of Rhodes. Spurious works Andronicus.

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gut. He agreed heartily with the recommendations for treat-
ment as outlined by Dr. Erdmann.

In discussing Dr. Dowd's remarks he said there was no question
about the difficulty of making a diagnosis of appendicitis in
infants and young children. He was surprised at a mortality
of 30 per cent, given by a certain Brooklyn surgeon in discussing
the subject. In the wards of the Post-Graduate Hospital he
had lost but one case during the last seven years; children stood
the operation remarkably well, if one was careful not to attempt
too much.

Dr. Godfrey R. Pisek said that one method had not been
referred to, a method of geat help in diagnosticating appen-
dicitis in infants and children, i. e., rectal examination. Children
stood this well, and the finger could readily be passed into the
rectum and a tender or enlarged appendix or an abscess could
be palpated and located, especially if the bimanual method was
used. This was a method that had not been employed as often

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as it should be. In suspected cases, or in cases in which there
was dij05culty in making an exact diagnosis, this would be of
great help.

With regard to cyclic vomiting he recalled the case of a child
of a physician who had this symptom-complex and who was
operated upon for a subacute appendicitis. Since the operation
she had become much improved, and under the same treatment
as before the operation. This was in accord with Dr. Dowd's
statement, that sometimes after an operation for appendicitis the
cyclic vomiting in many cases disappeared.

Dr. Sara Welt-Kakels had been impressed with the fact
that sometimes in these cases of intussusception there were
not always evidences of pain, muco-hemorrhagic stools, and
tumor in the abdomen, and she believed the general practitioner,
in treating cases of gastroenteritis, should think of the possibility
of intussusception, even in the absence of some of the well-
known cardinal symptoms.

The doctor remembered one case which occurred in her
experience over a year ago in the Mt. Sinai Dispensary. A
child was being treated for gastroenteritis; the mother did not
think the child was improving and asked for admission to one
of the best hospitals in the city, but was refused admission.
She then brought the child to Mt. Sinai Dispensary, and one of
Dr. Welt-Kakel's junior physicians asked her to examine the
child; this she did and by rectal examination a diagnosis of
intussusception was readily made. Within an hour and a half
the child was on the operating table. A loop of gangrenous
intestine was found, a resection was performed, but the child
died twenty-four hours later.

Dr. William P. Northrup taught his students that there
were three things they should always be keen about and which
they would meet often from the time of graduation until they
quit their calling; they were, the diarrheal diseases of summer,
the corresponding illness of winter, pneumonia, and intestinal

In speaking of intussusception Dr. Northrup felt like apolo-
gizing for a paper he published some time ago. The cause
for the production of that paper was this: He saw two cases
of intussusception within two weeks, and both were injected
with water, and both got well, and he believed that this was
. the worst thing that could have happened to him. One of the
cases Dr. NeflF saw two hours after the onset of the trouble; the
baby had sharp colicky pain; the baby was relaxed, pale, and in
the flaccid condition characteristic of shock; a sausage-like
tumor was also felt below the border of the ribs. Six hours
later Dr. Northrup saw the case and suggested rectal injection
to see if any blood followed. They got blood. The mother
had in the bath-room a complete douch outfit. They distended
the bowel, but the tumor persisted; they repeated it; again
they filled the baby with water and then the mass unbuckled.

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Two weeks later they had a similar case with similar symp-
toms, similar treatment, and a like result. The results in these
two cases Dr. Northrup believed was the worst that could have
happened to him. He published the results of these two cases.
He said that he had learned better since. He preferred surgical

One night Dr. Northrup went to the Presbyterian Hospital
and was seen standing at the door of the examining-room, and
was asked in because of an interesting case there. He found a
strong looking, husky youngster with symptoms of intussus-
ception, but they were not characteristic. He had had attacks
of colicky pain, and some blood was foimd on the cloth on which
he was sitting. There was doubtful history of vomiting. A
tumor could not be foimd. However, when ether was given
the so-called characteristic sausage-shaped mass was noted
extending across the abdomen. The question arose, shall we
inject water, or shall we call in the surgeon? They sent for the
surgeon, and the patient was all right now. An incision was
made and the gut was drawn out with much diflBculty, especially
the last of it.

Among the causes of intestinal obstruction, fecal impaction
had not been referred to, and Dr. Northrup related an interesting
case. These cases were quite rare and often hard to understand.
This child was a robust youngster with an inordinate appetite,
swallowing great quantities of food ; once he indulged in almonds
and meat. Soon he began to have pain, obvious peristalsis,
and he vomited and vomited and vomited. He got on his hands
and knees because of the pain, and of course he could not sleep.
What was the cause? For three weeks he went on in this way.
What was the diagnosis? Dose after dose of castor oil was given,
and each dose was followed by a watery discharge. Finally a
practitioner said, "Give him rheubarb and soda; if without
efifect, give it again and again." This was done and one day
this child passed a large, rotten, putrid bolus which contained
among other things almonds. The baby had been well since.

He recalled an instance when Dr McCosh being busy asked
Dr. Northrup to see a case for him. The child had a little fever
and had had some vomiting. There was tenderness in the right
flank. When the bladder was empty the patient complained
of pain; but when the bladder was full no pain was complained
of. There was nothing to be found along the genito-urinary
tract. There was a great deal of pain. The diagnosis, however,
was not difficult to make. The appendix was in an abnormal
position, for some reason becoming warped around that yiscus,
and there was found an abscess. The filled bladder caused
no pain; but when the bladder was emptied, the dragging pro-
duced caused the pain. The diagnosis was made of an appen-
dicitis with the appendix behind the bladder.

Dr. Northrup reported another case in which the appendix
was in a wrong position, tucked up behind the cecum.

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Dr. Charles N. Dowd closed the discussion. With regard
to the leukocyte count, this was in his experience a very indefinite
guide, for there were so many variations that it was hard to be
guided by it. He said he had operated upon abscesses where
there was a 3 per cent, polymorphonuclear count; in several
cases where there was a low differential count, and occasionally
there was a low leukocyte coimt; whereas in very many cases
where there was no discoverable lesion there was a high leukocyte
count. One had better forget what was said about the leukocyte
count and be guided by other things. Probably in the majority
of the cases the leukocyte count 'would correspond with the
condition fotmd; but there were so many exceptions that he
could not interpret and he did not know anybody who could.

The presence of calculi was another one of the traps in diag-
nosis and which might very easily mislead one. He said he had
never seen a ureteral calculus occurring in a child, although
since calculi occurred in the bladder he supposed they also
occurred in the ureter.

Rectal examinations he had never found as valuable as the
abdominal examinations although he regularly made them.
The abdominal muscle was a telltale, and he could find no
structure by rectal examination which gave an equal amount of



Cremasteric Reflex. — ^E. M. Corner (Brit. Jour. Child, Dis.,
Nov., 1909) says that the cremasteric reflex appears in the second
year of life. Rapid acquisition of the reflex would seem to indi-
cate a precocious nervous, not sexual, development. Its slow
acquisition would indicate either a slow nervous development or
the presence of some general or local disease. When it has once
appeared the reflex rapidly becomes brisk, perhaps so brisk that
the testicle, which was originally in the scrotum, ascends and
appears to be imperfectly descended. An abnormally brisk
cremasteric reflex is the cause of the apparent imperfect descent,
occasional disappearances, and the great mobility of testicle
often seen in young boys. From the ages of about eight to
twelve it is quite common for the reflex to become more sluggish
and feeble. With the onset of puberty the cremasteric act
returns to something like its former power and extent, but never
to the same degree as it is present in boys about six or seven.
Later in life it becomes lost again. It may be produced by stim-
ulating the crural branch of the genitocrural nerve, branches of
the internal cutaneous nerve, of the middle cutaneous nerve,
occasionally of the external cutaneous nerve, frequently by stim-

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ulating nerves suppl)dng the inguinal region or the side of the
abdomen, sometimes stimulation of the perineum and anal region
or of the prepuce and skin of the penis. As a general rule,
movement of the testicle of the side stroked is the result of the
stimulus. But it is not at all infrequent to find that there is un-
equal bilateral response, less frequently an equal bilateral re-
sponse, and still more infrequently, unilateral response of the
testicle of the opposite side. In girls a reflex contraction of the
lower fibers of the internal oblique muscle can be produced by
stimulating the thigh, lower abdomen, or external genitalia. The
writer suggests the name, ** inguinal reflex." It appears in the
second or third year of life, is often very brisk in girls of six to
eight years of age and disappears shortly after puberty, when it
becomes merged into reflex contraction of the lower abdomen.
There are unilateral, equal and unequal bilateral and crossed re-
sponses, just as with the cremasteric reflex. The reflex is best in
healthy children. It is weakened or abolished in ill-health. It
has therefore some value in detecting or in confirming the detec-
tion of malingering children. In the early stage of rickets the
cremasteric reflex is much weakened and often abolished. All
operations on the inguinal canal temporarily abolish this reflex.
If the inguinal canal has been sutured, it may be stated that — (a)
if the reflex returns in ten days or a fortnight some of the stitches
in the canal have not held; (6) if the reflex is abolished for more
than four weeks, the wound healing by first intention, the sper-
matic cord has been injured or there is deep suppuration; (c) if
the reflex returns two or three weeks after the operation its re-
turn is about normal. It is sometimes a question of diagnosis and
of importance in prognosis and treatment to decide if the imper-
fect descent of the testicle is due to — (a) lack of developmental
capital, when the reflex is weak or absent; (6) to some mechanical
obstruction, when the reflex is strong; (c) or associated with the
condition of movable testicle, arising from an abnormally brisk
reflex dependent on the summation of stimuli or on a tonic con-
traction of automatic origin. In siich cases there may be no
cremasteric reflex. They may be only separable from class (a)
by careful observation and the avoidance of stimuli, as by lying
in bed with the clothes raised by a cradle. An inguinal reflex,
comparable to that of young girls, can be found in males in whom
the testicle is retained in the abdomen. It has some practical
value, as if the testicle cannot be found it is either a movable
testicle or an imperfectly descended testicle; in the former case
there may be no inguinal, but a cremasteric reflex; in the latter
it is present with an abdominal testicle.

Different Aspects of Infantile Surgery According to Age. —
Kirmesson {BtUL mid., Nov. 13, 1909) says that surgery among
children is different in some respects from that of adults. It
can be divided into two great chapters : they are defects of forma-
tion and diseases of the locomotor apparatus. Deformities
include club-foot, spina bifida, harelip, and imperforate anus,

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all of which are found in the new-born. There are many strep
tococcic infections to which the tender skin of the infant is
especially liable. Such are erysipelas of the navel, gangrene of
the scrotum, osteomyelitis, and streptococcic arthritis, besides
affections of the skin of the same origin. Conditions vary
with the age of children. Among children under five years of
age dislocations are rare, while after that age those of the hip
and wrist occur. In young infants fracture of the femoral di-
aphysis results from slight causes. On the other hand, fractures
of the leg and arm are rare. In early infancy the epiphysis is
cartilaginous, and its elasticity permits it to avoid traumatism;
in later childhood and adolescence are found most of the trau-
matisms of the epiphysis. Invagination is peculiar to young
infants, the symptoms being violent colic, signs of obstruction,
and passage of bloody mucus. Appendicitis occurs only later
in childhood. In hernia strangulation is rare in babies, the
apparent strangulation being due to spasm, which is easily
relaxed under chloroform. Infectious osteomyelitis may be
seen at all ages. Over five years, it involves the tibia; while
under five, it is frequent in the lower extremity of the femur.
When this begins at an early age it causes inequality of the
condyles, and genu valgum of pronounced degree. In later
childhood it invades the region of the diaphysis and large sup-
purations of the shoulder and hip occur. In young children
tuberculosis generally involves only one location, while later the
foci are multiple. Cancers are rare in children, while gliomata
are much more frequent.

Use of Mprphine in Acute Spasmodic Affections of the Larynx. —
Delearde and P. Swynghedauw {UEcho med. du Nord, Nov. 7,
1909) give an account of the flattering results of various authors
in the use of morphine for spasmodic respiratory diseases and of
the criticisms of others whose results were not so good. They
then give an account of their own observations: four cases
of false, and eleven of true croup. In croup there were three
positive good results, six without result and two bad results.
Of false croup two good, and two bad results. They conclude
that morphine does not give as brilliant results as have been
promised. Still it is well to try it before operating. It should
never be given in children who have in addition to the spasm
any respiratory affection ; the dose of o . 003 of morphine should
never be exceeded ; hot baths, compresses, and vapor inhalations,
with rest in bed and a mixture of antipyrin, bromide of potash,
valerian, and belladonna in a suppository should be given in
addition. Massive injections of diphtheria antitoxin should be
added in diphtheritic cases.

The Heredo -syphilitic Cry. — Genaro Sisto (Ann, de mid. et
chir. inf,f Nov. i, 1909) tells us that in many heredo-syphilitic
infants there is a peculiar cry appearing in the third or fourth
month of life: continual, tenacious, persistent, especially at
night ; exaggerated by movement and pressure on the cartilages

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of the bones; persisting in spite of changes of diet and regime,
and disappearing when syphilitic treatment begins. Some-
times there are no other manifestations of syphilis; at others
there are enlarged spleen and liver, specific f acies, and other signs
of the disease. Not only does mercurial treatment stop the
cries, but it improves the condition of the child which begins
to gain flesh and regains calm sleep. The author believes that
the cause of the cry is pain in the cartilages which are inflamed
by the action of the specific virus. Bertarelli localized the
spirochetes in the periosteum and cartilages of syphilitic infants.

Wassermann Reaction with Jiilk. — Oluf Thomsen (BerL klin,
Woch., Nov. 15, 1909) says that up to the present time no tests
have been made for the Wassermann reaction with human milk.
He has made tests with women who were waiting for confinement
in the Kopenhagen Woman's Hospital the results of which are
given in the form of tables. The milk of syphilitic women
often gives a positive reaction with the Wassermann test, even
when their blood serum fails to do so. This reaction continues
undiminished for several days after labor, but disappears after
five or six days if suckling begins. If the child is not nursed
the reaction continues unabated for seven to fourteen days after
labor, and then ceases to be positive. During the last few days
of pregnancy the reaction is also obtainable. The milk of non-
syphilitic women will also give a slight reaction with this test.
The value of this test for milk in prognosis and diagnosis is not
yet determined, but it is a significant fact that it requires but
a small amount of milk to get the reaction.

Swelling of all the Lymph Glands with Rotheln. — F. Hom-
berger and O. Schey (Miinch, med, Woch., Nov. 9, 1909) de-
scribes ^n epidemic of rotheln observed by him in which the
symptoms were very slight, yet in which there was a general
swelling of the lymphatic glands. It has been stated that a
swelling of the occipital and mastoid glands is characteristic of
this disease, but in these cases the swelling was general in spite of
the mild character of the symptoms. This swelling is present in
the prodromal stage of the disease. The epidemic observed
consisted of forty-five cases in all. The author thinks that
whenever we have a general swelling of the lymphatic glands we
should be on the lookout for rotheln.

Surgery of the Thymus. — Victor Veau and Eugene Olivier
{Arch, de mid. des enf., November, 1909) writes that sudden
death is a not infrequent termination in hypertrophy of the
thymus. In other cases there are marked and peculiar dyspnea,
and spasm of respiration, which is quite characteristic of this con-
dition. The authors have collected seventeen cases of operation
for hypertrophy of the thymus, from which they deduce opera-
tive indications and a surgical technic. The signs of hyper-
trophy are permanent dyspnea, crises of suffocation, and stridor;
the dyspnea is caused by pressure of the enlarged thyroid on the
trachea and the respiratory nerves. The type is different from

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that of croup; at each inspiration the abdominal contents are
crowded back by the muscle, the sternum being thrown forward.
Crises of suffocation may occur in a patient who is apparently
perfectly normal, or they may be frequently repeated until the
patients fear death. These troubles are relieved by sitting up,
and return on lying down again. Intubation does not relieve
this form of dyspnea. Inspiratory congenital stridor is always
due to hypertrophy of the thymus. Dysphagia is sometimes
present. The physical signs are swelling in the location of the
thymus, and sensation of a mass above the sternum. Radiography
and radioscopy are difficult and of little value in a child strug-
gling for breath. Exothymopexy, or raising the thymus and fix-
ing it to the sternum is of little value as a remedy for this condi-
tion. It is easier to extirpate the thymus than to fix it; we need
not fear total removal, because the gland is so situated that it is
difficult not to leave some behind. Removal in the capsule
would be difficult on account of its relations and the difficulty of
dissecting out the entire capsule. Subcapsular enucleation is
not difficult. The thymus is easily removed by pulling out with
forceps and cutting off one lobe at a time. The immediate re-
sults are good, there having been sixteen recoveries in the seven-
teen cases, the death being in a case of delayed operation. No
bad results from removal have been observed.

Bismuth Paste Treatment of Tuberculous Diseases. — J. Ridlon
and W. Blanchard (Chic. Med. Rec, Nov., 1909) have treated
over 100 cases in this way with no serious case of bismuth poison-
ing. They say that it should never be used if there is progressive
destruction or the X-ray shows a sequestrum, in amyloid cases,
or continuously when large distal pus sacs become filled with
residuary bismuth. In sinuses of tuberculous bone disease which
have existed for less than two or three months, it is likely to
burst the walls and extend the sinuses, and in old sinuses with
extensive skin destruction and undermining of large areas of skin
the sloughing is increased. The ideal paste for flooding tuber-
cular sinuses and filling pus cavities should sufficiently solidify
at body temperature to crowd out the pus, compress the granu-
lations, and exclude the air. It should also be nontoxic and
absorbable. To avoid danger of bismuth poisoning and believ-
ing that bismuth is not a necessary constituent of a flooding
paste, the writers have adopted the following formula for the
treatment of old tubercular sinuses: White wax, one part;
vaselin, eight parts, mixed while boiling. To this is added for
use in badly infected cases from o.i to 0.5 per cent, of pow-
dered iodine at moment of injection. Iodine scales may be
reduced to a powder in a mortar by the addition of 20 per cent,
of potassium iodide. Immediately after injecting, a thick pad
of gauze saturated with alcohol should be bound over the open-
ing. The evaporation of the alcohol cools and hardens the paste
and prevents its escape. A limited experience with wax and

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vaselin paste either with or without the iodine seems to show
just as good results as the bismuth paste.

TyphobaciUosis of Landouzy and Late Localizations of Acute
Tuberculous Infection in the Child* — ^E. Weill and G. Mouriquand
(Presse mid,, Nov. 26, 1909) describe a case of typhobacillosis,
in which the child was supposed, from the general symptoms and
rise of temperature, to be suffering from typhoid, but in which
there were no rose spots and no positive Widal reaction. Later
a pleurisy developed, and it became evident that the case was one
of tuberculosis. The spleen may be enlarged, but less so than
in typhoid. Palatine ulcerations are absent. The pulse is
independent of the rise of temperature. In tuberculosis, at
first the temperature is like that of typhoid, but soon greater
oscillations appear than would be expected in that disease. It
is not always very high and it does not seem to disturb the child.
Then the child begins to emaciate and to get weaker in spite
of a good appetite. Finally the lung signs appear and bacilli
may be found in the sputum, or a meningitis or a tuberculous
peritonitis may develop . The location renders the prognosis fatal.

Tuberculosis of the Tonsil and Cervical Lymph Nodes. — ^E. S.
Carmichael (Proc, Roy, Soc. Med,, Nov., 1909) has examined the
tonsils removed from fifty out-patients of the Royal Hospital
for Sick Children, most of whom were brought on account of
glandular enlargement. Seven of these showed undoubted
tuberculosis of the tonsil, though none of them suggested the
trouble to the naked eye. The writer questions whether, if the
tonsils are primarily affected and have been the cause of a sec-
ondary infection of the cervical glands, the general opinion is the
correct one — ^that excision of tuberculous glands in the neck
is suflBicient, with the chance of leaving the original focus un-

Gastric Ulcer. — The great rarity of ulcer of the stomach in
children and the much greater rarity of such cases coming to
operation are the reasons given by F. B. Lund (Bosi, Med,
Surg. Jour., 1909, clxi, 930) for recording a case only eight
years of age. The boy had had two previous attacks of epi-
gastric pain with slight hematemesis within a year. In the

Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 73 of 109)