of Rhodes. Spurious works Andronicus.

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

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have had what I consider good results. The severity of the
whoop always lessens and the period is diminished to two or
three weeks.

In closing I wish to say that, due to the form of treatment,
vomiting was not a distressing symptom in the majority of
cases, consequently I have had very little trouble with the diet.

REFERENCES.

Griffiths on "Diseases of Children" in the Am. Text-book.

Rotch. Pediatrics.

Holt. Diseases of Infancy and Childhood.

Kerley. Treatment of Diseases of Children.

International Clinics, Vol. i, 17th Series.

Anders. Practice of Medicine.
514 Ninth Street.



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TRANSACTIONS OF THE CHICAGO PEDIATRIC SOCIETY. 553



TRANSACTIONS OF THE CHICAGO
PEDIATRIC SOCIETY.



Meeting of December 21, 1909.
The President, I. A. Abt, M. D., in the Chair.
Dr. a. C. Soper presented a case of

PROGRESSIVE MUSCULAR ATROPHY.

This boy, eleven years old, was admitted to the Chicago Half
Orphan Asylum eighteen months ago, physical examination
showing nothing abnormal. Less than a year ago there was
noted a great difficulty in walking up stairs; this has gradually
increased, together with a progressive weakness in practically
all his muscles. To-day he cannot rise from a sitting position
on the floor without ** climbing up his legs," first getting on all
fours. He has a [waddling gait, and the slightest opposition to
the use of his various muscles prevents their use. Some ** lordo-
sis" is present, and the infraspinati and calf muscles are slightly
hypertrophied and feel hard and rigid to the touch. The elec-
trical reactions are all normal, though weak, and the reflexes are
the same. There have been no fibrillary twitchings, and the
boy's mentality is apparently normal. He walks to school, a
block away from the Orphanage.

It seems probable that the muscles of the shoulder-group were
involved before the others, but escaped attention; when lifting
him up with one's hands under his shoulders he seems to **slip
through" one's hands.

His family history is that his mother's two brothers and a
sixteen-year-old brother of the patient died of the same disease.
History otherwise negative. No previous diseases.

I would classify this case as one of muscular pseudohyper-
trophy, of the general class of progressive muscular atrophy.

Dr. J. M. DoDSON presented a case of

ARTHRITIS OF INFECTIVE ORIGIN.*

Dr. L. M. Bowes read a paper on

GASTRIC ULCER IN CHILDHOOD.f
DISCUSSION.

Dr. H. F. Helmholz. — It is almost impossible to make a
diagnosis of duodenal ulcer unless there is vomiting of blood or
the passage of blood in the stools. In all the cases I have seen
there was neither pain nor tenderness, even those cases that

* Report to follow in near future.
t See original article, page 534.



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554 TRANSACTIONS OF THE

were complicated by peritonitis. The children were ex-
tremely marantic and had no temperature, no discomfort, and
no spasticity of the abdominal muscles. So that it is very
difficult in many of these cases to make a diagnosis unless the
above-named pathognomonic symptoms are present.

Dr. Abt. — ^Does duodenal ulcer give rise to the same symp-
toms as pyloric stenosis?

Dr. Helmholz. — ^In one case reported by Freund all the
symptoms of pyloric stenosis were present, but at the autopsy
there was found not a stenosis of the pylorus, but a large perfor-
ating ulcer of the duodenum. The spastic condition of the
pylorus was referred to the presence of the ulcer. In a number
of my cases the ulcers were immediately behind the pylorus,
and did not give rise to any symptoms indicating stenosis, so
that I am rather inclined to think that the ulcer was an acciden-
tal complication rather than one to which the spastic condition
of the pylorus was due.

Dr. J. H. Hess. — ^Dr. Bowes stated that there is a contrain-
dication to the use of the ice-bag because of increased peristalsis,
and yet we all use the ice-bag in cases of hemorrhage in typhoid,
hoping thereby to allay peristalsis. It seems to me that in such
cases I have secured the desired result, although theoretically
stimulation should be secured. Ice when ^iken into the
mouth stimulates peristalsis, but I believe that the panniculus
adiposus which lies between the ice-bag and the bowel has
much to do in allaying the irritation. My experience with it
has been very satisfactory.

Dr. Bowes (closing). — In the cases in which I used the ice-
bag it seemed to me that peristalsis was increased. Of course,
that may have been due to the poor condition of the child. In
the case I reported the child took a little ice cream and very
distressing symptoms followed.



TRANSACTIONS OF THE NEW YORK
ACADEMY OF MEDICINE.



SECTION ON PEDIATRICS.

Meeting of December 9, 1909.
Eli Long, M. D., in the Chair,
Dr. Isidore Goldstein presented cases of
amaurotic family idiocy.

Case I. — ^This patient was a female, aged one year, of Jewish
parents. Family history was negative. There was no relation-
ship between the parents. The patient was the first child and was
breast-fed. When six months of age the child could sit, and raise
itself from the supine to the sitting position without support.
Shortly after, the mother noticed that the child was no longer able



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NEW YORK ACADEMY OF MEDICINE. 555

to hold the head up, sit, or hold firmly in its hand any object
given her. She was constipated; she laughed aloud without
any apparent cause and was easily frightened. The tongue
always protruded and the child no longer acted as bright as
formerly. The hands were closed most of the time. Upon
examination the anterior fontanelle was found to be almost
closed. The child had a silly, vacant look. There were ir-
regtdar twitchings of the facial muscles. There was a tendency
to keep the eyes turned upward. Pupils were normal. The
fundi showed the characteristic grayish-white patch in the
mactdar region, in the center of which was a brownish-red,
sharply defined oval spot. There was optic atrophy. The
arms were held outstretched and stiff. The tips of the thumb
and index finger were usually in contact. The legs were usually
extended, spastic but not flexed. The reflexes were exaggerated.
There was no Kernig, Babinski, or Oppenheim sign. The Wasser-
man reaction in both mother and child was negative.

Case II. — ^This patient was a female, sixteen months old, of
Jewish parents. She was the tenth child and three of them were
amaurotic, one of them being a twin. The family history was
negative. The child was breast-fed. She was able to support
her head at six months. She never sat or stood without support.
The child was easily frightened. She did not grasp objects of
her own accord. She did not recognize her parents. She had
difficulty in swallowing. She was a very fat child, but now was
gradually growing thin and weak. The anterior fontanelle
was closed. The fundi showed the characteristic spot. The
child was stupid, and had a vacant, listless expression. There
were chewing movements and difiictdty in swallowing. The
spine showed a kyphosis and a right lateral lordosis. The upper
extremities were spastic. The tips of the thumb and index
fingers were in contact. The lower extremities were spastic.
The reflexes were exaggerated. There was no Kernig or Babinski
sign. The Wasserman reaction was negative in both mother
and child.

Case III. — This patient was fourteen months old, the second
child of Jewish parents. The family history was negative, except
for a history of consanguinity in mother and father. The child
was breast-fed. The duration of illness was ten months. The
child could not sit, was hardly able to support the head, did
not stand or walk. The eyes followed the light. The child cried
a great deal, and laughed frequently without apparent cause.
It was constipated, was weak and was growing very thin. It had
always been fat. The head was large and square. The anterior
fontanelle was open and pulsating. The fundi showed the
characteristic spot and optic atrophy was present. The saliva
dribbled, there was a smacking of the lips and chewing move-
ments. There was marked pronation of forearm; tips of the
thumb and index finger were in contact. The reflexes were
exaggerated.



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556 TRANSACTIONS OF THE



CONGENITAL MUSCULAR DYSTROPHY.

Dr. Kaufman Schlivek presented a female, aged two years
and three months. The famUy history was negative. The
present history dated from birth. The child had never been
able to flex the elbows or the knees, and the feet had always been
turned in. The child did not move the arms until she was six
months old ; then she began to raise them slightly. She moved
the legs from birth. During the past few months she cotdd
stand with support. She was bright and well nourished.
There were no signs of rickets. Upon examination the upper
extremities were held in a position of Erb's paralysis, complete
extension at the elbows and rotated inward. The anterior part
of the arm was flat, soft, and flabby. The posterior part was
better developed. The anterior surface of the humerus was
readily felt. The shoulders were fairly well developed. The
forearms were well developed. The child could raise the right
arm to almost 90 degrees and the left a little higher. Active and
passive motion (flexion) of the right elbow was limited to 30
degrees; the left elbow to 60 degrees. Pronation and supination
of the forearms were good. Motion in the fingers, wrists, and
hands was normal. The muscles of the thighs and legs were soft
and flabby. Passive motion at the hips was not limited. Flex-
ion at the knees was limited to 45 degrees. There was a marked
lateral motion in the knees, especially inward. Lateral motion
of the right knee was greater. There was no marked creaking
in the knees. The feet were in the position of talipes equinus
varus. The back muscles were well developed. The entire
skeleton had been a:-rayed and the only condition worthy of note
was that the articular surfaces of the elbows and knees were in
closer proximity than normal. The bones of the ankle were
undeveloped. The mental condition of the child was excellent.

To determine the diagnosis of this case one had to consider
the bony, nervous, and muscular systems. The bony system
could be eliminated, for the skiagram showed no obstruction
to motion. The nervous system could be eliminated as well,
for no lesion of it could giwQ such a peculiar distribution
of the symptoms. There were no trophic disturbances, the
sensations were normal and there was no reaction of degen-
eration. The only conditions referable to the muscles were
Oppenheim's disease, Thomsen's disease, and congenital mus-
cular dystrophy. In the first there was a general flaccidity of
the skeletal muscles excepting those supplied by the cranial
nerves. It varied in degree; in extreme cases the limbs were
mere useless appendages, really but flail joints. The muscles
were soft and atonic, reacted feebly or not at all to electricity.
In the second there was stiffness accompanying the beginning
of every muscular movement, which passed off on continuance
of the act and again accompanied the termination of the move-
ment. The myotonic reaction to electricity was present. The



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NEW YORK ACADEMY OF MEDICINE. 557

only other conditon to be considered was muscular dystrophy;
and from the symptoms described, the case corresponded to the
latter diagnosis.

DISCUSSION.

Dr. Henry W. Frauenthal said that the case presented by
Dr. Schlivek, which had been under his observation at the Hospital
for Deformities and Joint Diseases, where he had corrected the
club-feet, was possibly a case of muscular dystrophy, as it corre-
sponded with the literature on the subject. The doctor thought
that there was an absence of cartilage which caused the limited
motion, and Dr. Frauenthal had massage given and passive
movements, with the approval of Dr. Schlivek, and the range of
motion during the past few weeks had materially increased.
Dr. Frauenthal had presented a similar case before the Or-
thopedic Section; this child was seven months old and several
joints were involved.

Dr. Alfred F. Hess did not think the diagnosis in the case
presented by Dr. Schlivek was at all clear. The muscles ap-
peared to be in good condition. The rc-ray plate showed the
articular surfaces of the bones close together. The pathological
condition was a partial or complete absence of the interarticular
cartilege; sometimes there was an exostosis of the bones. The
condition was really a well-defined one, and was not always
hereditary. It was a separate disease, and he did not think
they should class it with the dystrophies.

Dr. Kaufman Schlivek said that the only way to make an
absolutely positive diagnosis of the case he presented was to
take a section of the muscle which, of course, was prohibitive.
There was no limitation of passive motion at the shoulder; this
joint was normal and still the child could not raise the arm abov^
90 degrees. From this demonstration they must infer that there
was muscular weakness. Last spring the patient was shown
at Dr. A. Jacobi's home, and a tentative diagnosis was made of
congenital muscular dystrophy. Dr. George W. Jacoby con-
firmed this diagnosis.

CEREBRAL HEMORRHAGE.

Dr. Henry W. Frauenthal presented a boy who had had an
attack of anterior poliomyelitis in August, 1907; his extremities
and face were involved. At the present time his right arm and
right leg were still involved, as well as the left side of his face.
He presented this case to compare it with a child similarly
affected, and whose father died of cerebral hemorrhage at the
age of twenty-six. The child was eighteen months old, and
had a paralysis involving the right side of the face, left arm and
leg, but his paralysis was due to a cerebral hemorrhage, resulting
most likely from syphilis, as the child still had a congenital
eruption with demarcations on the palms of the hands, soles of
the feet, and also on both legs.



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558 TRANSACTIONS OF THE

Dr. Frauenthal showed photographs of twenty cases of facial
involvement, associated with extremity involvement; these
cases were seen during the epidemic of infantile paralysis in
1907. He said he had seen nearly forty such cases, but had not
had them all photographed, as the paralysis could not be well
brought out, in some of the cases, on a picture.

** protective" action of the colloids in milk with some
ultramicroscopic observations.

Jerome Alexander, M. Sc., and Dr. Jesse G. M. Bullowa
presented this paper. If one examined the suspension of any
fine powder in the ordinary microscope, the individual particles
exhibited a slight trembling motion known as the "Brownian
movement." Although this movement was more marked in
the case of the smaller particles, it was not sufficient to keep
them afloat and they gradually sank out of solution. With the
ultramicroscope it had been demonstrated that with increasing
fineness of subdivision the motion of the subdivided particles
continued to increase in speed and amplitude, until it became
so vigorous and extensive that the particles no longer settled
but remained permanently afloat; that is, they had a colloidal
solution. If the subdivision proceeded still further they gradu-
ally passed into the sphere of true or crystalloidal solutions,
wherein the particles of the dissolved substances were reduced to
molecular dimension or even split up into ions. The colloidal
condition, therefore, was consequent upon an extremely fine
state of subdivision, and practically any substance could be con-
verted into or produced in this condition. Some colloids, such
as gelatine and gum arabic, were quite sensitive to electrolytes,
and readily redissolved after desiccation; others, such as pure
colloidal metals, were readily coagulated by electrolytes and did
not redissolve after desiccation. Zsigmondy had expressed this
difference by calling the former reversible and the latter irre-
versible colloids. The presentation of a diagram taken from
Zsigmondy's book served to elucidate this statement. A most
interesting property of rever^ble colloids was that they could
protect irreversible colloids from coagulation and permitted
them to redissolve after desiccation. As little as 1/10,000 of
I per cent, of gelatine produced this effect in a solution of col-
loidal gold. Such action was known as ''protection" and a
reversible colloid exhibiting it was known as a "protective
colloid.'* This power of protection was specific, and a reversible
colloid might protect one substance and not another.

Milk was then considered in the light of the principles of col-
loid chemistry. Many analyses of milk had included the casein
and albumen under the omnibus title of "proteids" thereby
obscuring a most important and vital fact — the ration of casein
to albumen. The importance of this fact at once became evi-
dent when it was stated that casein was an irreversible coagulat-
ing colloid, whereas albumen was a reversible or protective col-



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NEW YORK ACADEMY OF MEDICINE. 559

loid. Mother's milk was scarcely coagulated by acid or rennin,
and by increasing the amount of protection in cows* milk it
might be made to act in like manner, which was easily proven
by adding a small quantity of gelatine, gum arabic, or other
protective colloid. Cow's milk thus treated was not as well or
readily curded by acid or rennin. Besides studying the macro-
scopic effect of protection on the casein they made certain obser-
vations with the ultramicroscope which they reported. These
observations seemed to show the importance of the subdivided
condition of the casein of milk. The influence of ** protection"
was not, however, confined to the casein, but probably was im-
portant in maintaining the emulsion of the fat. The following
conclusions were presented :

1. The casein of milk is an irreversible, or coagulating, or
unstable colloid, which is protected by lactalbumen, a reversible,
or stable colloid.

2. In the modification of cows' milk for infant-feeding, it is
necessary not only to consider the per cent, of '* total proteids,"
fat, etc., present, but to see that the casein is adequately pro-
tected. Lest they be misunderstood to be only restating the
principle expressed in the doctrine of "split proteids" they em-
phasized that the casein existed in cows' milk in an already
formed higher degree of colloidal aggregation.

3. Bald chemical analysis, without taking into consideration
the principle of colloidal protectives, is an insufficient criterion
for the actual digestibility or availability of food.

THE TREATMENT OF INTESTINAL INDIGESTION IN CHILDREN ON
THE EXAMINATION OF THE STOOLS AND CALORIC VALUES.

Dr. John Lovett Morse, of Boston, and Dr. Fritz B. Talbot,
of Boston, presented this communication. It was apparently
taken for granted that the metabolism of children was essentially
the same as that of adults. It was generally believed that young
children required a relatively large proportion of carbohydrates
in their food and that they needed proportionately more proteids
than adults. None of these points, however, had been scien-
tifically proved. It seemed to the writers that if the stools of
children suffering from disturbances of digestion, especially of
the intestinal type, were examined in order to determine what
constituents of the food were not being utilized and the diet reg-
ulated on the basis of these findings, due regard being paid
to caloric needs, much better results could be obtained than by
the usual empirical methods. Their experience led them to
believe that comparatively simple tests were sufficient to give
results accurate enough to form the basis for satisfactory treat-
ment. They had also found that it was a very simple matter
to calculate the caloric value of the food and to regulate the
proportions of fat, carbohydrates, and proteids. They also found
that it was easier to control the diet of a child than that of an



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560 TRANSACTIONS OF THE

adult and that it was at least aseasy to get the cooperation of the
child in carrying out the diet as it was to get that of an adult.

With regard to the caloric needs of children, it was probably
not far from the truth to say that the average child ot four years
needed about 1,200 calories, or 70 calories per kilo in twenty-four
hours; the average child of eight years, 1,400 calories, or 60 cal-
ories per kilo in twenty-four hours; and the average child oi twelve
years, 1,600 calories, or 50 calories per kilo in twenty-four hours.
There was no objection to giving large amounts of proteids in
order to meet the caloric needs when there were disturbances
in the digestion of fats or carbohydrates. On general principles,
however, it was wiser to keep the proteids down somewhere
near the average need, because the metabolism of the proteids
required more energy and the products of proteid metab-
olism were more difficult of elimination than were those of
of the fats and carbohydrates. An excess of proteids, therefore,
required an unnecessary expenditure of energy and was
consequently not economical. In disturbances of digestion fat
might be substituted for carbohydrates and carbohydrates for
fat with great advantage, provided the total caloric value of
the food was kept up. The fats might be entirely replaced by
carbohydrates over considerable periods of time without doing
any harm. There was a certain amount of risk in replacing
the carbohydrates entirely by fats because of the dangers of
developing acid intoxication. A table giving the coloric value
and composition of the various foods commonly given to children
suflfering from disturbances of digestion was presented. With
it they found it an easy matter to plan out a diet for a child to
give not only the proper number of calories but also the desired
relations between the different food elements.

A child's stool was normally homogeneous; lumpy and mushy
stools were pathological. The reaction was weakly alkaline,
amphoteric, or neutral. A very strong alkaline reaction suggested
protein putrefaction. A strong acid reaction suggested disturb-
ances in the digestion of fat. The microscopic examination
showed a few remains of a vegetable nature, single yellow
masii"*' a few muscle fibers, a few crystals, rare starch granules,
and microbes. When acetic acid was added, a few drops of
fatty acid were seen in each field after heating.

The stools that deserved special mention were the fatty, the
stools of carbohydrate indigestion, and the catarrhal stools.
The fatty stools were gray or white in color, dry or of clay-like or
creamy consistency, acid in reaction, and of a rancid odor.
The carbohydrate stools were brown or golden-yellow in color,
salve-like in consistency, acid in reaction, acid or sour in odor.
The catarrhal stools showed an excess of mucus. It was otten
associated with protein putrefaction and a foul odor. The
character and the quantity of the food taken in the twenty-
four hours was known in every instance, so that for all practical
purposes the children had had a test diet. The methods of



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NEW YORK ACADEMY OF MEDICINE. 561

examination employed are essentially those described by Schmidt
in his work. The form, coherency, consistency, color, and odor,
and the presence or absence of extraneous matters were noted
in the macroscopical examination. The microscopical exami-
nation was made with a low-power objective and later with a No.
7 objective. Three slides were examined; the first contained
very thin crushed out feces which was examined in the fresh
condition. Another was stained with Lugol's solution and ex-
amined under the cover for starch. The third was stained with
a saturated alcoholic solution of Sudan III. In the first speci-
men an excess of undigested muscle fiber, connective tissue or
vegetable fiber could be studied, and pathological elements
differentiated. A preliminary estimation of the amount of
neutral fat, fatty acids, soaps, and starches could also be made.
Under the cover-glass the starch granules would stain blue or
violet and certain microbes would stain blue. There were practi-
cally no unchanged starch granules in a normal stool. An excess
was always pathological. Under the third cover-glass neutral
fat drops and fatty crystals stained red. Any increase in the
amount of fat after the addition of acetic acid indicated the
presence of a corresponding amount of soaps. The recitation of



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 57 of 109)