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pears to me that the character of the disease this year in a large majority of cases is more that of polioencephalitis than poliomyelitis. That explains a number of symptoms that formerly were not very common. We should remember that where polioencephalitis is predominating there should be intact patella reflex. In the cases where the cord is affected the reflex disappears in a very short time and atrophy will set in very soon. If we remember what we knew formerly of poliomyelitis, and that this winter the epidemic was twenty times as extensive as the largest of those that had been observed anywhere and the cases a hundred times as numerous as occurred in many of the epidemics, we should hesitate a little in demanding the same symptoms that were observed at that time, in those cases, that it was our lot to see last year. I would fall back upon the old reports—those of Heine in 1840 and 1860. Most all of his cases were of a different description altogether. He reported cases of children put to bed well and taken up paralyzed; nothing the matter with them at night and in the morning paraplegia. A number of cases, however, were reported by him in which there was the occurrence of fever in the night and paralysis in the morning. There were other cases in which the babies were sick in bed with, for instance, scarlet fever or pneumonia, and when taken from the bed it was found that they were paralyzed. So there were a number of different types even then. These are the cases and types which I have often seen, and described these nearly fifty years. Therefore, we should not be so astonished to find in an epidemic that is a hundred times as large as those were that there should be a number of different symptoms. We should be satisfied in saying, as we do not know the etiology, that it is a disease striking the nervous system as a whole, more in this place or that, as the case may be. Cases of polioencephalitis have a greater tendency to get well completely than cases of poliomyelitis. The latter get better frequently; well, entirely well, quite rarely.
DR. ABT.—Were there any autopsies on the fatal cases, and what were the findings ?
DR. KERLEY.—I had an opportunity to see in this New York epidemic 43 cases: 13 in the Babies' Hospital, 9 in other institutions, 3 in my own practice and 18 in consultation. I came into these cases late in August and early in September. The cases increased until October and then practically ceased.
Dr. Koplik and Dr. La Fétra have given such an admirable exposition of the symptomatology that I have little to say. I thoroughly agree with what Dr. Koplik says. I have seen more or less poliomyelitis for twenty years and I think in this epidemic we have had an entirely new proposition. In some of the cases it was absolutely impossible to differentiate between them and cerebrospinal meningitis. The rapid onset, retraction of the neck, stupor, etc., was marked. Kernig's sign was ruled out in many of the cases because there was so much tenderness.
As to the territory of the epidemic, I found that the northern boundary was at Malden. There, with only twelve or fifteen children in the school, they had four with poliomyelitis. That would seem to be the apex of a triangle which extended down the river until it reached New York. The area was, as Dr. Holt has said, of very wide distribution.
One of the cases was particularly interesting to me: the child came down with acute symptoms of fever and vomiting and developed facial paralysis, the only evidence of paralysis that occurred and it persists at the present time. Evidently there was a nuclear involvement.
DR. MORSE.-I recently had occasion to analyze the cases of infantile paralysis which I had seen. Only three or four of them were seen last autumn. The results of this analysis, as will be seen, show that the type of the disease in the sporadic cases is essentially the same as during the recent epidemic in New York. Pain and tenderness were present in two-thirds of the cases, in some at the onset, in others beginning after two or three days; the duration was usually but a few days, but they sometimes persisted for a month. They were most often in the neck, but were sometimes general, usually in the affected portions. Tenderness over the nerve trunks, especially the sciatics, was not uncommon, and in some cases obscured the diagnosis. Cerebral and meningeal symptoms were also common.
In some, delirium and stupor persisted for several days. In i case stupor persisted for a week. Nervous irritability was also very marked in a number of cases. Headache was the first symptom in I case and persisted for several days. It preceded the paralysis and other symptoms by thirty-six hours. Rigidity, retraction and tenderness in the neck were not at all uncommon. They appeared, as a rule, on the second or third day, but were sometimes present at the onset. They usually disappeared after a few days, but sometimes lasted one or two weeks. The blood, during the acute stages, showed a leukocytosis.
Dr. Koplik (closing discussion).-As to the postmortem findings, in 2 fatal cases at the Mount Sinai Hospital there were autopsies, the findings of which will be published later. In a general way they corresponded closely to what has been described here this evening; areas of softening throughout the cortex; areas of hemorrhage throughout the cord, and areas of softening in the cord. The opinion of Harbitz was confirmed that the disease begins in the meninges and extends from there.
This disease does not affect any other nervous disease that may be in progress at the same time. I saw a case, just before leaving : a child came to me in March with symptoms pointing to some general nervous trouble; he felt tired and did not feel like walking; when he sat down he did not care to get up. A positive diagnosis was not made at that time. The child went through the epidemic and developed poliomyelitis and came into my office with paralysis of right upper extremity and also with pseudohypertrophic paralysis fully developed. The course of this child's nervous affection, which was perhaps more serious than the poliomyelitis, was not affected by the latter, and the two nervous diseases existed side by side.
THE NEED OF POST-GRADUATE INSTRUCTION IN
BY AUGUSTUS CAILLÉ, M.D.,
In the making of a medical practitioner there is still a lack of system and uniformity, which is difficult to explain, except as we view it as one of the forms of inherited or transmitted human inertia noticeable along sanitary lines in general.
At the present time the best results are probably obtained where a student, endowed with good "preliminaries,” enters a medical school which is part and parcel of a large university so located as to be able to offer to the senior student in medicine ample hospital facilities and abundant clinical material; with its curriculum so arranged that the undergraduate's time is not taken up by didactic lectures, and the student is early brought into contact with the evidence of nature's manifestations in health and disease by means of practical courses in chemical, physiological and pathological laboratories.
Small medical colleges can, no doubt, also turn out good practitioners on account of the greater care given to each student, but to accomplish this they must offer a system of "object lesson teaching,” by means of which, as Agassiz tersely says, “One may study nature, not books.”
Faulty as it is, we must confess that the wholesome impetus of a good medical school makes the student eager for the two years' hospital and bedside training which is to follow, and at the end of which he is fairly well equipped to be let loose upon the public as a general practitioner.
In the realm of pediatrics, however, the young physician, as he starts out upon his life of service, is deplorably ignorant. He may be able successfully to cope with difficulties in diagnosis and to formulate indications for treatment, and even carry out proper treatment in the adult, but when he is confronted with the problems presenting themselves as regards the hygienic, dietetic and specific management of the ailing child, he stands, as far as practical knowledge goes, "vis à vis de rien," and is unable to stake and prove his claim in pediatrics unless he has nad the very exceptional good fortune to have spent half a year in a hospital devoted to diseases in children.
During a twenty years' service as teacher in pediatrics, the writer has not met a single young hospital graduate other than ex-internes of a children's hospital, who, on inquiry, did not freely admit his lack of practical knowledge regarding a line of professional work which makes up one-half the practice of the family physician. It is evident, therefore, that the present facilities for acquiring the knowledge necessary to combat preventable infantile sickness and mortality are totally inadequate and that more practical instruction along the lines indicated is urgently needed.
How best to meet the demand for practical post-graduate instruction in pediatrics has taxed the efforts of those devoted to this kind of work.
The value of a good post-graduate course lies in the fact that under guidance of competent teachers one may first see a patient in the "dispensary," then in the hospital ward, where medical, operative or specialistic treatment is carried out in detail. One may examine the patient, study his "chart,” examine blood, sputum, excreta, puncture fluids in the laboratory, and, if the patient dies, one may witness the autopsy and examine the specimens obtained.
Dispensary Clinics.-A large ambulatory service is the sine qua non feature of a good medical school. Dispensary work (apart from its value to the community) is excellent discipline for acquiring the art of making more or less accurate diagnoses and sharpening the power of observation.
Hospital Wards in Connection with the Clinical Laboratory.The "wards” in connection with a clinical laboratory afford every facility for accurate study and proper treatment of patients. The course and termination of disease may be watched, and it is frequently possible to "prove the case” by transillumination, surgical procedure, or autopsy. The "wards” are available for illustrating and demonstrating methods of prophylaxis (ventilation, isolation, disinfection and protective inoculation), for diet kitchen work, palatable medication, for surgical, orthopedic and other manipulative or electrical therapy and for teaching physical diagnosis and diagnostic punctures.
Bedside Instruction.-Making rounds with a large class of