of Rhodes. Spurious works Andronicus.

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

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of educational standards and age regulated by reference to the
anatomic index as obtained by the Roentgen Ray. Illustrations
were then shown of some of the southern children who were in-
fected with the hook-worm, looking as though they were years
younger then they really were and yet who, by means of their
anatomic index, could, if proper laws of development were
made, be prevented from working in the mills even though
their age was far above that prescribed by the laws. Professor
Rotch then spoke of the Roentgen work which by request of the
United States Government he was having carried on at the
U. S. Naval Academy for the purpose of aiding in the proper
grading of cadets. He showed how with this object in view
he was using the Roentgen ray to determine an antomic index
for older individuals at an age when they were in the Naval
Academy, college, or the technical and high schools.

He stated that while his anatomic Roentgen inciex had for in-
dividuals from one to thirteen years been determined by the
order of appearance of the carpal bones and the epiphyses of the
radius and ulna, from A to M, he was now presenting merely the
lines on which he was evolving the later age anatomic develop-
mental indices. He wished it to be understood that this later
index however was still merely empyrical and not yet worked out
as fully as the earlier index, but that there was no doubt but that
this later index from N to Z could be evolved just as rationally
as the earlier one from A to M. The method of establishing the
later index was to determine the time and thus classify the in-
dividual by tabulating in each individual the appearance of the
ossification or later union of the epiphyses of the metacarpal
bones, the epiphyses of the phalanges, and those of the radius
and ulna. He explained that this was not difficult from four-
teen years of age up to eighteen or nineteen, but that after that
period much finer Roentgen work would be needed to determine
the completion of development by the arrangement of the striae
in the bones at their epiphyseal junctions.

Professor Rotch then showed illustrations of how the Roentgen
picture would aid in deciding whether girls at the period of
maturity should have their mental and physical work increased
or decreased according as their anatomic index showed an ad-
vanced rigorous stage of development or an undeveloped condi-
tion irrespective of whether they looked well and were of the
average height and weight.

He next showed the Roentgen pictures of a set of boys who had



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entered college at eleven or twelve years of age and who were
doing the same mental work as boys four or five years older. He
explained how their anatomic index indicated whether they were
safely undertaking this work beyond their years or not. In
some cases the index showed that the individual was absolutely
safe in doing such work and that one of the cases, a boy of fifteen,
had been through Harvard and taken a cum laude, and was in
one of the post-graduate courses with young men of twenty-two.
Although seven years younger than his classmates his anatomic
index showed a development so nearly that of the older individ-
uals that there was evidently no question of his being harmed
mentally. Other cases showed the reverse of these conditions.

Professor Rotch also presented the beginning of some work
which he is undertaking on feeble-minded children where he has
found that where such individuals may be of the average height
and weight for their years, yet that their anatomic index corre-
sponded more to their low grade of mental capacity than to such
general physical development. He also gave instances of how
from time to time taking the Roentgen anatomic index it was
possible to determine whether the mental capacity was improv-
ing or standing still, this often in private practice being an exceed-
ingly difficult question to answer the parents unless by some
such aid as the^ Roentgen ray provides.

Finally he showed the Roentgenographs of some twins in
which two girl twins showed exactly the same development.
Two boy twins also showed the same development, but a twin
boy and girl showed that the development of the girl was de-
cidedly in advance of the boy. Professor Rotch stated that these
cases supported his view that from birth the development of the
girl's epiphyses were decidedly in advance Of the boys and that
they continued so throughout the whole of the child's life, the
final union taking place in girls earlier than in boys. Some
Roentgenographs of children infected by the hook-worm were
presented showing the arrest of development in these cases and
their low anatomic index.



Meeting of February lo, 1910.
Eli Long, M. D., in the Chair.

CASE OF INTUSSUSCEPTION.

Dr. Edward W. Peterson presented this patient. When
five months old he was admitted to the Babies' Ward of the
Post-Graduate Hospital. Two days before admission he became
very restless and fretful, and seemed to be sufiFering from abdomi-
nal cramps. Vomiting commenced early and continued at
frequent intervals. The bowels, previously regular, did not act
naturally, nor did enemata give relief. On the third day blood
and mucus were expelled, unaccompanied by feces or flatus.



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NEW YORK ACADEMY OF MEDICINE. 703

Upon examination, the abdomen was found to be moderately
distended and very rigid. On the left side an elongated tumor
could be felt abdominally and by rectum. The examining finger,
when withdrawn from the rectum, was covered with bloody
mucus. A diagnosis of acute intussusception was made and
preparation for operation ordered.

A three-inch incision was made through the right rectus muscle.
As soon as the peritoneum was opened the small intestines, much
distended, crowded out. The diagnosis of intussusception was
confirmed, the invagination being of the " ileocecal " variety. Be-
ginning at the distal end, or at the apex of the intussusception, with
great care the reduction was attempted. Owing to the edem-
atous and friable condition of the gut, adhesions having formed
at the neck of the intussuscipiens, it was very difficult to reduce
the last two inches of the invagination. This was accomplished;
however, with very Httle damage to the serous coat of the bowel.
The abdomen was closed in layers with catgut and reinforced with
three silkworm-gut sutures through all the layers except the peri-
toneum. Following the operation the temperature rose to
107.8° F., then gradually subsided, reaching normal about the
fifth day. Vomiting was persistent and annoying for the first
few hours, after which time it gradually stopped. The bowels
acted naturally on the second day. The secondary enteritis,
which is always present in intussusception cases, was not severe,
and yielded readily to appropriate treatment. The patient was
discharged cured on the seventh day.

CASE OF TUBERCULOUS PERITONITIS.

Dr. Edward W. Peterson presented a boy, three years old.
During February, 1908, the child had a severe attack of gastroen-
teritis, which lasted three weeks. Shortly after he very slowly
lost weight and strength, and at the same time there was a gradual
increase in the size of the abdomen. Several physicians examined
the boy and informed the parents that the condition was a malig-
nant one of the abdomen, and that the case was hopeless.
Finally the child was brought to the Post-Graduate Hospital Dis-
pensary in July, was examined by Dr. Carter, and referred to the
surgical service.

The examination showed a weak and emaciated child. The
conjunctiva and skin were jaundiced. There was a marked
brorizing of the cutaneous surface over the abdomen, so marked
as to suggest disease of the suprarenals. Examination of the
heart and lungs was negative. The abdomen was moderately
enlarged. There was a nodular mass to the left of the umbilicus,
and distinct nodulations could be felt over the entire abdomen,
most pronounced in the right iliac region. The blood examina-
tion showed erythrocytes, 2,360,000; hemoglobin, 55 per cent.;
leukocytes, 8,000; polymorphonuclears, 33 per cent.; small lym-
phocytes, 60 per cent.; large lymphocytes, 7 per cent. The



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704 TRANSACTIONS OF THE

urine showed a trace of albumin, hyaline and granular casts.
The tuberculin (Calmette) test was tried and proved negative.
(This test has since been abandoned as a diagnostic aid.) After
studying the case for a few dajrs they decided that they had to deal
with a case of tuberculous peritonitis. Treatment by fresh air,
tonics, etc., was tried for three weeks, but as the child lost two
pounds in weight and was losing strength, operation was decided
upon.

An incision two inches long was made in the abdomen, and Dr.
Peterson said that he had never seen a more extensive case of
miliary tubercles. A moderate amount of fluid was evacuated;
this was a dark straw-colored fluid and suggestive of an old hemor-
rhagic condition. The parietal peritoneum; the intestines,
omentum and other parts were simply studded with innumerable
tubercles. The peritoneal cavity was washed out with peroxide
of hydrogen, one part of peroxide to three parts of water, then
with normal saline solution, and the wound was closed without
drainage. When the child left the hospital, the parents were
instructed in regard to the hygienic and tonic treatment that
should follow. In addition inunctions of mercury were employed.
Within three or four weeks the jaundice cleared up, and the
bronzed condition of the cutraneous surface of the abdomen
disappeared. The child to-day was apparently perfectly well.

Dr. John F. Erdmann read a paper on

INTUSSUSCEPTION .

As the surgical technic of this class of cases is not the es-
sential feature for a Section on Pediatrics, he said he would
but emphasize the operative necessity and call attention to the
symptoms, difiFerential diagnosis, etc. In his series of operations,
now about forty-five, he had been impressed by the health of
the patients, few having been ill in any way before the onset of
the trouble. There was the sudden onset with colicky pain, ac-
companied with shock; this primary onset was then followed by
cramp-like pains, intermittent in character. During the periods
of cramp the child cried and was resUess; while in the inter-
mission during the first twelve or twenty-four hours, one was
surprised at the temerity of the diagnostician who was rash
enough to suggest an abdominal section. The early shock dis-
appeared as the first hour passed. The diapers were very likely
to be slimy and contain an admixture of blood. This evidence of
blood was pathognomonic when there was a previous colic,
shock, and spasm picture. The blood evidences might be slight
and with large quantities of mucus, or the reverse might obtain.
Frequent desire to defecate, tenesmus with little result except
small quantities of mucus and blood, vomiting, and distention
of the abdomen were later developed in the order mentioned.
Palpation, even under an anesthetic, was not followed in the
majority of the cases by the finding of a tumor, and certainly



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NEW YORK ACADE3iY OF MEDICINE. 705

not the classical sausage-shaped ones described in the text-
books; one was more likely to find no tumor from the fact that
very often the tumor was hidden behind the costal arch of
either side. Rectal examination revealed a tumor far less often
than abdominal palpation, unless the case be one of a day or
more duration; but, as a rule, withdrawal of the examining
finger was followed by blood and mucus. The abdomen was
lax in the early hours, but subsequently became distended.
The pulse was accelerated. The temperature was usually sub-
normal or normal at the onset, but a moderate rise ensued with
the progress of the disease. The dififerential diagnosis of these
cases was sometimes extremely difl&cult, especially in those cases
with visceral crises in the erythema group of skin diseases.
Little or no difficulty should be met with in making the difiFer-
ential diagnosis in a case of appendicitis; in these cases the pain
was a general one with a localization, with temperature and
pulse higher than in intussusception.

In considering the treatment he inserted, with a few altera-
tions, a portion of paper published in the New York Medical
Journal in May, 1904.

"Rectal enemas in the first few hours are not productive of
harm, but may, though rarely, be followed by reduction.

" Admitted that one meets occasionally with reduction by the
use of enemas, nevertheless, this very important fact must be
remembered, i.e., that the whole mass may be reduced except
the ileo-cecal junction and one or more inches of the ileum.
This being so, all the symptoms clear up for a time. They
again return and necessitate operative interference at a time
when the conditions of this region are not nearly so favorable
to reduction, and may even require excision. This condition
was well demonstrated in my sixteenth case, a male child, seven
and a half months old. Duration eight and three-quarter hours.
Injection used by the father, a leading physician of this city,
Dr. H. M. Silver and myself, was followed by a perfectly tranquil
picture; but realizing the possibility of this condition of incom-
plete reduction, we all felt that the risk of exploration would be
far less than that taken by leaving matters rest for further mani-
festations. That our fears were not groundless was proved by
the evidence of a mass at the cecum, which consisted of almost
three inches of the ileum and the entire appendix. Reduction
was readily accomplished, the appendix was removed, and re-
covery followed. I should, therefore, not feel satisfied that
reduction had taken place, even if the child should have no
further manifestations of pain, etc., unless this was followed in a
short time by a movement of the bowels that we could feel
satisfied had come from beyond the supposed site of the intus-
susception; and that in the waiting interval for a movement
we should be prepared to proceed at a moment's notice with
the operative measure. The use of enemas previous to operation
was offered as a suggestion, but I can say clinically that it is of



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very valuable service, as there is no doubt that the injections
reduce a portion of the intussusception, and any agency or pro-
cedure that limits operative time must of necessity diminish
shock in direct proportion. Although these little patients bear
operative interference quite well, it is quite significant that my
greatest mortality rate occurred in those cases which required
the longest time for reduction, and that these cases were also
the ones of longest duration. Enemas as a means of reduction
are not advised after six hours* time has elapsed from the first
f>ositive symptoms, as, after this period, much valuable time is
lost by such procedure.**

In Dr. Erdmann's last sixteen cases of operative reduction the
average age was six and a half months, the youngest being
sixteen weeks old, with males in excess. One of these sixteen
died, the cause, in all probability, being status lymphaticus.
All his excision cases in children succumbed.

In conclusion Dr. Erdmann said that early recognition of
this condition was absolutely necessary to a high recovery rate.
Inflation was decidedly not useful, but dangerous. Enemas
were successful in an exceedingly small proportion of the cases,
and should not be used after six hours. The earlier the operation,
the more likelihood of a small mortality. Late operation
predicated the possibility of gangrene, with all its horrors.

Dr. Charles N. Dowd read a paper on

APPENDICITIS IN INFANTS AND CHILDREN.

Appendicitis in children ofiFered many peculiarities; he could
not consider all, but wished to refer to a few points which hinged
about two questions, i. when to operate and 2. how to operate?
It was easy to say, operate at once, but this depended upon the
diagnosis, and the diagnosis of appendicitis in children was very
difficult. In adults the diagnosis usually could be made promptly
and a successful result obtained; whereas in children there
occurred repeated consultations with delay and often a general
spreading peritonitis with a fatal result. Murphy of Chicago
had called attention to four important symptoms in acute
appendicitis which followed as a sequence; if they did not
follow as a sequence, the diagnosis of appendicitis might be
questioned. First, pain in the abdomen, sudden and severe.
Second, nausea or vomiting, usually three or four hours later.
Third, abdominal sensitiveness, most marked in the appendicular
region. Fourth, moderate elevation of temperature from two to
twenty-four hours after the onset of the pain. The first, second,
and fourth symptoms were of little significance in children
except as confirmatory of the third. Therefore, one was easily
misled in making a diagnosis of appendicitis in children. One
must depend mainly upon the third symptom in making such
a diagnosis. Muscular rigidity which indicated this tenderness
was as definite in children as it was in adults. It was not.



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NEW YORK ACADEMY OF MEDICINE. 707

however, so definitely localized since children's appendices were
relatively longer than adults, and the rigidity would vary with
the position of the appendix. It would be in the hypochondriac
region if the appendix lay upward; it seemed like a general
abdominal rigidity if it lay toward the median line. The
rigidity was less marked if the appendix lay in the pelvis, since
the bony parts protected it from traumatism; but one was
helped here by the occurrence of bladder irritability. This
one symptom of vesical irritability was, in many cases, a very
valuable guide in determining the diagnosis. It was easy to
see that if only the ordinary symptoms of appendicitis were
considered they had a much more difiicult problem in children
than in adults. There were several distinct inflammations
which were apt to make a dififerential diagnosis difficult and
among these were the following:

1. A Beginning Pneumonia. — Occasionally adults with a com-
mencing pneumonia will give symptoms very suggestive of an
appendicitis. But in children this occurred frequently; such a
diagnosis was frequently made in children who were sent in to
St. Mary's Hospital with beginning pneumonia, but soon the
rapid respiration, the peculiar appearance of a child ill with
some thoracic disease, and the absence of other classical signs
point to the real trouble in the lungs, and operation was avoided.
But those cases were very misleading.

2. General Peritonitis from Unknown Causes. — Children were
very apt to have a spreading peritonitis from an unknown site
of infection. Holt and Kerley had described it. Dr. Dowd
had recently published a paper on the subject in the Annals of
Surgery. The condition caused a very rapidly spreading
peritonitis usually with a fatal termination. This was found
more often in children than in adults, and it constituted one of
the traps which awaited the diagnostician.

3. Tuberculous Peritonitis. — This was common in children and
often simulated appendicitis; it was usually the form with a
plastic exudate, and not the ascitic form as found in adults.

4. Pneumococcus Peritonitis.

5. Gonococcus Peritonitis.

6. Cyclic Vomiting. — ^This often gave symptoms very much
like those of appendicitis. It was interesting to note that Comby
of France operated upon many cases believing the condition to
be due to a chronic form of appendicitis, and a large proportion
of his cases had been cured by the operation.

7. Foreign Bodies. — Dr. Dowd said that he had taken three
pins, for instance, from the appendix. In one instance he found
a round worm free in the peritoneal cavity with no indication
of its point of exit from the intestine.

8. Hip Disease.

In looking over this list it would be shown that the diagnosis
of appendicitis in children presented more difficulties than it did
in adults, especially when one remembered the lack of history



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708 TRANSACTIONS OF THE

in the case of the infants. But really the diagnosis of appen-
dicitis in children was not so difficult as the long list indicated.

When the diagnosis of appendicitis had been made the question
then arose when to operate. Whatever opinion one might have
in regard to this question in adults, when dealing with children
all ideas of delay should be thrown aside; so soon as the diagnosis
was made, operate. Children were more apt to have a spreading
peritonitis with appendicitis than were adults. Ochsner said
there were two classes of people (?) who from the thinness of
the omentum were apt not to have their appendicial inflam-
mations shut in; i. old emaciated adults and 2. young children.

Dr. McCosh once read a paper in which he advanced the same
idea as did Dr. Ochsner. Operate as, soon as the diagnosis
was made; this should be written down as a general rule in
dealing with appendicitis in children.

With regard to the mortality, it was once very high. Rotter
reported having lost 66 per cent, of six cases tmder five years;
Isreal lost 47 per cent, of fifteen cases; Broca lost 44 f)er cent, of
fifty-nine cases; Kerewski lost 41 per cent, of seventeen cases;
Senander lost 25 per cent, of four cases; and Sonnenberg lost
15 per cent, of twenty-six cases. Last year George Alsberg re-
ported sixteen cases occurring in children without mortality.
The following was Dr. Dowd's own table:

Time of Operation and Mortality Rate.

No. of cases. Early date. Later. Interval. Mortality rate.

Group I, 70 15.7 57.1 27.1 10

Group 2, 50 16.0 74.0 lo.o 8

Group 3, 61 36.1 49.2 14.7 o

Murphy of Chicago made this statement: "A man who is
having more than three or four deaths in a hundred operations
for appendicitis is either receiving his patronage from incom-
petent and procrastinating medical men, or is doing too much
manipulating in the peritoneal cavity under unfavorable path-
ological conditions." This statement brought in two essentials
of success in appendix work.

The second, simplicity of operation, was as important as the
first, promptness in operation, and it was remarkable to note
how generally a simple technic had been adopted, removing the
appendix when practical, draining the local abscess and leaving
the rest of the peritoneal cavity to care for itself. And even
the removal of the appendix should not be done at the primary
operation if too extensive treating of adhesions are necessary
in order to accomplish it.

With regard to the age, a child under two years would not
stand as good a chance as one over two years; yet these yotmg
children would do well if one was able to make an early diagnosis
and did not attempt to do too much at the operation.



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NEW YORK ACADEMY OF MEDICINE. 709

The following was Dr. Dowd's own table:

Under five years. Five to ten years. Ten to fifteen years.
Group I, 5.7 41.4 52.8

Group 2, 6.0 38.0 56.0

Group 3, II. 4 32.8 55.7



Children had a great capacity for getting well if they were
given a chance. It was the difficulty of diagnosis rather than the
question of operation which made the mortality rate so high
for little children. They stood the simplest operations wonder-
fully well.

DISCUSSION.

Dr. Edward W. Peterson believed that there was no type
of intestinal obstruction so easy to diagnose as intussusception.
An acute invagination usually manifested itself in a subject
whose previous health had been good. The onset was sudden,
with severe paroxysmal colicky pains, vomiting and straining,
and muco-hemorrhagic stools. There was constant desire to
go to stool, with a passage of mucus and blood, without feces
or flatus; this was pathognomonic of intussusception. If, in
connection with the symptoms just mentioned, a cylindric or
rounded intestinal tumor could be felt, then the diagnosis was
rendered reasonably certain. It might be added that in cases
of intussusception, a careful examination of the abdomen
and rectum, under an anesthetic if necessary, would generally
reveal the presence of a tumor. Dr. Peterson said he had
operated upon nine cases and had seen as many more, and in
every case a tumor could be felt. In intussusception the
prognosis was going to depend not so much upon the duration
of the afiFection as upon the amount of obstruction and the
degree of strangulation to the blood supply of the invaginated



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 72 of 109)