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The purpose of this paper is to direct attention to a symptom that in my experience and in that of my immediate associates is of very frequent occurrence and which has, so far as I know, received little, if any, attention in the literature. Several recent exhaustive papers on the subject of abdominal pain in children do not mention it and a partial search of the literature would lead one to think that others have either not made the same observation or else have failed to consider it as a distinct entity worthy of record. For nearly ten years this symptom has so regularly and so insistently intruded on our attention that it has seemed to me worth while to discuss it on an occasion like this. The symptom to which I refer is that of abdominal pain occurring often to the exclusion of all other subjective symptoms, or, at

The curds that occur in the stools of infants, especially of those fed on cow's-milk, have been the subject of much discussion among pediatricians. A great deal of importance attaches to the solution of the problem of their etiology and nature, because their presence in the stools has always been considered an evidence of an overstepping of the infant's tolerance for the particular food element from which the curds were thought to be derived. The pendulum has swung from the first natural interpretation that they were undigested particles of curdled milk, therefore chiefly protein in origin, to the opposite extreme, if we are to accept the teaching of nearly all the foremost German pediatricians, that the casein takes no part in their formation. From observations that we have made in our clinic at Northwestern University Medical School, and from some experiments that I have made in the past year, I

In our progress upward, whether in religion, in economics or in the science and art of infant feeding, we advance by epochs, and often the gospel of one epoch becomes the heresy of the next, only to become again the gospel in the light of some newer truth. In the first flush of bacteriologic activity, the idea that infantile diarrheas were infectious and that milk carried pathogenic micro-organisms naturally led to sterilization of the baby's milk by heating it. Then scurvy intruded itself, and pasteurization at lower heat, yet high and long enough to destroy pathogenic germs while influencing the milk less, took its place. But pasteurization was still held as only less objectionable, and for the same reasons, than sterilization, and offered serious technical difficulties. There naturally followed a demand for a milk clean and fresh and nearly enough germ free to be safe without heating. By analogy with

We are all familiar with the fact that disturbances of the alimentary tract, such as indigestion, summer complaint, ileocolitis, cholera infantum, etc., are commonly accompanied by more or less profound nervous symptoms that in their totality make up the clinical picture of an intoxication. The babies thus affected are listless, drowsy, stuporous, heavy-eyed, with eyes fixed on vacancy, are hard to rouse and quickly sink back into their stupor, which in severe cases may amount to coma. They look as if under the influence of a drug, as if poisoned or intoxicated or "dopey." We have become so accustomed to thinking that such intoxications, characterized as they are by fever, leucocytosis, psychic depression, collapse and evidences of indigestion or enteritis, must be due to a bacterial toxin that a simpler explanation has escaped us. In a series of papers that will serve as models of profoundly critical and convincing scientific

During the last decade the problem of infant feeding has been a peculiarly interesting one in this country. While European writers are fairly well agreed on fundamental methods, there has grown up a system of infant feeding in this country that in its elaboration is unique. This so-called percentage, or American, system has received such universal and unqualified approval among our pediatricians that it seems almost like heresy to doubt its tenets, and yet an overwhelming mass of evidence has appeared in the last few years that to my mind discredits the fundamental principles of that system. I shall first outline what I believe to be a rational dietary for the first year of life and will then advance briefly some objections to the percentage method. It is important at the start to define the term "healthy" baby, because there is an essential difference between a healthy and a sick

The rheumatic nodules that receive so much attention from British writers on rheumatism in children are almost universally considered a rare condition with us. In all our textbooks there is a striking uniformity of expression that these nodules are common in England, but are rarely seen in this country. Thus Holt and Howland 1 say: "They are certainly not common in this country, and although we have made it a rule to examine rheumatic patients for them, we have seen them but seldom, and they have been prominent in only eight or ten cases. This has also been the experience of most observers in this country. From published reports, however, they appear to be much more frequent in England." In the 1911 edition of Holt 2 the prominent cases had been placed at "two or three." Koplik 3 says: "The so-called subcutaneous rheumatic nodules are seen in children less frequently

For a number of years my attention has been drawn with increasing frequency to a peculiar lesion of the meatus urinarius occurring only in circumcised male children, and characterized by ulceration, crusting, narrowing of the urinary passage, and nearly always accompanied by painful urination, often with distended bladder, and, occasionally, by hemorrhages. I have been able to find only one reference 1 to it in the literature. While this condition probably is common in occurrence in the experience of all pediatrists, I am inclined to believe that it is more common in this locality and in more recent years than in some other localities and in my own earlier years, and that the manifestations are more severe. My first impression was that this lesion was caused by rubbing against the clothing of the naturally most accessible and most vulnerable portion of the exposed glans, the meatus. This, however, seemed improbable

To the Editor:— At the time my paper on pediatric emergencies was written, to my knowledge no child with congenital atresia had ever lived, and the duration of life was usually shortened by operation. On a recent trip to Minneapolis I saw, however, a baby that had been operated on three months before and was still living. In that case a gastrostomy had been done and a catheter had been passed some little distance beyond the pylorus, followed by a tying off of the lower end of the esophagus near the bifurcation of the trachea. I quite agree with Dr. Brescia that "our task as physicians is to strive to maintain life against all odds and to aim at perfection in our work and nothing short of perfection." Since the child on whom the operation I have just spoken of was performed may live for years and since an artificial

That overfeeding in infancy is apt to be followed by indigestion is a universally recognized fact. The term, however, usually suggests the giving to an infant of a food that is too rich in one or more food elements, or that is unsuitable to age and conditions, or that is given in too great variety and at too short and irregular intervals. We have not been sufficiently impressed with the fact that even an appropriate artificial food and one properly adapted to the individual case, can give rise to the profoundest nutritional disturbances when given in quantities that exceed the actual economic needs of the infant. In this discussion the term overfeeding will be used in this restricted sense, the giving to an infant of too great a total quantity of good, clean, fresh, unexceptionable, properly modified cow's milk, usually, but not necessarily, at too short intervals. Continental writers have

Why should a pediatrician, who is a general practitioner to the young, presume to discuss a subject that might seem to belong to a regional specialist? The answer is evident. In the first place, it is because he is a general practitioner and must therefore be usefully informed on one of the most common and most important diseases of childhood. Furthermore, he and the general practitioner, alone, are in a strategic position to acquire extensive and practical knowledge of the developmental period of middle ear disease and a resulting ability to prognosticate with some assurance in an early questionable case. The otologist commonly sees only the ear in the case presented to him for surgical judgment or treatment. The pediatrician, as a rule, sees the patient for the underlying throat infection before the ear is involved. If he is a good pediatrician he has long ago found his otoscope as

My subject may seem both simple and stale. And yet, to one who knows the hazards, and has on his conscience the responsibility for the conduct of an infant ward, it is never either of these. An infant mortality that, in our experience, is easily four times that of the whole Children's Memorial Hospital, and seven times that of the children beyond the age of 18 months, is a constant challenge. Some of this mortality is inevitable; there is no cure for tuberculous meningitis or congenital atresia of the esophagus. Nor is there need to be so deeply concerned if this mortality represented only the futile efforts to overcome a disease with which the child entered the hospital if there is no better way to meet the situation elsewhere. The specter of an institutional casualty, more insidious and less evident here, but far more real than elsewhere, sits always with

The excuse for reporting a single case lies, in this instance, in the twofold fact that it is unique in our experience, and that we have been able to find but one other apparently identical case in the literature. For about eight years, or since he was 10 months old, a boy with a striking general deformity of the body has been in and out of our clinic at the Children's Memorial Hospital. From the start an object of curiosity, he became increasingly so as he grew older and the deformities became more evident (fig. 1). The early diagnosis of rickets—made even then with much reservation—was soon abandoned. His diet and hygiene and his general care by an intelligent mother had all been unexceptionable. Beyond the period of infancy the whole clinical picture was unlike anything that could be attributed to rickets. Free consultation together with sporadic attempts at a

Purulent infections of the urinary tract are by no means infrequent in infancy and early childhood. They form probably 1 per cent, of all the illnesses that bring these little patients under the physician's care. Roughly speaking, I should estimate them to be about as frequent in my own practice as meningitis. These infections still occupy rather a unique position, in that they are almost never recognized in general practice. This is not because the babies are not sick, or because the diagnosis is difficult. The babies are alarmingly ill, have long-continued high septic fevers and become emaciated and anemic to an extreme degree, and a considerable per cent, die if untreated. The diagnosis, on the other hand, is easy and positive, and can be madeby any one who can recognize a pus cell under the microscope. The reason why the diagnosis is not made in these cases is that

During the calendar year 1928, thirty-seven patients were treated for empyema at the Children's Memorial Hospital. All of these were treated by aspiration alone except the following five patients: One child with an old postoperative fistula with a rubber drainage tube lost in the empyema cavity. One child with an aspirating needle in the empyema cavity following an attempt at aspiration before entrance to the hospital. One baby, aged 4 months, who anticipated aspiration by coughing up the pus and getting well by himself. One child who was operated on after three aspirations because of the insistence of the attending physician who had sent him into the hospital. One patient in whom, because of a natural anxiety in the early part of the series, we thought it best after eight aspirations to resort to operation because the right heart border persisted in the right nipple line. In the light of

When your president honored me by asking me to address the New England Pediatric Society I submitted several subjects on which I might speak. Among them I had very hesitatingly placed the title of the present paper. When I received his reply saying that it would be "very nice" if I would discuss the menace of psychiatry, I confess that I broke out into a cold perspiration and had a bad night. From that reaction I have not yet fully recovered. I still feel keenly the hazard of perhaps prematurely attemping a critical evaluation of a very popular movement that has a tremendous momentum and that has not yet reached its acme. It is as though I had come to Boston twenty years ago and had questioned percentage feeding or had foreseen a menace ten years ago in the general propaganda of weighing and measuring all children. Other considerations enter

Seven or eight years ago, an infant about 1 year of age entered the Children's Memorial Hospital showing the clinical picture of acute sepsis, with high fluctuating temperature, yellowish color, slightly enlarged spleen and a fairly abundant crop of petechiae. Immediately after admission, the child was presented at a postgraduate clinic by one of us (J. B.) as having severe sepsis of unknown origin. The blood count, however, revealed marked anemia and still more marked leukopenia, with an almost complete absence of polymorphonuclear cells. The diagnosis was changed to that of an aleukemic stage of acute lymphatic leukemia, and the case, as was expected, went on to a rapidly fatal termination, with an ever-increasing exacerbation of all the cardinal symptoms. The history of this case, unfortunately, cannot be found, and so the exact details are not reportable. It made, however, a deep impression, as we had never encountered the much

The pediatrician is a general practitioner to the young, a chronologic, and not a regional specialist. We have not, therefore, that incisive special knowledge concerning the diagnosis of pulmonary tuberculosis that the specialist in tuberculosis has. We sit in proper awe, possibly a little skeptical at times, but only wholesomely so, as you unravel the mysteries of a suspected chest with that peculiar precision that you have acquired and that we, and I might include not a few internists, frankly do not possess. If we sometimes feel that an immediate autopsy might be instructive it is only because of that reasonable skepticism that is imposed on every intelligent clinician by the still existing limitations to unfailing diagnosis in chest conditions, that makes it still rather an art than a science. I shall not therefore "bring coals to Newcastle" by dwelling on finer points of diagnosis but will attempt as a

Six years ago I1reported some observations and impressions on the occurrence of a peculiar abdominal pain, or pains, in the course of throat infections in children. Although the paper did not elicit any comment at that time, the symptom complex then described has since attracted rather wide interest and has entered fairly extensively into the recent literature on abdominal conditions, accompanied by pain, in children. I am more than ever convinced that this pain, which is of little, if any, therapeutic or prognostic interest, is of great importance in the differential diagnosis of abdominal conditions in children when pain is a cardinal symptom. Of these, appendicitis is obviously the most important in this connection. Since writing that paper and others,2it has been my unhappy experience on a number of occasions to see the diagnosis of appendicitis discounted, or even excluded, because the patient had a throat

Milk, alone of all foods, enters the stomach a liquid and becomes there a more solid food. This hidden and insidious solidness, if I may use the term, is peculiarly characteristic of raw cow's milk, as compared with boiled cow's milk, or human milk. The housewife and the dairyman are practically familiar with the fact that boiled milk forms a different curd from raw milk. We, on the other hand, have quite ignored the fact that raw and boiled milk are not identical foods. If we have thought of it at all it has been rather from a bacteriologic than from a physiologic point of view. And yet boiled cow's milk forms in the stomach, as does human milk, nearly a liquid food; while raw cow's milk, as I shall hope to demonstrate, is not even a soft food, but a solid food, so solid, in fact, that, unless modified

It is well known that temperatures taken by rectum run about 1 degree (F.) higher than those taken by mouth. It is also generally known that the body temperature may rise several degrees with exercise, the elevation varying directly with the amount or intensity of the exertion. It is apparently not widely known that exercise will cause the rectal temperature to go up several degrees while the oral temperature taken at the same time may remain unchanged, rise slightly or, as often, fall to a lower point. I have, indeed, never personally encountered any one familiar with this phenomenon. In what would seem an adequately large and representative series of observations, herewith presented, I have failed to find a single instance in which this disparity was not strikingly in evidence. The purpose of this paper is to present data on the disparity. The clinical implications will at once be obvious

Acid milk of one kind or another has long held first place in the therapeutic armamentarium in the artificial feeding of infants with diarrheal disorders. Buttermilk, a by-product of the dairy industry and for generations a standard food for babies in Holland, found its way into scientific pediatric circles at about the beginning of the present century, chiefly through the efforts of Teixeira de Mattos. 1 For many years it held its place as the ne plus ultra of artificial foods in the feeding of pathologic infants. Its evident superiority over fat free sweet milk was never seriously questioned, authoritatively, except by Czerny and Keller, 2 in 1906, with whom it followed as a logical corollary to the view that in the fat lay the essential difficulty in artificial feeding. In the latter part of the second volume of the same edition 2 (1917), and in the second edition, they

In 1929 we 1 reported a series of thirty-three consecutive cases of empyema in children, with a mortality of 9.1 per cent. Of these patients, twenty-eight, or 85 per cent, were cured by aspiration alone. One infant of 4 months of age recovered by spontaneous rupture through a bronchus. One older child was operated on after a number of aspirations had been done because the heart remained far to the right of its normal position. In the light of subsequent experience we feel sure that this child, too, would have recovered by aspiration alone. There were three deaths. One of these occurred in a child who went home against advice and died a week later; the second in an infant who died of pneumococcus septicemia and meningitis and in whom the incidental empyema cavity had a capacity, at autopsy, of less than 1 fluid ounce (30 cc.), and the third

This report deals with 250 cases of true and potential, or abortive, abscesses in the throats of children under 14 years of age observed in the wards of the Children's Memorial Hospital, Chicago, over a period of ten years ended Dec. 31, 1940. In 181 of these cases there was frank suppuration, as shown by spontaneous rupture or surgical drainage. In the remaining 69 a localized inflammatory lesion, apparently differing in no way from the lesions in the early stages of the other group, subsided without evident pus formation for one reason or another. Nearly all of these cases were treated in the pediatric service exclusively except when laryngologic help seemed indicated as in any analogous situation. This rather unusual procedure requires some justification, at least an explanation. At the Children's Memorial Hospital, except for one resident in pathology, all the house staff are future pediatricians or general practitioners and

Congenital atresia of the esophagus is everywhere considered one of the rare anomalies. Sir Morell Mackenzie 1 (1884), after an exhaustive search could collect only sixty-two cases from the literature, and added only one of his own. Shukowsky, 2 with a hospital experience of 50,000 new-born babies, saw only one case. And yet within a period of one year three of these cases came under my observation, and I have knowledge of at least one other within the following year. 3 Even more striking was Hirschsprung's 4 experience, who, in 1861, in Copenhagen, with only 180,000 inhabitants, saw four of these cases within a period of seven months. Although such grouping is a matter of chance, yet one cannot help but wonder whether these cases are not more frequent than we have been led to think. The cases here reported were all under exact observation in hospitals, and in each

It is only in recent times that the outpatient department of our medical schools and hospitals for children has shown encouraging symptoms of assuming its properposition as a teaching force. Dispensary work has long been, and in many quarters still is, considered a sort of necessary drudgery or apprenticeship that the younger man must serve for many years, partly to supply material for the older men in the wards, and partly to prepare the younger man for the more important house service of later years. I myself have never shared that point of view. This may have been, at first, largely due to the peculiar and limited clinical situation of my earlier years; but even today, with a large hospital and a very large material, I find myself instinctively heading for the outpatient department when I begin my daily rounds. To give to an outpatient department a maximum of attractiveness

There is probably no more interesting, uncertain or hazardous clinical domain in childhood than acute conditions in the abdomen and pain is the presenting symptom, the warning signal, that something has gone wrong and that it may be serious. That it is not usually so has in itself an element of danger. The very fact that the incidence of conditions that are not serious is much higher than that of those that are may lead to a lack of wariness that may be fateful. The differentiation cannot be made safely on the telephone. The difficulty in diagnosis is not due to the fact that the infant cannot talk and the older child may not be able to give an intelligent account of his symptoms. The pediatrician is as much at home with the youngest child as he is with the oldest. The morbid anatomy of the child is distinctive and

Congenital anorectal stricture, unaccompanied by other anomalies of that region, is apparently a rare condition, if one may judge from the literature. Especially infrequent are reports of cases seen in infancy, or as a cause of megacolon. In support of these statements I might quote from two recent (1923) papers of Vernon David:1 The different types of imperforate anus, varying from complete lack of formation of the rectum to the incomplete formation of the rectum with fistulae leading from the rectal pouch to the bladder, urethra, vagina and perineum, are well known and well described in the many textbooks of embryology, pathology and surgery. In contrast, congenital strictures of the rectum with the external anal opening apparently normal are rare, and not only is scant mention made of them in textbooks but reported cases are very infrequently seen. In a second paper, after referring to an operation for megacolon

[Editorial Note. —This paper, together with the paper by Dr. Graham, which follows it, concludes the symposium on "Chronic Nonspecific Infections of the Lungs and Bronchi." The last issue ofThe Journalcontained the papers by Dr. Jackson, Dr. Morse and Dr. Mullin.] The medical treatment of chronic nonspecific infections of the lungs and bronchi in children is a topic that admits of individual interpretation and requires definition. Under "chronic nonspecific infections of the lungs and bronchi" I shall include chronic bronchitis, together with recurrent bronchitis, both simple and asthmatic; unresolved pneumonia; lung abscess, bronchiectasis, and certain types of massive collapse of the lung; and chronic empyema. Under "medical" treatment I shall include not only such measures as I, a nonsurgical man, would suggest in the treatment of chronic nonspecific infections of the lungs and bronchi; but also such advise as I, a medical man, might give with reference to