rise to exaggeration of the normal reflexes and the appearance of some reflex reactions corresponding to some earlier stage of phylogenetic evolution. These reactions are normal propriospinal or palaeencephalic reflexes, which manifest themselves only in case of loss of the cortical influence on the cord. The author believes that Babinski's phenomenon belongs to this group of reflexes. He next endeavors to explain the origin of the reflex. The normal plantar reflex, consisting of flexion of all the toes, is a function peculiar to man. The lower extremity, which has purely static function in man, is evolved from an extremity with the function of grasping. In the act of grasping, the great toe makes no flexion, but a movement of opposition. In man, unlike most other primates, the opponens hallucis muscle is absent, thus the function of opposition is lost and plantar stimulations should cause flexion of the little toes and no movement of the great toe. The fact that all the toes flex on plantar stimulation is explained as a special adaption of the neencephalon acquired gradually in learning to walk, that is, flexion of the great toe is not an inherent propriospinal reflex but an automatic reflex acquired by voluntary effort (learning to walk) and therefore under cerebral control. A lesion of the pyramidal tract destroys this reflex arc, resulting in no flexor respond of the great toe. The more difficult problem is the explanation of the extension of the great toe in pyramidal lesions. In the evolution of the grasping reflex there was a period when the act consisted only of flexion of the little toes, the great toe having lost its function of opposition. In this period the great toe may have been excluded from the grasping act by extension. In Western monkeys the great toe is not opponible and, unlike the other digits, has a nail instead of a claw. In grasping the great toe, not participating in the act, must be removed from the other toes by an act of extension. The same is true in the act of scraping or clawing. THE PROGRESS IN PEDIATRICS By HUBERT C. KING, M. D., Cleveland Results of the Newer Methods in Treating Diabetes in children has long been regarded as a serious disease in which the results of treatment were discouraging. With the announcement by Allen of his method of treating diabetics clinicians began applying the methods in the treatment of the disease in children and to wonder if the apparently brilliant results attained in adults might be equalled in the care of the young. It is not our province to pass judgment upon the value of the Allen treatment of diabetes even were we able. The time since its inauguration is far too brief for any of us to put a final value upon Allen's contribution. In the preface to his new book Joslin, who is a master in this field, says that "three years ago I would not have wished to write a book. on diabetes; today it is a pleasure and an inspiration because the improvement in treatment is beyond question." There are equally able clinicians who are not so optimistic. I shall merely refer to the statements of three men who have had considerable experience with the new treatment in children. Joslin in his book-Treatment of Diabetes Mellitus (Lea & Febiger, 1916), says that children make exceptionally good patients, that the days of starvation and the diet are borne without complaint and that in otherwise healthy children a gain in weight takes place. He does infer that adherence to the rules over a long period of time is difficult to obtain. He states that children are especially sensitive to acid poisoning and that "when acid danger lurkes, beware!" In the Medical Clinics of Chicago for September, 1916, Dr. Solomon Strouse, who has had considerable experience with this method of treatment, writes on the results he has obtained in children. His opinion of the value of Allen's methods may be well summarized by the statement that if the co-operation of some intelligent and interested person in the home may be obtained the results are far from discouraging. He reports two cases in which the co-operation of a responsible party was obtained and in which the patients are sugar-free some months after leaving the hospital and are gaining in weight. Both these patients were seen and treated very early in the course of the disease. A third patient seen later in the course of a more severe diabetes was not cured but showed a very definite improvement after a year of careful treatment. He believes the child would have been lost under the older methods of treatment. He mentions the case of a boy, who, after going home from the hospital, went on a "carbohydrate spree" and died in coma. His summary is that diabetic children usually die in coma and that coma is less common with our new methods of treatment. He is not sure that a child can be kept in a state of under nutrition for a period long enough to improve the diabetes without seriously impairing development. He quotes Joslin as saying that practically the only cases of diabetes in children which have survived have been those in which there is a familial tendency to the disease. It is quite certain that the earlier the case is seen the more likely are the results of treatment to be satisfactory. The basis of years of experience is against a hopeful prognosis. In an article entitled "The Relation of Prognostic Factors to Treatment in Diabetes"-Am. Jour. Med. Sc., Vol. CLI, No. 2, 176— Nellis B. Foster expresses a gloomy prognosis in cases of diabetes in children which come to treatment after the disease is of some duration that is in advanced cases. He says that the glycosuria is easily controlled but that the blood sugar is difficult to reduce to normal and remains normal only under the most restricted conditions. This tolerance is usually too meager to preserve health over long periods. The patients that adhere to the diet die in coma precipitated by an infection, as pneumonia or influenza. Those who do not adhere to the diet rigidly also die in coma. The cases of this type which he has followed and which have survived the disease are "under nourished, and altogether pathetic." Iodid Medication by the Mouth.-Studes of the spinal fluid during iodid medication by mouth are reported by J. H. Catton, San Francisco (Journal A. M. A., Nov. 4, 1916), made in order to determine the presence of organic or inorganic compounds of iodid. Study I includes observations on five patients in the San Francisco Hospital on routine iodid medication, and Study 2, observations on one person receiving very large doses of iodids. Two specimens of spinal fluid were used in each case. The test was made as follows: "A portion of spinal fluid was added to some dry sodium carbonate and the mass powdered; the latter was added slowly to a quietly fusing mixture of potassium nitrate and sodium carbonate; the entire mass was allowed to cool, was removed from the crucible and dissolved in distilled water; to a portion of the latter was added some starch paste, and then nitric acid containing a little nitrous acid, drop by drop. Controls containing minute traces of iodin gave a blue color, but no reaction occurred with any of the fluids examined." In all the series of cases examined by the above and other tests, regardless of the amount of iodin administered by mouth, no iodin or compounds of iodin were found in the spinal fluid. Catton concludes that either iodin compounds do not pass through the choroid plexus in any measurable amount or such iodin as does reach the spinal fluid is very rapidly fixed in the tissues. REVIEW OF THE PROGRESS OF MEDICINE. By HAROLD FEIL, M. D., Cleveland The Dietetic Management of Hypercholesterinemia in The recurrence of cholesterin gall stones in spite of careful surgical relief has prompted various investigations to determine the relationship between cholesterin metabolism and the formation of these concretions. Chauffard and Bacmeister in their studies. showed that there was a relation between hypercholesterinemia and the formation of gall stones. Normal cholesterin content of blood: Varies from 0.160 to 0.180 per cent. Physiological variations of cholesterinemia: In pregnancy we have a physiological hypercholesterinemia. Bacmeister and Havers showed in pregnant dogs that there is a lipoid retention. Upon the birth of the offspring there is a sudden excretion of lipoids-leading to the excretion of a more or less lipoid saturated bile-thus favoring the deposit of pure cholesterin stones. The conglomerate masses of cholesterin which compose some of the stones and the absence of concentric layers of deposit give evidence of their rapid formation. Rothschild showed "that the cholesterin content of blood and bile depends upon the type of food the organism consumes. There is no synthesis of cholesterin in the body. Our supply of lipoids is maintained by our food intake. Free cholesterin is esterized in the intestinal canal, absorbed by the lymphatics, delivered to the blood stream and then distributed to the body cells. With the breaking down of cells, as in the general catabolic processes, it is again freed to the blood stream, carried to the liver, where the endothelial cells. possibly produce a deesterization (an intermediary part), excreted with the bile as free cholesterin and again partially reesterized and reabsorbed from the intestinal tract by means of the lymphatics." Chalatow produced small concretions in gall bladders of rabbits by feeding large quantities of cholesterin. Cholesterin in blood in cholelithiasis: Rothschild and Rosenthal conclude that in general hypercholesterinemia is found, but that exceptions occur. That there might have been a temporary hypercholesterinemia at the time of the deposit of the stones, which later disappeared, cannot be denied. Group 1. Cases that have a normal cholesterin content of the blood. Group 2. Cases that are hypercholesterinemic. A. Obstructive hypercholesterinemia Temporary Stone with obstruction permanent B. Diathetic hypercholesterinemia without obstruction intermittent It is the diathetic cases-which have been surgically relieved that have been investigated especially by Rothschild and Rosenthal. They conclude that these patients have a real diathesis-which has a definite etiological relationship to atherosclerosis. The recognition of this diathesis is extremely important for the patient. Examina. tion of the blood of every case of cholelithiasis without jaundice before operation will detect the diathetic cases (there is a temporary hypercholesterinemia in jaundice). In the presence of hypercholesterinemia provision should be made for drainage of the bile to deplete the body of retained lipoids-the drainage tube remaining in place until normal blood and bile determinations are made-meanwhile the diet should be low in lipoids. After removal of the drainage tube and the closure of the fistula the blood should again be examined and if cholesterin content is high the patient belongs to the diathetic group. Diathetic management of the post operative cases: (2). Diet poor in fats-which favor lipoid absorption. Foods rich in lipoids: Eggs, cream, butter, meat and fish. Lipoid free foods: Vegetables (excluding peas and beans), cereals, sugars, skimmed milk and butter milk (fat free). Because of the difficulty of keeping a patient on a strict lipoid free diet-fast and feast day periods have been devised. For three or four days the patient lives on a strict diet in order to lessen the lipoid content of the blood. Following the first three or four days a more liberal diet is allowed-the diet including well cooked lean meat and fish (excluding salmon, shad, and blue fish-rich in fat). Oleomargarin is preferred to butter. Conclusions: Adequate drainage reduces the hypercholesterinemia which can be guarded against post-operatively by careful dieting. The authors have under observation cases from which they have drawn these conclusions.-Rothschild, Rosenthal, 1916, Am. Jour. Med. Sc., CLII, 394. |