprived of all carbo-
hydrate food, acetone, above the small quantity present nor-
mally, usually appears in the urine. Diacetic and beta-oxy-
butyric acids also appear occasionally. All these acetone bodies
disappear in a few days, however, even though the carbohy-
drates continue to be withheld. In the majority of cases of
diabetes, especially in those of a milder type, the same rule holds
good. Most of the patients who enter the wards of Mt. Sinai
Hospital with diabetes show acetone, and many of them have
diacetic and beta-oxybutyric acids as well. I have up to now
been fortunate in never having seen a single case in which coma



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360 rudisch: diabetes in children.

followed a strict protein and fat diet to the exclusion of all
carbohydrates.

"Those patients who have been under observation and have
been kept on a strict carbohydrate-free diet for some time form
a different class. If they develop acetone bodies, it is necessary
to allow them some carbohydrates, with a corresponding dimi-
nution in proteids, until the diacetic acid diminishes or disap-
pears. We may thus be able to prevent the onset of coma."

As to medicinal treatment, alkalies, especially bicarbonate of
soda, has proven itself in the hands of many practitioners of
great value. It is certainly highly indicated in cases of acidosis.
The quantity to be given will have to be regulated by the condi-
tion of the patient's stomach. Opiates in older children can be
tried, especially where there is a neurotic element. As to very
young children, opiates will have to be given, if at all, in a very
careful way.

**It has been my good fortune to discover that atropin has a
more marked influence on the sugar excretion than any of the
drugs that have heretofore been tried. It has the advantage of
being well borne in large doses, if given cautiously and in gradu-
ally increasing amounts. In two and a half years* clinical ex-
perience I have not found that a habit has been established in
any case or that there are any bad eflfects on the general
health from its prolonged administration.

"With atropin the glycosuria disappears much more rapidly
than with a carbohydrate-free diet alone. When, with the
cautious increase in carbohydrates in patients whose urine has
become sugar-free, sugar again appears, it is often possible to
suppress the sugar excretion solely by atropin without reducing
the carbohydrates. In other words, the carbohydrate tolerance
is greater with atropin than without. The sulphate is the
form most generally used in the wards. Methyl bromide (Merck)
has certain advantages. It is much less toxic than the sulphate
and is therefore safer for patients who are not under daily
supervision. Its action is not as striking as that of sulphate.
The glycosuria does not disappear as rapidly nor is the limit
of carbohydrate tolerance raised as soon as with the sulphate.
Its expense, too, limits its use somewhat.

"Extremely large doses of methyl bromide of atropin are well
borne if given with care. I have found that an initial dose of
gr. 2/15 t. i. d. can be safely used in adults and can be increased



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 37 of 109)