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is such that drainage into the pelvis is very apt to occur, and,
therefore, in the event of infection, early posterior drainage is



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BRIEF OF CURRENT LITERATURE. 533

often indicated. Its affections are, undoubtedly, the cause of
many obscure and unexplained backaches and persistent sciaticas.
The important ligaments of this joint are so placed that the
sacrum and the ilium swing open in the event of a symphysi-
otomy and little permanent damage results, even if the pubic
separation has been great enough to rupture the unimportant
anterior-inferior part of the capsule. The relaxation of this
articulation should be guarded against by support of the lumbar
spine with pillows, etc., in cases of protracted postoperative
convalescence.

Enucleation of Uterine Myomas. — E. E. Montgomery (Jour.
Amer. Med. Assn., Oct. i6, 1909) favors the enucleation of
uterine fibroids when the growths are few in number and the
structure of the uterus is but little involved; when they are
readily accessible through the vagina or cervical canal ; when
the woman, whether unmarried or married, is under forty
years of age, and particularly when she is childless or has but one
or two children; when the tubes and ovaries are free from com-
plicating conditions. He condemns the operation when the
woman affected has reached the age of forty, as with the changing
conditions incident to the climacteric, the tendency to degenera-
tive processes is increased. He considers it inadvisable when the
uterus is spread out by the growth or growths to such a degree
that the reconstruction of a functionating uterus will not be
feasible, and when the tumors are so distributed in the struc-
ture of the uterus that the circulation will be greatly affected
in the necessary suturing to replace the disordered structures.

Wassermann Reaction in Different Periods of Sjrphilis. — ^P.
Minassian and O. Viana (Folia Ginecologia, vol. ii, F. i, 1909)
experimented on the application of the Wassermann reaction
in sixty individuals having syphilis in various stages, with posi-
tive reactions in many cases. In the primary period it was
positive in 25 to 30; in the secondary period it reached 86 to
87 per cent, of positive reactions; in the tertiary period 83 to 84
per cent, were positive. Its value is less in the primary stage
than in the later periods of the disease. Its specific action was
shown in many cases, and in some it was the only element in the
diagnosis. As antigen the reextract of syphilitic liver is most
valuable, its results are more constant than that of the other
tissues. The syphilitic antibodies were found in the milk, amni-
otic fluid, pemphigus bullae, and the fluid of syphilitic hydrocele.
The mercurial treatment did not sensibly influence the presence
of this reaction. In nonsyphilitic individuals the search for
antibodies always yielded negative results. The presence of the
Wassermann reaction makes the diagnosis of syphilis positive,
but its absence is not a proof of the nonexistence of the disease.



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DEPARTMENT OF PEDIATRICS.



ORIGINAL COMMUNICATIONS.



GASTRIC ULCER IN CHILDHOOD.*

BY

L. M. BOWES, M D.,

Assistant in Medicine, Rush Medical College,

Chicago, 111.

Gastric ulcer is a very rare disease in childhood, more par-
ticularly between the ages of one and ten years.

This is due to the facts that the stomach rapidly empties its
food contents into the intestines; that there is a small amount
of hydrochloric acid secreted, and the extreme rarity of
hyperacidity.

In the literature I have been able to find fifty-two cases. One
in a fetus was reported by Carteaux, and one in a newborn child
which was reported by Cocks. There were seven cases under
one year; nine between the ages of one and five years; seven
between the ages of five and ten years; eighteen between the
ages of ten and fifteen years, and four at sixteen years of age.
Chrostek also reported a case in a girl of eighteen who had a
chronic ulcer that dated from her fourth year. In four cases
the age was not given.

Gastric ulcer predominates in the female, in childhood as in
later periods of life. In these cases thirteen were in males;
twenty-seven in females, and in twelve the sex was not given.

CAUSES.

I. There may be erosions caused by slight injuries or defects
in the epithelium of the mucous membrane of the stomach,
which under normal conditions heal promptly, but when there
is hyperacidity, the healing is hindered. 2. There may be
hemorrhagic extravasations, due to passive hyperaemia, due to
an uncompensated valvular heart lesion or to a dilated heart
complicating chronic pulmonary disease. Or they may be

♦ Read before the Chicago Pediatric Society, December 21, 1909.

o34



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BOWES : GASTRIC ULCER IN CHILDHOOD. 535

found in the nutritional and blood diseases, as scurvy, anemia,
chlorosis, purpura, leukemia, hemophilia, and jaundice. Anemia
and chlorosis not only predispose to ulcer, but prevent the healing.
According to the experiments of Quincke and Daetwyler, hy-
peracidity is frequent in chlorosis. 3. Hyperacidity is a large
factor in the prevention of healing. Fischer says, "If an excess
of hydrochloric acid is found in addition to the subjective
symptoms of pain, the diagnosis of gastric ulcer is positive.*'

According to C. Mansell Moullin, an excess of free hydrochloric
acid is present at one time or another in three-fourths of all
cases. Nothnagel's "Encyclopedia of Practical Medicine*' says:
'*It is generally recognized, as a rule, present in ulcer of the
stomach. Some authors are undecided whether or not hyper-
chlorhydria is the cause or effect of the ulcer; I am of the opinion
that hyperchlorhydria is neither the cause nor effect of ulcer.
The relationship must be interpreted as follows: If hyperchlor-
hydria is present, much less favorable conditions for the repair
of the injured mucous membrane of the stomach are given than
if the acidity of the stomach is normal.**

There is, normally, about one-fourth of i per cent, of free
hydrochloric acid in the gastric juice in infants. Hyperchlor-
hydria and hyperacidity are extremely rare in infants and young
children, but are present in the majority of cases of gastric ulcer
in older children and adults.

4. Gastric ulcer may be of infectious origin as when it is a
complication in tuberculosis, measles, typhoid fever, pneumonia,
noma, diphtheria and empyema.

5. Ebstein reports the occurrence together of gastric ulcer and
trichinosis. The patient was a young girl who had eaten large
quantities of meat containing trichinae. The autopsy revealed
the presence of five round ulcers in the pyloric region of the
stomach.

6. The ulcer may be the result of a thrombus or embolus.
Emboli consisting of masses of bacteria closing up the smallest
vessels of the mucosa (Adler). "Thrombosis of the umbilical
vein and of its small ramifactions and local embolisms in the wall
of the stomach, some of which depend on congenital diseases of
the heart" (A. Jacobi).

7. Follicular ulcer is caused by irritation of one or more in-
flamed lymphoid follicles in the mucous membrane of the stom-
ach, followed by enlargement, the breaking down of the follicles
leaving a superficial erosion. Probably the majority of these



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536 BOWES : gastric ulcer in childhood.

eroded follicles heal promptly, but in case the irritation con-
tinues one or more erosions may persist, enlarge, and form an
ulcer. Therefore there may be one or more ulcers at the same
time, or fresh ones may develop at intervals, giving rise to recur-
rent ulcer. In these cases the patient may feel perfectly well
for months at a time and then suddenly all the symptoms return.
These cases are not chronic, but recurrent acute ulcers.

8. True peptic ulcer may be an advanced stage of follicular
ulcer. The latter being acted upon by the gastric juice and
producing the true peptic ulcer. Ewald (Deutsche Klinik, p.
459) supports this view, and Gerhardt (Vtrchow's Archiv, Band
cxxvii, p. 85) furnishes examples of erosions changed into true
peptic ulcers. Erosions and ulcers are often found together.

Symptoms. — ^Pain is the most common symptom found. It
may be caused by oversecretion, overdistention of the stomach,
by undue peristalsis, or by pressure. The pain and tenderness
are either in the median line or slightly to the left, below the
ensiform. In older children there may be shooting pain from
front to back, located between the ninth and tenth dorsal verte-
brae. Pain may be caused by cold. It may be due to adhesions.
It has been proven by cutting, pinching with the artery forceps,
and burning with the actual cautery, without the patients*
feeling it, that the lining of the stomach has no sensation. There-
fore, the cause must be something which is not always present, as
we do not always have pain. So, according to MouUin, "the
real cause is the dragging of the stomach upon that portion of
the parietal peritoneum which lines the undersurface of the dia-
phragm. This, like the rest of the parietal peritoneum, and
unlike that which covers the viscera, is normally very sensitive."
According to Lennander, it owes its sensitiveness to filaments
of the cerebrospinal nerves distributed in the subserous areolar
tissue.

"If there is no absorption from the surface of the ulcer or if
the ulcer is so situated that the irritation spreading from it does
not affect the parietal peritoneum, there is no pain and the
presence of the ulcer may be unknown." This explains why
we may have ulcers rupture with no previous symptoms and
without our knowing of their presence. When the irritation
ceases, the pain ceases and the ulcer begins to heal. This ex-
plains the characteristic shooting pain from front to back in
older children and adults. Also why the pain commences im-
mediately with the taking of food, increasing with the increase



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BOWES : GASTRIC ULCER IN CHILDHOOD. 537

in peristaltic action, and stopping when the peristalsis stops after
the stomach empties its contents into the intestines. Pain is
seldom recognized in ulcer in infants, but becomes more common
as the child increases in age.

Vomiting is more common in infants and less common in older
children. It is caused mostly by hyperacidity.

Hemorrhage is next in frequency. There may be either liquid
or clotted blood in the vomitus. The liquid blood may be either
bright red or black, depending upon whether it is vomited imme-
diately after the hemorrhage or after the stomach secretions have
had time to partially digest it. We can accept it as a diagnostic
factor only after a thorough examination of the nose, throat,
mouth, esophagus, and mother's breast in case of nursing infants.
Blood may be detected in the stools by the guaiac test. The
stools are black or dark brown in color, caused by digested blood.
An examination must be made for rectal polypi, varicosities, or
erosions of the anus. But in these conditions the blood is un-
digested. There may be no hemorrhage or there may be blood
in both vomitus and stool or in either without its being present
in the other.

Fever may be present. But when present it usually indicates
a complication or septic process. It has been noted in a consider-
able number of cases, even running as high as io6°. Cutler
reports a temperature of 102° in a girl of six years of age and loi**
in a child of eight years of age. Constipation is a very common
condition.

Prognosis. — ^Ulcer of the stomach is usually fatal in infants,
but the mortality decreases as the child increases in years.

Deaths from ulcer of the stomach in New York City for the
ten years from 1886 to 1896 by age are as follows: Under one
year, seven; one and under five, six; five and under ten, six; ten
and under fifteen, three,' making a total of twenty-two.

Diagnosis. — ^In making a diagnosis of gastic ulcer in children
we have to take into consideration the general findings in the case.
If there is the characteristic pain and tenderness, vomiting with
hyperacidity, we are justified in making the diagnosis. If blood
is present in vomitus or stool also, the diagnosis is certain, provid-
ing the bleeding could not possibly be from nose, mouth, throat,
esophagus, or, in case of infants, swallowed in nursing.

Treatment. — Owing to the fact that all the wounds of the
stomach tend to heal promptly even where the entire thickness
of the wall is involved, and even where an ulcer is excised,



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538 BOWES : gastric ulcer in childhood.

except when the patient is absolutely exhausted by hemorrhage
or starvation, the failure of an ulcer to heal must be in connection
with the ulcer and in the process of digestion. That is to say, the
irritation w hich food causes by increasing peristalsis and acidity.
Therefore our treatment must follow along these lines, namely,
to give no food by mouth and neutralize the hyperacidity. The
patient should be kept in bed. In case of pain enough morphine
must be given to get relief.

In case of hemorrhage an ice bag to the abdomen has been
advised, but as cold tends to increase peristalsis it would seem
that this measure would tend to increase both pain and hemor-
rhage. Iron is indicated in anemic patients and chlorotic girls.

Feeding should be commenced very slowly after the acute
symptoms have subsided, commencing with milk eaten with a
spoon to avoid coagulating into a large mass.

The giving of solid food must be added very carefully as, in
my case, the eating of a very small piece of toast caused a
severe hemorrhage, and' three tablespoonfuls of eggnog caused
intense pain.

For the neutralizing of the acidity the alkalies and some form
of bismuth are required. The subnitrate is good, but the sub-
carbonate is less irritating and hence is better. As constipation
is so common, it is better to avoid the drugs which increase
this condition when possible.

In chronic cases eighth- to quarter-grain doses of silver nitrate,
in pill form, are of great benfit.

Some mention should be made of the advisability of attempting
rectal feeding in these cases. In infants and young children
this would be extremely difficult or impossible owing to the
inability to obtain the cooperation of the patient. In certain
cases in children over ten it might be feasible.

REPORT OF CASE.

The patient w-as a girl eight years and nine months of age,
who had always lived in the good surroundings and conditions
of a farm.

The family history is negative. The father and mother, one
brother, and three sisters, all in robust health.

The birth of the child was normal. She was taken sick at
three weeks of age with bronchopneumonia and never was quite
well. She had several attacks of follicular tonsillitis, scarlet
fever and slight attacks of palpitation of heart. During the first
week of her illness she complained of malaise and nausea, vomited



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BOWES: GASTRIC ULCER IN CHILDHOOD. 539

once, complained of a sharp pain especially after taking any
thing cold, as ice cream. Bowels constipated.

On the night of July 31 the patient was suddenly taken sick
with sharp shooting pain in the epigastric region and vomited
once. The vomitus was highly acid and contained black liquid
blood and a large clot.

The pulse ran from 100 to no and temperature 100 to loi .5°
for one week. The child was anemic and poorly nourished.
The mouth was red and inflamed. Tongue was slightly swollen,
and epithelial desquamation was present. The tonsils were large
and red. The throat red. The mouth was acid in reaction.
The lungs were negative. The heart was slightly hypertrophied
and a mitral regurgitant murmur present.

There was an area of tenderness about the size of a silver
dollar slightly to the left of the midline in the epigastric region.
The abdomen was otherwise negative.

The urine was acid. No albumin and no sugar present.

The pain disappeared on August 7, the eighth day after the
sudden attack. And there was blood in the stools until August
9, two days later or the tenth day after the acute attack. There
was no tenderness after August 1 1 .

The pain was controlled by morphine.

The alkalies were given to neutralize the acidity.

Although four months have passed, there has been no recur-
rence.

BIBLIOGRAPHY.

Adler. Amer. Jour, of Medical Sciences, Jan., 1907.
Ewald. Deutsche Klinik, p. 459.
Fischer. Diseases of Children.
Gerhardt. Virchow's Archiv., Band cxxvii, p. 85.
Holt. The Diseases of Infancy and Childhood.
Jacobi. New York Medical Journal y Oct. 30, 1909.
Koplik. Diseases of Infancy and Childhood.
Moullin. The Surgical Treatment of Ulcer of the Stomach.
Nothnagel. Diseases of the Stomach.
Osier. Practice of Medicine.

Kaundler and Schlossmann. The Diseases of Children.
Sajou's Analytical Cyclopedia of Practical Medicine.
Stowell. Medical Record, July 8, 1905.
Van Valzah and Nisbet. Diseases of the Stomach.
6031 Circle Avenue.



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540 meister: vaginitis.



VAGINITIS.*

BY

WILLIAM BERTRAM MEISTER, M. D.,

Attending Pediatrist to Polhemus Memorial Clinic; Attending Podiatrist to the Brooklyn
Home for Consumptives. Etc.

Vaginitis is a catarrhal inflammation of the mucous membrane
of the vagina, characterized chiefly by a mucopurulent discharge
and a tendency, in older children, to invade the mucous mem-
branes of the urethra, the bladder, the uterus and the Fallopian
tubes, and even the peritoneum.

It may be divided into three classes, according to the etiology;
simple, specific (or gonorrheal), and diphtheritic. The latter,
because of its rarity, its easy diagnosis, and the specificity of its
treatment, may be dismissed.

Etiology, — Simple vaginitis may occur during infancy, but is
usually seen in those over two years of age. Those whose resistance
has been diminished by malnutrition, anemia, and acute infec-
tious diseases are frequently victims. It is often met with during
the course of measles and varicella. Traumatism from the
introduction of foreign bodies, masturbation, and attempted
rape may cause simple vaginitis. The great contributory
cause is uncleanliness: pin -worms and bacilli coli communis make
the trip from rectum to vagina by way of the soiled diaper.
Scabies may be mentioned as another not infrequent cause.

Gonorrheal vaginitis must primarily be laid at the door of the
diplococcus of Neisser. Of perhaps greater interest than the
gonococcus in this connection, however, is its mode of convey-
ance. Institutions of high and low degree, boarding schools,
hospitals, asylums, etc., seem to be the happy hunting-ground
of this infection. Holt found, in a routine examination of the
vaginal discharges from the inmates of various institutions,
from 2 to ID per cent, positive at times when specific vaginitis was
not considered to be epidemic.

Epidemics are frequent occurrences, and are detected easily
enough when trained attendants and physicians are parts of the
institutions. In institutions and boarding schools without medi-

♦ Read before the Section on Pediatrics, Kings County Medical Society,
December 22, 1909.



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meister: vaginitis. 541

cal supervision, in out-patient and dispensary practice, and in
private families gonorrheal vaginitis is perhaps more common
but less under control, and therefore relatively more dangerous.

In an institution, only a primary case is necessary. A little
carelessness will do the rest. And when once an epidemic has
begun, only the strictest hygiene will prevent its rapid spread.
The commonest fomites are napkins, towels, wash-cloths, under-
clothing, bed linen, rectal syringes (carelessly inserted), thermom-
eters, bath-tubs, bath-water, and the hands of nurse or attend-
ant. In private families, in addition to the above-mentioned
factors, direct contact with an infected mother or nurse and rape
must be considered. One very plausible mode of infection seems
to have been generally overlooked. Most of us take the pre-
caution to instill nitrate of silver into the eyelids of the newly
born as a routine measure, because of the possibility of a future
gonorrheal ophthalmia. Granting that ophthalmia may be con-
tracted during delivery, it requires no great stretch of the
imagination to presume that vaginitis too may be contracted
en route through an infected birth canal.

Pathology. — The pathological changes in both forms are those
of a simple catarrhal inflammation. The mucous membrane is
at first red, swollen, and dry. The papillae project as a result
of cell infiltration, and give to the involved surface a granular
appearance. Later, local secretion is abnormally increased, and
may be mucoid, muco-purulent or purulent; it is usually foul-
smelling. The tops of the papillae are exfoliated and the surface
becomes raw and reddened ; these raw surfaces appear as localized
spots; in long-standing cases they become cicatrized and cause
different degrees of atresia. The labia and the inner sides of
the thighs, in neglected cases, are excoriated from the irritating
discharge.

Symptoms, — In both types of the disease, the symptoms are
similar and relatively few in number. Both begin as a subacute
inflammation. There may be a rise in temperature of one or two
degrees and some lassitude at the onset. These are the only
constitutional symptoms in uncomplicated cases. There is
rarely any pain or discomfort in mild cases. In severe cases
some pain and scalding during urination may be complained of,
especially in the simple type. If urination be painful or frequent
in the gonorrheal type, urethritis probably exists. In many
cases the only symptom is the discharge. This in both types of
the disease is at first thin and scanty; later, copious, thick,



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542 meister: vaginitis.

greenish-yellow and very ill-smelling. It may contain traces
of blood from the excoriated patches of mucous membrane.

Its microscopical characteristics are better considered under
diagnosis. In older girls (those over ten) the discharge forms
thick yellow crusts in the labial fissure.

Complications. — ^In young children with gonorrheal vaginitis
and in all children with simple vaginitis, the complications are
usually few. There may be vulvitis, dermatitis of the inner sides
of the thighs, and enlargement of the inguinal glands. In-
volvement of the urethra and bladder are seldom seen. But in
older children with the gonorrheal type, the complications may be
many and are much more destructive than the primary vaginitis.
Conjunctivitis is probably the most frequent one because of the
careless manner in which young children transfer their fingers
from one part to another.

Inguinal adenitis and urethritis are very common; inflam-
mation of the bladder a little less so. Endometritis, salpingitis
and peritonitis occur frequently enough to warrant the same
care in diagnosis and treatment in children as is exercised for
adults. Proctitis, endo- and pericarditis and arthritis are
occasionally seen in the course of a specific vaginitis.

There should be no sequelae in a thoroughly cured case. The
only possible one is a partial atresia vaginae in a case which
came under treatment late in the disease.

Diagnosis, — ^The diagnosis of vaginitis itself is a very simple
matter, but the diagnosis of the kind is more complex, and
upon it depends so much that it behooves one to be most careful.
If, in a given case, the history points to masturbation, if the
pin-worm can be demonstrated, if a foreign body is located, etc.,
the natural conclusion arrived at is that here is a simple vaginitis.
But is it fair to assume so much? Is it not possible and even
probable that the gonococcus is the chief etiological factor, and
that the others are only incidental?

A bacterial examination is imperative in every case, and,
unfortunately, it can only help us in one direction. If gonococci
can be demonstrated, then we may be certain that we have to
deal with a specific vaginitis, but, as in tuberculosis, their absence
proves nothing. Under the microscope, the gonorrheal dis-
charge is seen to contain large numbers of diplococci, which are
generally the only bacteria present, and if found in the pus
cells they are considered diagnostic. Stained by Gram's
method, they are distinguished from other diplococci which



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meister: vaginitis. 543

may be present. If available, the services of a trained bacteri-
ologist should be enlisted to diagnosticate the gonococci by
means of their cultural characteristics. So much for a positive



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 55 of 109)