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illustrated cases closed the paper.

DISCUSSION.

Dr. Thomas S. Southworth said that it seemed to him as
though something had been now produced which all desired,
namely, a means of securing an interpretation of the stools
which could be taught and placed in the text-books and read and
understood by all; heretofore the students had to be taught to
make their interpretation of stools by actual exhibition of the
different forms of abnormality. What had been presented was
perhaps what they had needed most in order to advance success-
ful infant-feeding. Unless they could know what results they
were going to obtain from the feeding by the proper interpre-
tation of the condition of the stools, they could have no criterion
upon which to base any intelligent changes in the feeding. The
microscopical examination of the stools seemed to confirm what
they shrewdly suspected from simple inspection of the stools.
Setter's work, published four years ago, taught them to interpret
stools according to their odor, reaction, and other evidences of
fermentation with some microscopical test showing faults in the
stools and faults in the types of the individual elements in the
food. What had been presented went much further in that
it clinched the matter. By means of such an examination one
might be able to anticipate difficulties, since the microscope
might show that there was a nonassimilation of the food even
before the symptoms came strongly to the front. In listening
to the reports of the cases by Dr. Morse one was more and more
convinced that the succesrful feeding of the child or infant
meant a rationally mixed food of proper proportions. If an



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662 TRANSACTIONS OF THE

examination microscopically of the stools was made, one might
more often make such changes in the diet as would result in
benefit to the infant. The confirmatory knowledge which one
got from an examination of the stools should result in greater
success in the future feeding of chidren.

Dr. John Rowland said that Dr. Morse had done them a real
service in insisting upon an estimation of the caloric values of
foods. That was the only satisfactory and accurate way to
know the exact amount of food the child was taking. The
impression seemed to prevail among some that these caloric
methods told exactly what kind of food the child should take.
This was not so. It simply told what amount of food was suit-
able for a child in order to satisfy his caloric requirements. It
frequently happened that a child could not digest food in suffi-
cient quantities to satisfy his caloric needs; in such cases the
physician with his eyes wide open to the deficiency had to wait
until the child's digestion improved. What was found more
frequently, however, was that the caloric requirements of the
child were exceeded. It very frequently happened that a
diminution in the quantity of food was followed by very prompt
relief of symptoms and a gain in the child's weight. Almost all
the exact chemical studies in metabolism that had been made
in children had been made in infants; this of course was accounted
for by the ease with which they could obtain the twenty-
four hour specimen of feces and urine. Data upon the met-
abolism of children after the first year were very few and incom-
plete, and exact data were very greatly needed. For this reason
Dr. Rowland regretted that Dr. Talbot had not confirmed in
older children the admirable investigations he had made upon
infants.

Dr. Elias H. Bartley asked if they really could determine
the condition of the digestion of fats by this microscopical exam-
ination of the stools. If by this microscopical examination of
the stools they could determine what was going on in fat diges-
tion, that would give them a determination not before clearly
brought out. They all admitted that fat indigestion w^as certainly
a very common thing in intestinal disturbances occurring in early
childhood as well as in infancy. Dr. Bartley had noticed what
to him was a very peculiar thing, and he did not know whether
there was any clear explanation for it. In some of the cases he
had had to deal with where there was evident fat indigestion, he
had been obliged to reduce the fat in the milk down to between i
and 2 per cent, in order to give the children any sort of com-
fort; in such cases he had found that some cases would tolerate
butter if given with cereal, or given with bread or zwieback,
but, on the other hand, they would not tolerate the same amount
of fat if given in the milk. He did not know whether others had
noted this same thing or not. The only interpretation he could
give of this was that it was the cereal that broke up the butter
and made something like an emulsion in the stomach. He



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NEW YORK ACADEMY OF MEDICINE. 563

had one child under his care at present where he was obliged to
keep the fat in the milk down to about 2 per cent. If more than
that was given, it was evidenced by the putty character of the
stools, an excess of mucous excoriation of the nates, etc.

The statement had been made that it was an excess in the
quantity of food that was the foundation of the digestive troubles
rather than its quality. In general, all believed that when
they gave a fairly well balanced food, the question of quantity
was very important. And here was where the heat value of the
food came in. He said that he had adopted in his feeding, as a
minimum for children under one year of age, one gram of protein
for every pound of body-weight per day. That meant the
giving of about one ounce of milk for every pound of body-
weight per day. One could not always determine the particular
amount of protein actually absorbed by any particular baby.
To get the requirements of protein he thought they would be
furnished by giving one and a half ounces of milk per pound
weight of body per day. In practice this worked fairly well.
But some children would not obey the rule as to caloric values
when it came to fats. All these calculations for determining
the caloric value of the food of infants must be modified to
suit the baby under trial.

Dr. Fritz B. Talbot, of Boston, said that in cases of star-
vation some fat was excreted and was found in the stools.
Under normal conditions the amount of fat excreted in the
stools did not increase when food containing fat was given. On
this basis he believed that the amount of fat seen under the
microscope gave an estimate of the amount of fat in the stool.
Normally, about 20 per cent, of the dry stool was composed
of fat. There was no difficulty in recognizing an absolutely
normal or markedly pathological stool. He had made a rule
based on experience with the stools of older children, that when,
with a No. 7 objective, he found six, seven, or eight droplets in
each field and when, after the addition of glacial acetic acid
and heat, nearly the whole preparation showed fat, he called
that an excess. But there was to be taken into account the in-
dividual equation in this as in other microscopical examinations.
With regard to Dr. Bartley's two cases which he reported,
Herter and Kendall had shown in their bacteriological work on
stools that an excess of one component would change the bac-
teriological flora; therefore, it was fair to assume that the pre-
dominance of certain types of bacterial flora might cause in-
digestion. It was well known that overfeeding of protein would
cause fat indigestion, and he believed that overfeeding of fat
could cause sugar indigestion. In Dr. Bartley's second case,
the increase in the fat in the milk formula might have caused
sugar indigestion, and the products of sugar decomposition
caused the burning and irritated buttocks. Experience had
shown that the microscopical examination of the stools was a
very valuable aid in diagnosis and treatment, and he had found



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664 TRANSACTIONS OF THE NEW YORK ACADEMY OF BiEDICINE.

that it was valuable in its negative as with its positive results.
When he saw a youngster with some obscure dyspeptic upset
and examined the stools and found nothing abnormal, he felt
that it was safe to say that simple methods of treatment would
cure the indigestion.

Dr. William P. Northrup expressed his appreciation of
the work done by Dr. Morse and Dr. Talbot. Many years ago
when exact percentage methods for feeding infants were being
investigated one heard frequent remarks about the child's
stomach not being a test-tube, and that percentage feeding
might and might not meet the needs of the child. However,
practitioners had profited by these methods. A cook might
prepare an excellent dinner by adding a pinch of this ingredient,
a dash of that, and a cup of another, it might have been the
result of years of thought and she might not be able to tell the
next day what she had placed in it. Many cooks provide ex-
cellent dinners without their receipt books and exact methods.
Valuable after all were fixed data and exactness for the many
dinners, the many cooks, and the improvement of methods.

What had been presented to them was another exact
method of feeding infants and children by determining their
needs. It seemed to Dr. Northrup to be a very valuable con-
tribution. If one sees an indication of an excess of any one
ingredient, it certainly furnished a control. It furnished a point
of departure which was destined to be very useful in the future.

Dr. L. E. La Fetra wished to add a word of apprecia-
tion for the paper presented by Dr. Morse and Dr. Talbot.
Some points already emphasized might be still further dwelt upon,
especially that a microscopical study of the stools would help
to avoid certain errors which without it were not easy to discover.
He agreed with Dr. Morse that the stools in carbohydrate in-
digestion frequently look like normal stools, being often brown
and smooth. It was also quite common to discover that in
feeding children that were losing weight the caloric value of
the food was too high.

It had frequently been stated that the caloric method was a
method of feeding. It was not a method of feeding. It was a
method which merely told them whether they were giving too
little food to the infant. It therefore served as a measure for
any method of feeding.

Dr. John Lovett Morse, of Boston, said there were a few
things from the clinical side that he would like to refer to in
closing the discussion. He agreed entirely with Dr. Kerley
that the prolonged use of milk was often the starting-point of
indigestion in infants, but he said he could hardly agree with him
when he stated that milk was not well borne by older children
with indigestion. In proper amounts milk usually did agree
with them, although at times it was necessary to substitute
skimmed milk for whole milk. In the vast majority of the cases
of indigestion in children, this condition could be easily straight-



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REVIEW. 565

ened out by common-sense methods of feeding, and such very
careful treatment was not required. While this was true, he
personally felt safer if he knew just what to do and tried to do
it. He found that, as a rule, he knew what the condition was
from the macroscopical examination of the stools; but now and
then Dr. Talbot surprised him very much by the results of his
microscopical examination of the stools and prevented him
from falling into serious error.

What Dr. Schwarz had said in regard to the importance of
rest Dr. Morse agreed with. Rest was an important adjunct
not only in intestinal, but also in children who were run down
from any cause.

REVIEW.



Diseases of Children. By Henry Ends Tuley, M. D.,
Professor of Obstetrics, University of Louisville, Medical De-
partment; Ex-Secretary and Ex-Chairman of the Section on
Diseases of Children, American Medical Association; Secretary
Mississippi Valley Medical Association, etc., Louisville, Ky.
Octavo volume of 653 pages. Printed with clear type on
heavy calendered paper. Illustrated. Cloth, $5.00; Half
Morocco, $6.00. Southern Medical Publishing Co. No. 2427-
29 York Road, Baltimore, Md.

Dr. Tuley adds another to the constantly growing list of books
on this subject. In his own words, he states that he seeks to
reach the practitioner and student rather than the specialist.
In this aim he succeeds, since his work lies midway between a
compendium and a treatise. The various subjects are handled
directly and briefly, while the suggestions for treatment appear
chiefly limited to those measures which the author has found
effective in his daily practice. Space is given more freely to
the important subject of Infant Feeding and attention is duly
paid to the necessary measures for obtaining a pure milk supply.
This latter is natural since the author has been identified with
the movement for clean and safe milk in his State. While the
percentage system of feeding is employed and recommended,
only the bare fundamental facts are introduced into the main
text, while all complicated and divergent mathematical formulae
for producing milk modifications are wisely relegated to the
appendix where they do not confuse the student and interrupt
the continuity of the text. Newer subjects, like the serum treat-
ment of cerebrospinal meningitis and diseases such as pellagra
and uncinariasis which have recently attracted attention are
briefly but competently outlined. While the volume is unduly
bulky and the medical proof-reading of the prescriptions should
receive attention in future editions, the volume itself should be
well received, and especially in the region from which it ema-
nates, for, if we mistake not, this is the first book on the subject
written and published in the South.



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666 BRIEF OF CURRENT LITERATURE.



BRIEF OF CURRENT LITERATURE.



DISEASES OF CHILDREN.

Senun Therapy of Epidemic Cerebrospinal Meningitis. — Simon
Flexner (Jour. Amer. Med. Assn., October 30, 1909) is still ex-
tremely conservative in his estimate of the value of his anti-
meningitis serum. He calls attention to the fact that in most
of the countries in which it has been employed with such appar-
ently favorable results the epidemic was at its height or already
on the wane; but, fortunately, in France it was just beginning.
Reports covering 100 or more cases in that country show a
mortality which will probably be less than 25 [per cent, while
a smaller number treated by other methods have given a
mortality approaching 80 per [cent. Thfe writer presents a
tabulation of 712 cases in which the bacteriologic diagnosis was
made and the serum treatment used. It shows that the highest
mortality occurred in the first two years of life. But, contrary
to the rule under the older forms of treatment in which the
mortality was 90 per cent, or over, in this series it was 42 . 3 per
cent. The second age period is from two to five years, in which
the mortality was 26 . 7 per cent. The third age period embraces
children from five to ten years of age and gave the lowest mor-
tality of all, namely, 15.9 per cent. The next period extends
from ten to fifteen years and gave a mortality of 27.7 per cent.
The next period of from fifteen to twenty years showed a con-
siderable rise in mortality, equaling 32.7 per cent., and the last
period, embracing the cases of twenty years and over, gave a mor-
tality of 39.4 per cent. The average mortality in all the age
periods was 31.4 per cent. The importance of early injection
of the serum is shown by another table. The rule of the
effects of early injection is preserved in the age periods up to
the period of from fifteen to twenty years, when it disappears.
The discrepancy occurring in the two highest age periods can-
not be wholly accounted for at present. The percentage mor-
tality in the first-to-third-day period was 25.3; in the fourth-
to-seventh-day period, 27.8; and the period later than the
seventh day, 42.1.

G. Muls (La Cliniqiie, October 2, 1909) says that serotherapy
has reduced the mortality from 45 to 15 per cent, when the
treatment is applied early in the disease. He has found the
sera of Dopter and especially that of Flexner to be the most
active. They are injected directly into the spinal canal, in
quantity somewhat under the amount withdrawn. The advan-
tage of this procedure is that more poison is withdrawn, there
is lessened pressure, and the serum is less diluted. The patient
is placed with his head somewhat lower than his pelvis to allow



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BRIEP OF CURRENT LITERATURE. 567

of better diffusion of the serum. The injection should be re-
peated daily for three or four days, even when the patient im-
proves, in order to avoid recurrence. The guide to improve-
ment should be the fall of temperature. A cure is effected in
about six days under this treatment. Antidiphtheritic serum
in this disease can only be condemned.

Transmission of Acute Anterior Poliomyelitis to Monkeys.— r
An advance in the study of this disease has been made by the ex-
periments of Simon Flexner and P. A. Lewis {Jour. Amer, Med,
Assn,, November 13, December 4, 1909). Working with emulsions
in salt solution of the spinal cord of fatal cases in children and
subsequently of the monkeys injected with this, they have
shown that the virus of epidemic poliomyelitis is readily trans-
missible from man to monkeys and from monkey to monkey,
by way of the brain, the peritoneal cavity, the sciatic nerve, the
subcutaneous tissue, and the circulation, and that, however
transmitted successfully, it becomes established in the spinal
cord and medulla, where it sets up characteristic lesions which
are followed by equally characteristic effects that exhibit them-
selves as the; usual symptoms of infantile paralysis in human
beings. This experimental form of poliomyelitis in monkeys
is a severe and very often a fatal disease, and when recovery
from the disease takes place there persist residues of paralysis
which resemble the paralytic effects also persisting in human
subjects of poliomyelitis. They have shown also (Jour. Amer.
Med. Assn., December 18, 1909) by suspension in glycerin of
the comminuted cords of monkeys affected with poliomyelitis,
and by filtration through a Berkefeld filter before injection into
other monkeys, that probably the infecting agent of epidemic
poliomyelitis belongs to the class of the minute and filterable
viruses that have not thus far been demonstrated with certainty
under the microscope. The fact has been determined that the
virus of poliomyelitis can be transferred to the central nervous
system by way of the subcutaneous tissues in monkeys.

To determine whether an attack of epidemic poliomyelitis
followed by recovery will afford immunity to reinfection, the
writers (Jour. Amer. Med. Assn., January i, 19 10) have rein-
oculated several of the recovered monkeys and have noted in
some instances failure of the virus to act while causing paralysis
in the control monkeys. An attempt to modify the course of an
intracerebral inoculation by the simultaneous injection beneath
the skin of a virus altered by heating was a failure.

Treatment of the Onset of Acute Anterior Poliomyelitis. —
Feeling that an effort should be made to control this disease
before the appearance of paralysis, Le Grand Kerr (L. /. Med.
Jour., Nov., 1909) thinks that during the course of an epidemic
all cases of< indefinite illness in children under five years of age,
especially if fever, diarrhea, cough, and vomiting are present,
should be treated as positive cases of this affection. He has
employed tentatively for this purpose a hot pack, administration



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568 BRIEF OF CURRENT LITERATURE.

of water freely by mouth even if vomiting is increased thereby,
a hot enema followed by a large dose of castor oil, and rest in a
quiet and darkened room, restriction of diet, and the use of
belladonna and ergot in fuU doses.

Intensive Serotherapy in the Treatment of Severe Angina and
Diphtheritic Paralysis. — ^H. M^ry, B. Weill-Hall^, and Parturier
(Arch, de mSd, des enfants, Sept., 1909) describe their technic
in the use of antitoxin in large and repeated doses to prevent
and to cure diphtheritic paralysis and in the treatment of very
severe sore throats of diphtheritic origin. They increased the
size of the doses used during, the acute stage of the disease, and
continued them after the false membrane had fallen from the
throat. After beginning this treatment they lost no case of
malignant angina, nor did any die of paralytic syncope. No
albuminuria was caused by these large doses. Anaphylactic
symptoms result rather from small than large doses of serum.
The use of serum systematically in convalescence from these
throats will result in an absolutely preventive action.

Contagion and Semiology of Scarlatina. — ^A. Lesage (Gaz.
des Hdp.f Oct. 16, 1909) questions the necessity of quarantine
for scarlatina in the desquamative stage. He contends that
there are many arguments to show that the contagion is only
from the throat, and that the eruption is similar to the serum
rashes, an adventitious occurrence not always present, the result
of toxemia, and not a necessary part of the disease. He gives
many illustrations to show that children have been in contact
with scarlatina patients during desquamation and have not
been infected, while, on the other hand, cases in which there
was angina without eruption have communicated malignant
scarlatina. The early contagion is conveyed by the mucus from
the mouth. The author claims that when scarlatina is taken
while the communicating case is in a late stage of the disease
this is due to the germs remaining a long time in the mouth
and throat. This mucus may become dried and be carried
about with virulent germs in it. It may also be maintained
in cases of scarlatinaJ otitis. Stickler inoculated ten children
with the mucus from the throat of a patient in the eruptive
stage of the disease, and all of them took the disease, it appearing
within two days from the inoculation. By inoculation of scales
the same result has not been obtained. The scarlatinal tongue
is characteristic long before it is a strawberry tongue. Isolation
of school children should begin with those who show this tongue.
To base the diagnosis upon a symptom-like eruption, which is
inconstant, is an error. It should be based on the cycle of the
throat and tongue alone. About the fifteenth day the tongue
returns to normal; the evolutive cycle has ended. When the
tongue and throat show the characteristic color and membrane
for a longer time the disease remains contagious, being still a
culture medium. Isolation should last only during this cycle.



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BRIEF OF CURRENT LITERATURE. 569

Epidemic of Varicella. — Bruno Bosse (Arch,/. Kinderheil.,
vol. li, parts i-iv) states that although in general chickenpox
is a disease that is not accompanied with serious symptoms,
when it occurs among very young infants the results may be
serious and even fatal by reason of a mixed infection of the
secretion in the bullae with streptococci or staphylococci. He
gives the histories of eight septic cases, with four deaths, out
of thirty-seven cases occurring in a maternity hospital, all being
nursing infants or bottle babies. He shows that we can never
be sure of the prognosis of this disease in young infants, it de-
pending on the virulence of the infection, the resistance of the
organism, and the duration of the suppurative process.

Spasmodic Paralysis due to Hereditary Syphilis in the Child. —
A. B. Marfan (Presse w^rf., Oct. 9, 1909) describes a case of hered-
itary s)rphilis in which the manifestations began some years
after the birth of the child and ended in a spastic paraplegia of
the lower extremities. The author has seen several similar cases,
and considers this a picture which is characteristic of this affec-
tion alone. It consists of paraplegia, with spasm of the muscles
of the lower extremities. This spasm is absent when the child
is quiet, but the reflexes are much exaggerated. There are no
sensory symptoms, and no trouble with the bladder or rectum.
Argyll-Robertson pupils are present, combined with some
lessening of the intelligence. When the patient walks the toes
are dragged because of the spasm of the muscles, which prevents
the action of the knee- and ankle-joints. The thighs approach
one another and the knees touch. There is ankle clonus. Elec-
trical examination of the muscles shows exaggeration of the
f aradic contraction with the normal galvanic reaction. A spastic
paralysis is always the result of an affection of the spine or



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 58 of 109)