EDITORIAL

GONOCOCCUS INFECTION IN CHILDREN'S INSTITUTIONS.

Probably no known infection is more to be dreaded in institutions tenanted by large numbers of young children than the gonococcus infection. This is true because of the unmanageable character it presents, and until comparatively lately its dangers were augmented by a large ignorance on the part of those whose duty it should be to guard against them.

The sheer good luck and natural resistant powers of the body which in some instances come to the rescue of institutions exposed by the carelessness or ignorance of their guardians seem to have been ineffective where this infection is concerned, and an infected child once received spreads disease unchecked among the other inmates. This state of affairs is not so much to be wondered at when we reflect that where only clinical symptoms are taken into consideration many cases must go undetected, even where the danger is recognized and watched for, and that in many minor institutions, day nurseries and the like, only the most obvious cases are treated and these in a wholly inadequate manner. That such conditions imply an appalling increase in gonorrheal vaginitis and arthritis, to say nothing of the threat of ophthalmia, is inevitable in view of the obstinate resistance of the infection even where it is fought with every precaution known to science.

The experience of the Babies' Hospital in New York City and the investigations made by Dr. L. E. Holt in regard to other institutions form at present the most significant body of literature in our possession upon this subject, and one that should be studied and taken to heart by everyone connected with the management of public homes, nurseries and hospitals where numbers of children are cared for.

In the New York Medical Journal for Saturday, March 18, and March 25, Dr. Holt recounts the struggles of the Babies' Hospital with the gonococcus during the past ten years. Up

to 1896 no microscopical examinations were made, and cases identified by clinical symptoms received no treatment beyond the use of a boric acid solution when napkins were changed. Even when the opening of the clinical laboratory brought the microscope into use as an aid to diagnosis, the extremely contagious character of the disorder was not appreciated, and a boy of five months was allowed to occupy the same ward with two established cases of gonorrheal vaginitis. The fact that he developed gonorrheal arthritis and general pyemia was easily explained in the light of subsequent experience.

In 1899 the hospital experienced its first epidemic, starting from three children from a day nursery who were transferred to the country branch before the nature of their disease had been discovered. As soon as cases were discovered the patients were put in the infected cottage and cared for by separate nurses. The napkins from this cottage were washed separately, boiled and disinfected, but although the precautions prevented successfully the contraction of ophthalmia, the infection spread, and every girl in the infected cottage, which was used as a dormitory by the larger children, contracted vaginitis. A general house disinfection, as rigorous as that employed for scarlet fever, was found necessary to check the disease. Greater care in the admission of patients kept the following year comparatively free from trouble, but in 1901 three children, two of them from another hospital, started another house epidemic equally obstinate. The same precautions were employed, but no amount of napkin disinfection was effective, and it became necessary to stop admitting female infants entirely. The year 1902 was signalized by the recognition of the existence of some other portal of entry than the eyes or the vagina. Three cases of multiple gonococcus arthritis developed in the wards in patients none of whom had ophthalmia. One was a boy two and a half months old, and another was a girl of one year who had no vaginitis. In this year also the infection was introduced into the new hospital building by one case of vaginitis and one of ophthalmia, and in spite of every precaution, in absolutely clean new wards eleven new cases promptly developed, including three of gonococcus arthritis in boys less than ten weeks old. Within the first six months

in the new building 29 cases of vaginitis and 8 of arthritis developed. Finally, in 1904 the rule was inaugurated to admit no female child without microscopical examination of the vaginal secretion, and if infection was found in children whose condition demanded hospital treatment, to place them under quarantine.

If so much difficulty was experienced in dealing with the matter in an institution with the equipment of the Babies' Hospital, it may readily be imagined what was the result of investigations among other institutions, and there is no doubt that Dr. Holt is justified in his conclusion that gonococcus infections, especially vaginitis, are steadily increasing in the city. This conclusion was confirmed by the discussion that followed the reading of his paper before the Academy of Medicine. That this increase can be checked only by the most extreme rigor of isolation and disinfection is evident when we find Dr. Holt establishing the fact that the contagion in the epidemics mentioned was conveyed by the nurses in the change of napkins. The precautions implied by this means of contagion are infinite in number and toilsome in nature, but absolutely essential if the ravages of the gonococcus are to be checked. The question of the portal of entry in gonococcus arthritis has not been solved, but Dr. Holt strongly suspects the mouth.

Space does not permit a recital of the prophylactic measures which have been found most effective. It can only be said that the invariable use of napkins on suspected children of any age, and a rigid quarantine extending to nurses and attendents must accompany strict measures of disinfection.

The most imperative need in the matter is for an awakening to the danger and a determination to fight it intelligently on the part of all who have the care of children in institutions.

RECURRENT VOMITING IN CHILDREN.

One of the most puzzling disorders encountered by the physician in the treatment of children is the recurrent vomiting which appears independent of errors of diet and accompanied by no pain save what can be referred to the strain of the vomiting. Some attempt has been made of late to study this matter, and it offers an interesting field for investigation.

There are wide differences of opinion as to its etiology and its treatment, but great unanimity as to its obstinate character. It has been known to appear as early as the second month, but generally after the first year, and tends to disappear as puberty approaches somewhere about the age of eleven years. Sometimes, but not invariably, a prodromal period is noticed characterized by malaise, headache, loss of appetite, coated tongue, and generally constipation, in a child previously well. The attacks vary widely in duration, from a few hours to several weeks, although the latter period has not been common and was broken by brief intervals of relief. The periods at which the attacks recur also vary markedly, from a few weeks to several years, although three months is probably about the most common period. While the attack lasts no food is retained, and retching sometimes becomes violent. Rapid emaciation results from practical starvation, but after the attack subsides, building up goes on as rapidly in its turn.

The first attack is easily confounded with acute gastritis, appendicitis, intussusception and other forms of intestinal obstruction in their early stages, or even with Addison's disease, as the marked pigmentation has been known to be present.

The prognosis is generally good, only four fatal cases being recorded. In two of these autopsies were obtained, but without conclusive results, the important feature in one case being an almost complete necrosis of the mucosa of the stomach and intestines, and in the other a fatty degeneration of the liver.

Almost the only constant symptom is the persistent vomiting, although constipation is common. Thirst has frequently

been noted, and the abdomen may be either distended or retracted. There may be a tenderness in the epigastrium, and some headache.

Examination of the urine does little to clear up the problem, even when, as is the general rule, it confirms the presence of acetone indicated by the odor of the breath. Right at this point is where the "doctors disagree." Marfan believes the acetone to be the toxic factor and the vomiting due to acetonemia. Griffith thinks that the acetone is merely a guide to altered metabolism which produces toxins and eventually vomiting when no more toxins can be stored up. Holt thinks that a lithemic state is responsible for the condition, a view supported by a history of gout in the parents of some of the patients and, in one case observed by him, a diminution of uric acid excreted during the attack. Rachford, too, believes that a lithemic state exists due to an incompetence of the liver, producing autointoxication.

Edsall has a theory which he is able to support to a certain degree by success in treatment. He believes that the vomiting results from acid intoxication, calling attention to the similarity between the worst cases of this disorder and fatal diabetes. Respiratory difficulty of the "air hunger" type, drowsiness passing into coma, thirst, acetone in the breath and a urine composition identical with that of diabetes mellitus save in the absence of sugar, are all found in recurrent vomiting. In pursuance of this theory he treats with large doses of bicarbonate of soda, and has seemed able in some cases to avoid or cut short the attacks. But on the other hand, many cases have failed to yield to this treatment, and, as Langmead points out, the constituents of the urine on which Edsall places dependence are so frequently found unassociated with vomiting as to lessen their value in his theory. There is little doubt that acid intoxication occurs, but that it occasions the vomiting is yet to be demonstrated. And when improvement has followed the administration of the bicarbonate of soda it is only by the post hoc ergo propter hoc argument that we can assert that it is due to correction of the acid poisoning.

Other measures that have been employed more or less empirically are starvation for twenty-four hours, rectal feeding,