SOME VIEWS UPON THERAPY FRANK C. NEFF, M.D. Professor of Clinical Diseases of Children, It may not be uninteresting nor untimely to consider briefly some observations which have come to me in the past ten years bearing upon the subject mentioned in the title of this paper. When we realize that even more care has to be exercised in the handling of patients of tender years than in that of older persons, it is evident that it must be made a study, and that it is worthy of much personal effort and investigation. On account of the inability of infants to make known their symptoms; because of the failure of older ones to complain; because children usually do not reason nor understand the why of a certain measure, we should limit our efforts to those which are best suited to the age and to those which will not frighten the child nor embarrass its already disturbed delicate make-up. You are all familiar with the opinions prevalent among the laity concerning the administration of so-called strong medicine during childhood. This instance once narrated to me is in substance frequently heard: A homeopath had been employed in a certain case of typhoid in a young girl, because the parents feared the consequences of the remedies which are reported to be used in undue strength and large dosage by practitioners of the regular school. This notion. may be exaggerated, but it has arisen sometimes because of a lack of candor on the part of the physician who, recognizing that a certain case does not need drugs, has continued to use them for fear that the relatives will criticise him otherwise. As has been repeatedly said, our profession should be an educator. We should teach the truth that our province is not necesarily one of pill-dispensing, but that through our study of the body in health and disease, through our knowledge of hygiene and preventative measures, through the agency of such therapeutic influences as diet, fresh air, cold, heat, massage, electricity, climate, etc., we physicians have other great resources for combating morbid conditions. We do not have to resort to drugs except as they are specifics or adjuvants. I do not mean that our therapy should be selected with the purpose of pleasing the persons concerned, nor that we should be cowards in giving medicine when needed and in sufficient doses to accomplish results. But I do feel that by the proper instruction the laity will understand and appreciate our candor in refusing to give drugs when not needed. In correcting this wrong impression of our profession, the parents will not feel that they have to employ one in whom they have no other confidence than that his medicine is in such infinitesimal doses that it will do no harm. In common with many practitioners I have gone through the period of materia medica skepticism. I am glad to say that from the practical demonstration of the curative and beneficial results achieved in many cases I have reached again the safe ground of orthodox belief in its efficacy. After as careful a diagnosis as I can reach, if need be with the help of the laboratory and consultation, I am in a position to consider what measures are indicated. If the condition is a simple one and needs to be met by the administration of medicine alone, the chief concern is to give it at proper intervals, in sufficient doses and in the form that will not produce untoward results nor hinder the natural healing process. Personal observation is necessary to teach one if his prescriptions are as palatable as possible. I have often tasted a mixture to see if there could be some improvement to make it less objectionable to a child. In most instances all remedies by the mouth are "medicine" to little folk, and I have found that the simpler a prescription can be made the less nauseating and objectionable it will be. Mixtures with bulky syrups are usually unnecessary, for they serve no purpose that cannot be attained in other ways and they have the objections of becoming tiresome and irritating to the stomach. The same results can be eached by giving the small dose in tablet or powder form. If the child is too young or objects to it the tablet may be crushed and given dry on the tongue. When liquids are to be administered they may be added by a dropper to a lump of sugar or to some bland fluid. As an instance of this kind I might mention the difficulty one meets in getting a suitable mixture containing cod liver oil. On account of the fact that proprietary formulas containing this oil are bulky and have often been robbed of their real value and that so much smaller a dose can be used in children I have sought to give it in a way that will be palatable and still keep all its properties. It can be given in doses of fifteen to thirty drops or more. Some children do not object to its taste in the pure state, but it may be rendered palatable and more nourishing by suspending it in a portion of freshly beaten egg to which has been added some orange, lemon, or grape juice. If the oil is not well borne by the stomach there is the alternative of using it by inunction. The same is true of the iodides and mercury. An occasional dose of medicine can be satisfactorily given by the rectum as I have frequently done with a child. suffering from convulsions, gastritis, tetanus and angina. Rotch states in his last edition of 'Pediatics": An important fact to remember in the treatment of infants and young children is that drugs play a very insignificant part in the actual cure of the disease. He decries the promiscuous use of drugs. During my interne days at the New York Infant Asylum it was shown that many gastro-intestinal, including typhoid cases get along just as well with conservative feeding and proper nursing with only an occasional symptomatic dose of medicine. In the January number of the American Journal of the Medical Sciences you will find reported a large series of pneumonia cases treated solely by the out-door method, not a drug given. In this series the percentage of recoveries is just as high, if not higher, than an equal number of cases where the quinine and other nauseating methods are used. Northrup is entitled to the credit of bringing successfully to our attention the beneficial effects of cold fresh air in pneumonia and other respiratory diseases. He modestly claims nothing personal in this method. He would not underestimate the value of drugs, but would use them if indicated. One great thing in the favor of this out-door treatment is that it has proven frequently a success as a last resort in those extreme cases where other remedies were not giving rsults. If we are too conservative to use this in a case that is apparently doing well, we can find no objection to trying it with the endorsement of so many pediatrists. in attempting to save the life that will otherwise go out. My limited experience with it has shown no bad results and I shall not be afraid to employ it whenever indicated. It is certainly very grateful to an almost asphyxiated child, and the breathing is immediately benefited. In hydrotherapy we have a field which is worthy of more careful statistical knowledge than I have been able to find in the material at hand. Children respond and react well to baths and applications. In the children's wards at King's County hospital we used tubbing seldom as a routine method, but the mustard bath early in pneumonia, the hot and tepid alcohol sponge baths in febrile conditions were as universally satisfac tory as any other treatment. Whether an elevated temperature is beneficially altered or not, it is far safer than to use internal febrifuges, and in addition we gain the benefit of the massaging, cleansing, comforting and sedative action upon the child. To encounter a child smothered in ridiculously heavy and numerous clothes covered with an accumulation of sour perspiration is indication enough that if for no other reason its comfort can be greatly increased by occasional baths, unless there be a condition of hypersensitiveness as in cerebrospinal meningitis. The educational value to the mother is considerable, for when she sees that no ill results from carefully bathing underneath a sheet, she will be less anxious to keep the child uncomfortably swathed in clothes. Kerley of New York correctly states that the greatest difficulty in the treatment of children's diseases is the mother herself. To get an intelligent and painstaking co-operation in carrying out the necessary details is frequently an impossibility. A mother will listen to all meddlesome suggestions of outsiders. is solicitous to the point of interfering with calm judgment and as a result she is apt to be a poor nurse. If the chil She is spoiled or if the mother is ignoram and the victim of a mistaken sympathy, your instructions will not be obeyed. I have seen institutional infants that needed the sympathetic handling that we call "mothering," but I more frequently encounter a child who suffers from too much "mother," "grandmother," "aunts," and neighbors. It is therefore usually impossible to do as well at home as in a well conducted hospital with an experi enced nurse. Many mothers bring up their children to fear the doctor. He is pictured as an inhuman punisher. The parents' lack of firmness in exercising discipline is reenforced by coaxing, and when that fails the offender is threatened with being tortured by the man who is associated with pain and suffering. So the physician works under a handicap. He has to take things as he finds them, which means that his therapy and his results will suffer accordingly. Children of this age can be handled more successfully if they are friendly and if they have been taught that we have come to help relieve them of their ailments. In such we get the benefit of the helpful psychic influence, a therapeutic agent which is unavailable in treating babies. We have not yet reached the point of believing that helpless unthinking infants can be "thought over" and cured by the demonstration of someone else's mind over their matter. The most important therapeutic measure is undoubtedly found in the use of the proper diet. So many of the pathological conditions are due to errors in feeding, or are of a self-limited nature. Correct food is frequently the only treatment needed. The ideal nourishment for infants is of course found in the secretion of the normal breast. Amberg, of Johns Hopkins, and others have shown that the phagocytic power of even weak breast-fed infants is greater than that formed in the blood of the artificially fed. The high alexin content of a mother's milk gives an immunity or a degree of resistance that cannot be reached by any other food. It is evident that the greatest efforts should be made to guar antee to the infant this life-preserving and disease-resisting diet. To that end the mother should be encouraged to nurse within the normal period as long as there is healthful secretion, no matter if the amount be small. The infant has a better chance with one or two breast feedings a day and the additional mixed feeding than with an all artificial diet. I am more than ever convinced since it is proven that the opsonic index is higher in breast babies, that where the maternal breast is not available we should resort to that of a properly selected wet nurse. In conclusion let me say that it is reasonable to suppose that as organisms are being isolated and proven the cause of certain diseases; and as vaccine and serum therapy is increasing in efficacy and in wideness of application, that the future treatment will be largely upon this basis. In addition we shall continue to use certain therapeutic agents which I have mentioned as supportive measures and to enhance the comfort of the patient while a return to the normal is being secured. TUBERCULOSIS OF THE KIDNEY. J. M. TAYLOR, M. D., Renal tuberculosis may be primary or secondary, and it may be bi-lateral or unilateral. Primary cases are usually unilateral in the early stages; later on the infection may descend to the bladder and thence to the opposite kidney. Secondary cases are concurrent with other tubercular foci. It is with primary cases that this paper is more concerned. The mode of infection in primary cases is not exactly clear. It may result from latent infected glands, or it may pass through the healthy tissues to the blood stream without causing any lesion at point of entrance; possibly through the stomach from infected milk, or it may be an ascending infection through the urinary canal. More frequently, however, the infection is hematogenous. The claim is made by some authors that there is no such thing as primary renal tuberculosis, but when we consider the complex structure of the kidney and its enormous blood supply, it receiving nearly fourteen times as much blood as any organ in the body, according to comparative weight, also that a principal function of the organ is to rid the economy of impurities, it does not seem strange that it should frequently be the organ first infected by tuberculosis. Professor Ernst Kuster cites numerous cases of primary infection, in fact, in his opinion the majority of cases are of primary origin. It occurs more frequently in the male than in the female, in the proportion of three to one. It is more often found in persons between 20 and 40 years of age, but may occur at any age of life; in fact, it is not infrequent in children of 10 or 12 years and has been found in an infant 3 months old. In the hematogenous form the lesion. is usually in the cortex encapsulated in the dense connective tissue, while in the ascending form the wall of the pelvis is the part more frequently affected, usually in the form of ulcers. Occasionally in the late stages the affected kidney may be enlarged; more frequently, however, it atrophies. Not infrequently a true pyonephrosis may exist. The symptoms are, a persistent remittent hectic fever, often without any apparent cause; progressive loss of weight and strength and loss of appetite. There may or may not be pain or tenderness in the region of the kidney. The quantity of urine may be normal, yet more often the amount is slightly increased, and may contain albumen, although the albumenuria is spasmodic. The specific gravity of the urine is low, usually 10.10 to 10.15, but sometimes runs as low as 10.04. The microscope shows few casts and little or no epithelium. Tubercular bacilli are present in the urine in all advanced cases, occasionally shreds or bundles of connective tissues are found and pus and blood are frequent. There are no disturbances of the heart and arterial system, and anasarca is ab sent. Cystitis is the usual accompaniment or sequence, and very often hematuria is present. Hawley says that in all cases of transient hematuria of doubtful cause we should consider the possibility of renal tuberculosis. The diagnosis should not be difficult. For this purpose the finding of the bacillus tuberculosis is invaluable, but the possibility of confusing smegma bacilli with tubercular bacilli should always be borne in mind. For this reason, and because tubercular bacilli may be present in such small numbers as not to be readily detected, it seems advisable to innoculate the Guinea pig for confirmation of the test. However, in the early stages of the disease the bacillus tuberculosis may not appear in the urine, since the tubercular foci are situated in the cortex encapsulated by the strong connective tissue and must break down and ulcerate before the bacillus is liberated. And again, tubercular bacilli may be found in the urine and it may be impossible to decide whether they come from the kidney or bladder, yet this mistake will seldom be made if we remember that renal pus is always acid and that of cystitis invariably alkaline yet where a concurrent cystitis exists the acidity of the renal pus may be masked. Since it is important that we make an early diagnosis, and as the origin of the tubercular bacilli may be in doubt, and for the further reason that the microscope is not always convenient or practicable to the busy practitioner, we should be able to make a diagnosis with a fair degree of certainty by a careful clinical examination. Persistent hectic fever, loss of weight and strength, transient hematuria, increased amount of urine of low specific gravity, and the absence of anasarca and of heart and arterial complications, should be sufficient to make a diagnosis to which finding of tubercular bacilli could only be a valuable confirmation. Renal calculus and chronic non-tubercular pyelitis are perhaps more likely to confuse the diagnosis than anything else. There may or may not be pain in either case. Hematuria may be present as also may be the fever, but in renal calculus. hematuria is more constant, fever is rare and tubercular cachexia is absent. The X-ray will often clear the diagnosis. In pyelitis the fever is irregular and long periods of normal temperature intervene. Following a period of apyrexia a high fever ushered in by a chill is dependent. upon an obstruction of the ureter and consequent retention of pus. The pain in the loin is more constant and severe and there is a more frequent desire to urinate, and the urine contains an abundance of epithelium. Primary hematogenous renal tuberculosis may be mistaken for typhoid or ma larial fever. The following case is illustrative: The patient, a lady 57 years of age, whose family history was negative, came to Fort Smith, to her daughters, about the first of April, 1907. She said that her doctor told her that she had chronic malarial fever. From my examination I was inclined to believe that she was convalescing from a protracted case of typhoid fever. She was able to sit up some, had a variable appetite, with very poor digestion, and had a slight rise of temperature every afternoon, which subsided before midnight, to return the next day. She complained of no pain except a slight tenderness in the abdomen. Inquiry about the kidneys was answered by "Oh, they are all right. I never have any trouble with my kidneys." Consequently I neglected a duty we owe to our patients and ourselves in all continued fevers, that is, an examination of the urine. Instead of the patient convalescing, as I had expected, she gradually grew weaker, the fever increased and the remissions became shorter. I finally askd for a sample of urine, which I found contained. pus and slight traces of albumen, with a specific gravity of 10.08, which finally ran as low as 10.04. The daily quantity was about sixty-five ounces. After a careful examination of the heart and arterial system with negative results, I made a diagnosis of renal tuberculosis, which was afterwards confirmed by the finding of tubercular bacilli in the urine. |