of Rhodes. Spurious works Andronicus.

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

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Average length of time under active treatment (260 cases) by the

irrigation treatment, 10. i months.
Average length of time under active treatment (84 cases) by the

vaccine treatment, i . 7 months.

Of the eight-four cases to which the vaccines were given,
sixteen had been under the irrigation treatment for long periods.
Three of these cases were not benefited at all, one did not
return, and twelve were cured. Some of the cases which did
not respond to the treatment with one vaccine frequentiy did
well on one of the other vaccines. In the cases which were
not benefited new strains were tried; increased dosage, less
frequent dosage, and more frequent dosage was attempted, but
with negative results. The five uncured cases were all over
five years of age, two of them being over nine years. Contrary
to the findings of some other published results in young infants
under one year of age, three cures were obtained by the vaccines,
the youngest being three weeks old.

A copy of the following instructions was given to each mother:

Department of Diseases of Children.

instructions for treatment of vulvo-vaginitis in little


1. This is a local contagious disease which requires treatment
until the physician pronounces the child cured. It sometimes
persists for many months.

2. To avoid infecting other members of the family, always
wash the hands thoroughly both before and after bathing the
parts. The discharge, if carried to the eyes, may cause blindness.

3. The child should sleep alone. Be sure that no one uses
any toilet articles, towels, napkins, or wash-cloths used by the
patient. All napkins, sheets, underclothing, towels, and wash-
cloths should be either boiled or immersed in a solution of creolin
(one tablespoonful to a gallon of water) before washing. Bath-
tubs, basins, and everything else coming in contact with the
patient should also be washed with this solution.

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4. It is advisable that all children with this disease should
wear a napkin or pad, which should be changed daily.

5. Parents are cautioned not to allow the child to mingle
intimately with other little girls. The child should not attend
school or day nursery lest other children become infected.

6. Cleanse the parts externally at least four times daily with a
solution of borax or boric acid crystals, one teaspoonful to a
pint of boiled water.

7. Report to the Clinic every


Vaccine therapy has a place in the treatment of this infection
in little children for the following reasons:

1. The short time required for a cure in over 85 per cent, of

2. The ease of administration of the vaccine; no special
apparatus or knowledge of technic being necessary.

3. The vaccine is apparently harmless when used under
aseptic precautions.

4. It is not necessary to take the opsonic index with its
complicated technic, although it is perhaps desirable.

5. Doing away with irrigations which direct the child's atten-
tion to its genitals, at times encouraging precocious mastur-
bation. The frequent douches necessary in the irrigation treat-
ment will, with the best care and gentleness, produce some
injury when continued over a long period of time.

I wish to express my thanks for the clinical cases referred
to me from other hospitals and clinics, to Dr. L. E. LaF^tra for
his courtesy in extending me additional facilities of supplies and
nurses at the Vanderbilt Clinic, to Dr. R. V. Lamar, of the
Rockefeller Institute for Medical Research, and Dr. J. C.
Meakins, of the Presbyterian Hospital, for cultures and vaccines,
and finally to the visiting nurses of the clinic, who have made
this record of cases possible.

125 West Seventy-sixth Street.

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Meeting of Jantuiry i8, 1910.
Julia D. Merrill, M. D., in the Chair,
Dr. Effa V. Davis reported
"three cases of meningitis: history and clinical course,'**
with the

"bacteriology and pathology"
by D. J. Davis.


Dr. J. M. DODSON. — I had the opportunity to see the second
case reported which was referred to my service.

Lumbar ptmcture in the second case yielded very little fluid.
Unfortimately, the interne who made the pimcture allowed
this to stand for some time before examining it, and that always
vitiates an examination of this sort as the diplococcus is likely
to lose its vitality. It is rather interesting, however, that when
the fluid was examined on the following day the organism was
quite obviously not the diplococcus, but its size and other
features suggested the influenza bacillus. As we were preparing
to make a second lumbar puncture the {child died. A puncture
was made immediately after death and a portion of fluid was'
kept for examination.

One point I would like to emphasize in this connection, and
that is the futility of injecting a serum tmtil one knows the
cause of the meningitis in the case in hand. There has been
some insistence that the Flexner serum should be injected im-
mediately after the first fluid is withdrawn in every case of
meningitis. I feel very strongly that this is a mistake; that there
is not the urgency that demands the immediate injection of
serum that is specific for only one kind of meningitis. One
can in a few minutes, as a rule, determine the nature of the
invading organism by making an examination of the fluid
withdrawn. There are no clinical symptoms which enable us
to determine whether the diplococcus of meningitis, the influenza
organism, or some other microorganism is concerned. The
Flexner serum would be useless for meningitis of this sort, as it

♦ See original article, page 811.

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would be for any form of meningitis, except the diplococcus

Only where conditions preclude a prompt examination of the
cerebrospinal fluid withdrawn and the symptoms present point
strongly to the diplococcus of Wechselbaum as the etiologic
factor, are imjustified in injecting the Flexner serum before a
bacteriologic diagnosis has been made.

Dr. C. G. Grulee. — ^There are a few things about the first
case that are interesting. First, there is the question of hemor-
rhages. Two or three years ago I reported a case of a child,
five days old, that died in convulsions. I thought then, and am
of the same opinion now, that this was the result of the mother's
eclampsia. The child's kidneys were involved, and there was
albuminuria. At the autopsy we found marked meningeal
hemorrhages. Two of them covered almost half of the cerebral
cortex, one on each side of the brain. They were not in the
dura, but in the pia.*

With respect to the injection of the meningococcic serum,
I must say that I agree with Dr. Dodson, although I believe that
there are "circumstances which alter cases." The case came
under my observation not long ago of a child, with a marked
Kemig and a stiff neck. The general condition of the child
seemed to be against meningitis, and I told the attending
physician that I did not think it was a case of meningitis. He
insisted on a lumbar pimcture, and we made it. The circum-
stances were such, however, that twenty-four or thirty-six
hours would elapse before we could get a report. Therefore we
injected 30 c.c. of Flexner's serum. The case turned out not
to have been one of meningitis, but there were no immediate
effects from the injection of this amount of serum, which was
rather interesting.

Another thing to which I want to call attention is the sign
(in meningitis) described by Brudzinski, for which he claims a
great deal. He says that on attempting to bend the neck there
is flexion of the thigh on the body or of the leg on the thigh, or
both, and that this is more constant than the Kemig sign or than
the opisthotonos. It would be interesting to determine the
correctness of this statement.

Dr. a. C. Cotton. — ^The remarks of Dr. Grulee calling atten-
tion to other signs that are noteworthy recall to my mind the
sign of the alternating dilatation and contraction of the pupil
when extreme flexion is forced on the neck that is rigidly re-
tracted. I have seen this sign in a few cases of meningitis, and I
would like to know whether others have seen it and whether they
consider it of any value.

In regard to the injection of the antimeningococcic serum,
I could conceive of cases where one would be in a position that
would justify making an injection. A case in point occurred in
my own experience last year. The patient lived at Sterling,
Illinois, so that the fluid to be examined had to be brought to

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Chicago for examination, which would mean the loss of valuable
time to say nothing of the changes which would likely take place
in the fluid and which would vitiate the result. I had taken the
precaution of carrying some serum with me, and I injected it.
Again, it is sometimes very difficult to get the serum within a
reasonable time. Considering all things, then, it is advisable
always to carry the serum and to use it in every suspicious case.
I have never heard of any harm coming from the injection of
the serum.

Dr. Effa V. Davis (closing the discussion on her part). — The
study of the first case was very interesting, because of the youth
of the child and the severity of the attack. The child was sick
only about ten da)rs, but was very sick from the onset. At the
autopsy we foimd many interesting things, but we did not dis-
cover the cause of the convulsions, which were very severe.
I had the child under observation all of her life, excepting about
a week, when it was under the care of foster parents. So far as I
know, she had no influenza when she went into the home, but
the discharge from her nose and the bronchial trouble looked
as though she had had an infection at some time or other. The
thing which concerned me the most was whether we were going
to have any more of these cases. We still have some cases of
colds which are causing me a little anxiety, although Dr. Davis
made smears from the nose and throat of all the children in the
nursery, and found them negative.

Dr. D. J. Davis (closing the discussion). — I have injected
human serum into the spinal canal in two cases. One patient
did very well and recovered; the other seemed to improve for
four or five weeks, when there was a sudden change for the worse
and the patient died. Death occurred in this case about six
weeks after the second injection of normal human serum.

I also injected one case with normal horse serum, but there
was not the least sign of improvement afterward. These three
cases were meningococcic infections.

The atrium of infection in these cases of influenzal meningitis
is very interesting. It has been rather variable. In some
instances the infective agent seemed to have entered the cranial
cavity by way of the tympanum. In other cases it seems very
certain that the infection extended from the nasal mucosa
through the cribriform plate into the cranial cavity. I think
that there is very little doubt that this was the avenue of infection
in the second case on accotmt of the acute influenzal rhinitis.
In other cases, again, there seems to be a marked involvement
of the throat, and it is possible that the infection extends from
there. It is unusual to find the influenza bacillus on the tonsils.
I have studied between one and two htmdred cases, but have
never isolated this germ in this locality. On the posterior wall
of the pharynx, however, and in the thick mucus secretions
brought up from the bronchial tubes, it is very common to find
the influenza bacillus. Occasionally it may be found in appar-

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ently normal throats. It is also commonly found associated with
the various infections, such as measles, whooping-cou^h, chicken-
pox, scarlet fever, bronchitis, and tuberculosis.

Another point worthy of emphasis is that these cases are not
only infections of the meninges, but are septicemias. Thus
far there has not been an opportunity for careful blood culture
work before death. The bacilli have in several cases been found
in abundance in the heart's blood postmortem, and with proper
technic probably can be isolated in every case. That is well
shown by animal experiments. If the organisms are injected
into the animal in suflScient doses, they quickly enter the circu-
lation and are foimd there in large numbers.

I made the examinations of the throats of the other children
for the purpose of determining whether we were dealing with an
epidemic of influenza. Although the cultures were made on
pigeon blood agar, I failed to find the influenza bacillus in a
single case. Swabs were made from the throat and nose,
and these were stirred in plain broth tubes. From these var3ring
quantities, from a drop to two or three centimeters were plated
out on pigeon blood agar. A variety of organisms were found,
but the predominating organism was the pneumococcus. Strep-
tococci were common in some cases, and staphylococci in



Meeting of March lo, 19 lo.
Eli Long, M. D., in the Chair.


Dr. Sigmund Arthur Agatson presented the boy, four
years old. The father and mother are first cousins, with phy-
sical and mental conditions normal. The child was a premature
one at the seventh month; the presentation was cephalic, and the
delivery was instrumental, the duration of labor not exceeding
three hours. Soon after the birth the baby developed snuffles.
The baby was breast-fed for one year, nursing being supple-
mented by grocery milk from the start. He had measles, and
adenoids were removed when he was two years old. During
the first six months of his existence the child gave no trouble;
then it began to cry frequently unless taken up and carried.
During the first year he never had any convulsions. He sat
up at eight months and walked at fourteen months. The
eruption of the teeth was normal. He never learned to speak.

The present illness began at the age of fourteen months when

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the mother noticed that upon awakening the child would get
attacks of bowing of the head and trunk. These attacks would
recur from eight to ten times a day, but were most marked after
sleep. The child's mentality remained at a standstill. His
irritability increased. When displeased he would yell and cry,
run around the room, jump up and down, and gave the general
impression of imbecility. At times he would cry and laugh
alternately. He sucked his thumb incessantly. His appetite
is good. He has little control over his vesical and anal sphincters.

The child is somewhat undersized, weighing twenty-eight
pounds and being well nourished. The head is small, the occipio-
frontal measuring nineteen inches. The facies is that of an
imbecile. The examination of the thoracic and abdominal
organs is negative. The spine shows a fairly marked kyphosis
apparently due to weakness of the vertebral muscles. The eyes
show a normal fundus.

His attacks of salaam convulsions come on without any
premonitory symptoms, whether the patient is standing or
sitting. There is a sudden bowing of the head, the chin touching
the sternum; simultaneous with this there is an inclination of
the trunk to an angle of about 60 degrees when in a sitting
posture; the right arm, partially flexed at the elbow, is brought
forward in slight abduction until it reaches the level of the
shoulder, the palm with fingers extended pointing downward
and inward. When the convulsions occur when the child is
standing, he will frequently fall forward, his head striking the
floor. During the spasm there seems to be a momentary loss
of consciousness. Between the spasms the child appears to be
contented, at times smiling and clasping his hands in apparent
joy. Each attack consists of twenty to thirty spasms, lasting
about twenty seconds, at intervals of fifteen to thirty seconds.
Toward the end of the attack the spasms are incomplete and
may consist of merely a partial bowing of the head. During
the last eighteeen months, while the patient was under observa-
tion, there had been no perceptible improvement at any time,
or any diminution in the number of attacks.


Dr. William Shannon presented a baby, eleven months of
age, who was taken to the clinic three and a half weeks ago. The
mother stated that the infant had not been doing very well, and
was constantly constipated. The child had been breast-fed
with the mixed feeding added and occasionally things taken from
the table. The mother said that when the baby was ten days
old it had meningitis, the convulsions lasting for a few days.
Except for these facts, the child was apparently well up to a
little over three weeks ago. When Dr. Shannon first saw the
patient, while perfectly relaxed at times, as soon as touched the
spasm characteristic of tetany was created, with the hands
assuming the characteristic position, wrists flexed, and fingers

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in the well-known position peculiar to the disease, the thumb
extending across the palm, strongly adducted almost to the
little finger. Both hands were drawn somewhat to the ulnar
side. When the spasms were severe the arms would be flexed
on the chest. The feet of this child also assumed the charac-
teristic position, being extended, and the toes completely flexed.
During the spasm the plantar surfaces became arched and the
dorsum prominent. Two weeks ago the feet became swollen.
Another peculiar thing regarding this case was that the infant
assumed the position of opisthotonos, that posture being as-
sumed for some time probably because the muscles of the
trunk were involved in the spasm. Trousseau's phenomenon
was sometimes present and the facial phenomenon was well
marked. The Imee reflexes were greatly exaggerated. Con-
sciousness appeared to be present at all times. There were no
symptoms of brain pressure, and the eyes were always normal
except that sometimes they were fixed and staring. The diagno-
sis of tetany was made because of the exaggerated reflexes, the
bilateral spasm, which could be excited or increased by pressure
on the nerves, no loss of consciousness, and the presence of
gastrointestinal disturbances. The infant was placed on oatmeal
and later hominy, etc., with a dose of castor oil and calomel
every day. At the end of one week's treatment the child was
practically well. The mother, however, neglected the instruc-
tions given her and the convulsions came on again. Sometimes
the spasms lasted five or ten minutes, and as times at long as an
hour or two. Dr. Dana and Dr. Winters had concurred with his


Dr. Kaufman Schlivek presented this case. The patient
was a boy, eleven years old, bom in Roumania. The mother
had had eleven children and one miscarriage. This child was
the ninth. The miscarriage occurred four years before his
birth. She has eight other children alive and healthy. One
child died at four weeks, cause unknown, and the other died of
measles. The father had an ulcer on his penis when the mother
was pregnant with this child about four months. He was
treated with mercurial ointment.

When four weeks old the patient had what was probably a
specific epiphysitis; he was treated with mercurial ointment.
He developed normally mentally and physically. He went to
school at seven years and was promoted in six months; since
then he has not advanced.

His present illness began about three years ago with a gradual
onset. The child became listless, could not find his way home,
ate food from garbage barrels, complained of headache and poor
vision; he always points to one spot on his head as being very
painful. When the headaches were severe he vomited frequently.
He does not walk well, and has to be assisted up stairs.

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The physical examination shows his general condition to be
good. His expression is blank; he looks like an imbecile and his
speech is not intelligent. He slurs his words. He is hyper-
sensitive. The skull is sensitive to pressure and to percussion.
The left pupil is larger than the right; they react readily to light.
There is no paralyses, no nystagmus, and the fundi are nor-
mal. The tongue protrudes to the right. The left facial nerve
is weak. There are no enlarged glands. The hands and feet
are cold and deeply cyanotic. The skin over the dorsum of the
second phalanx of three fingers is infiltrated. There is a double
pes planus. The gait is slightly spastic and waddling. Grip is
poor. There is no ataxia. Superficial reflexes are present.
The reflexes in the upper extremities are exaggerated. The
knee jerks are markedly exaggerated. There is a double ankle
clonus. There is no Babinski reaction. Sensation to touch,
temperature, and pain are not impaired. The Wassermann and
Noguchi tests are strongly positive. One week ago he had a
transitory paralysis of the right arm and leg. After eight
days this subsided, and now the right leg is dragged somewhat
and is more spastic. Without the serum test the diagnosis would
have been uncertain. The prognosis is bad, for the lesion most
probably is a sclerosis, and he has not responded to treatment.
He received twenty inunctions of mercury, then had large
doses of iodide of potassium, and is now getting both mercury
and the iodides. In all cases of disseminate involvement of the
nervous system one should suspect lues. The serum test in
these cases is of great diagnostic aid.


Dr. B. Wallace Hamilton read this paper.*


Dr. Godfrey R. Pisek congratulated Dr. Hamilton upon his
paper and the results he had recorded. Vulvovaginitis in
infancy and childhood was such a bugbear to those who did
much work in the hospitals that they were glad to have such an
enunciation showing the results, especially the consecutive
results, because heretofore their time had been almost wasted
in the treatment of these cases. Dr. Pisek said he had used
vaccines in the treatment of vulvovaginitis, and that he had
probably used all the irrigation treatments mentioned with no
success in the great majority of the cases. He never felt that
any of the cases were absolutely cured; he felt that after months
or years he could take smears and again find the gonococcus,
and even this held good in those instanced where the child was
discharged as cured, basing this statement on the smears. He
recalled a serious case of pelvic peritonitis in a child which did

♦See original article, p. 837.

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very well with treatment with a stock vaccine. He had lately-
attempted treating vulvovaginitis by making an autogenous
vaccine with the hope of getting better results, but as yet he
could not report on these. Cures in these cases should not be
recorded until the patients were examined one or two years after
treatment. Previous to the vaccine treatment he had used sup-
positories of 25 per cent, argyrol, having them made large enough
to distend the vaginal mucosa; in this way he found that he could
at least control the discharge. At the same time he uever felt
that he had been able to absolutely cure these patients.

Every girl who entered the hospital had a smear made before
entering, as well as subsequently. In the way of prophylaxis,
the argyrol ointment and suppositories had been as an experi-
ment used even if there was no discharge. Such children invari-
ably went through the hospital care without becoming contami-
nated. It seemed a horrible thought that these children in the
hospital were being exposed to such a contamination in spite
of the fact that they were all treated with all the precautions
they had been able to devise for their protection. With regard
to the amount of vaccine used, he had employed in children as
much as five million dead bacteria at a dose and had never seen
any bad results from such a large dosage.

Dr. L. E. LaFetra had seen most of these cases and could
confirm what Dr. Hamilton had stated in regard to the satisfactory
results obtained from the vaccine treatment. For several

Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 87 of 109)