bluuebunny/crossref_metadata_2025 huggingface dataset:
Letter to the Editor
Authors: Meislin Aaron G. , Rothfield Naomi
Published: December 2021

So long as the diagnosis of SLE is based on an overall view of the entire clinical picture with assistance from various laboratory tests such as LE cells, antinuclear antibodies, and skin and renal biopsies, there will be problems in arriving at a definitive diagnosis and the inevitable "semantic arguments" will continue to arise. We welcome Drs. Stickler and Burke's letter, which provides the opportunity to further clarify our concept of SLE.

Criteria for diagnosis of SLE were set forth in our second paragraph of the section entitled Discussion, in as precise a manner as we feel the disease permits at the present state of knowledge.
PROPOSALS FOR CHILD HEALTH CARE
Authors: Yankauer Alfred
Published: December 2021

In contrast to the prevailing tenor of less than a decade ago, few voices can be heard today reassuring the public or the professional that the American "health care system" is itself in good health. Having dealt with the aged through Medicare, the national spotlight now focuses on children who form the other major segment of our "poverty population." Analyses and complaints, proposals and programs flow forth at an accelerating pace.

Two types of programs are discussed in the current issues of Pediatrics-one as a proposal presented to the American Academy of Pediatrics last fall, and the other as a report of work in progress.
THE CRITICALLY ILL CHILD: SALICYLATE INTOXICATION
Authors: Segar William E.
Published: December 2021

Salicylate is a potent pharmacologic agent, and the rational therapy of salicylate intoxication must be based on an understanding of its pharmacologic actions and consequent pathophysiologic effects.l Because it acts to uncouple oxidative phosphorylation in a manner analogous to that of 2,4-dinitrophenol, salicylate is, first of all, a general metabolic stimulant.2 Oxygen consumption, carbon dioxide formation, and heat production are increased by its action; consequently, oxygen requirement, blood CO2 concentration, and the need to eliminate heat are also increased. Respiration, heart rate, and cardiac output must increase to satisfy the demands imposed by the acceleration of metabolic processes.

Second, saiicylate interferes in a complex manner with the normal metabolism of carbohydrate.3 Many factors seem to be involved, some tending to decrease and others to increase the blood glucose concentralion, and, clinically, either hyperglycemia or hypoglycemia may be observed. Hyperglycemia may be partially explained by the release of epinephrmne due to activation of hypothalamic sympathetic centers. However, large doses of salicyiate also decrease aerobic metabolism and increase glucose-6-phosphatase activity, effects which tend to increase the blood glucose level. Hypoglycemia, on the other hand, may be caused by an increased utilization of glucose by peripheral tissues or by interference with gluconeogenesis by salicylates. Recent studies suggest that brain glucose concentration may be decreased despite minimal alterations in blood glucose level.4

As a result of these salicylate-mnduced alterations in carbohydrate metabolism, organic acids, particularly lactic, pyruvic, and acetoacetic, accumuiate.5 Infants appear to be particularly susceptible to the toxic effects of salicylate on carbohydrate metabolism and are more likely to have disturbances in blood glucose concentration and metabolic acidosis than are older children.
Children with Fevers: I
Authors: Heller George
Published: December 2021

The article by Dr. Thomas E. Cone, Jr. (Pediatrics, 43:290, 1969), is worthwhile if only the section under Management is respected by our colleagues. However, a little nit picking may be called for.

1. Certainly in private, as opposed to hospital practice, infections of the urinary tract are much less frequent than he suggests. Roseola, the exanthemata, gastroenteritis—even fever of undetermined origin—are way, way ahead, in my experience.

2. I'd hate to have a mother or a nurse insert the thermometer 2 in. into the child's rectum.
Children with Fevers: II
Authors: Whipple Deryle T.
Published: December 2021

In a recent article in Pediatrics (43:290, 1969) , Dr. Cone reviewed the approach to a child with fever. The list of patients with fever of undetermined origin will shrink markedly in the presence of a complete physical examination (especially the ears), a CBC, and urinalysis performed properly.

I am surprised Dr. Cone omits infectious mononucleosis from his admittedly limited coverage of this subject. In the young child the Mono test or Heterophile may remain consistently normal.
Children with Fevers: III
Authors: Shaw Edward B.
Published: December 2021

I enjoyed reading Dr. Cone's excellent paper, "Diagnosis and Treatment: Children with Fevers" (Pediatrics, 43:290, 1969), which contains many things that physicians and, hopefully, mothers should heed. I hope he will not object to two or three comments.

Just what is sepsis, or septicemia as an isolated phenomenon independent of a source? The blood culture may be positive and the source not easily determined, but a continuous bacteremia must be fed from somewhere. Sinus thrombosis, S.B.E., osteomyelitis, lymphangitis due to streptococci, infection of the umbilical vessels in the newborn, and so forth.
Children with Fevers: IV
Authors: Myers Burt
Published: December 2021

In a recent review article by Dr. T. E. Cone, Jr., (Pediatrics, 43:290, 1969), the author referred to Familial Mediterranean Fever as an example of one of the periodic fevers.

The early descriptions of this disease referred to it as a "periodic disease." However, more comprehensive studies from 1955 to the present clearly indicate that this disease is characterized by episodes of irregular (non-periodic) recurrent attacks of fever and serositis. Thus, the reference to Familial Mediterranean Fever as a periodic disease is misleading.
Letter to the Editor
Authors: Hughes Gerald E.
Published: December 2021

Thank you for the opportunity to reply to the letters from Drs. Silverman, Halpern, and Hervada. Questions about the selection of sites for the Academy's meetings arise periodically, and the reasons for the selections should be reviewed periodically in response to these questions.

As an initial consideration, the Executive Board of the Academy, after questionnaires to the members and discussions with District Committees and Chapter Chairmen, has decided that it is preferable that the Annual Meetings be held in hotels and under one roof.
Diagnostic Sign of Otitis Media: Belching and Pain
Authors: Newman Arthur J.
Published: December 2021

I should like to call to the attention of your readers a symptom which I have encountered in my general pediatric practice which has been of considerable diagnostic assistance.

Infants with otitis media who are too young to rub at or touch the affected ear frequently evidence pain, discomfort, and crying following belching.

It is my impression that belching can produce a modified Valsalva manuever, with increased pressure being exerted on the tympanic membrane through the eustachian tubes.
Laboratory Manual of Pediatric Microbiochemical Techniques, ed. 4, by Donough O'Brian, M.D., F.R.C.P.E., Frank A. Ibbott, Ph.D., F.I.M.L.T., and Denis O. Rogerson, M.S., F.I.M.L.T. New York/Evanston/London: Hoeber Medical Division, Harper and Row, 1968, 367 pp., $11.90
Authors: Sunderman F. William
Published: December 2021

This manual of micro-techniques is one of the finest compendiums of clinical laboratory methods which is currently available in the English language. The analytical procedures have been selected with consistent care to ensure their reliability as well as their applicability to the relatively small volumes of biological fluids which can be obtained from infants and young children. The procedural instructions are written clearly and succinctly, so that they can readily be followed by experienced laboratory workers.
Developmental Language Disability: Adult Accomplishments of Dyslexic Boys, by Margaret B. Rawson. Baltimore: The Johns Hopkins Press, 1968, 127 pp., $5.50
Authors: Gallagher J. Roswell
Published: December 2021

Physicians, educators, psychologists, and parents frequently ask how much improvement they can expect in those children who, despite average or better intelligence and freedom from a primary emotional disorder, experience difficulty in learning to read, write, and spell.

The author of this book, a wise and exceptionally competent teacher who has had years of experience, reports the bong-range educational and vocational accomplishments of a group of such boys. All of these boys, and the ones with which she compared them (who found little or no difficulty in learning Ianguage skills), attended the elementary grades of the same small independent school between 1930 and 1947.
Genetische Familienberatung: Ein Leitfaden Fur Den Arzt, by Walter Fuhrmann and Friedrich Vogel. Berlin/Heidelberg/ New York: Springer-Verlag, 1968, 98 pp., $2.20
Authors: Zellweger Hans
Published: December 2021

This small paperback appeared as Volume 42 in the series, Heidelberg Pocket Books (a translation of L. S. Penrose's Introduction to Human Genetics is Volume 4 of the same series). The authors, both directors of a German institute for human genetics, wrote this syllabus to familiarize the genetically uninformed physician with the common and practical aspects of medical genetics and genetic counseling. They advise the reader to consult a professional geneticist for more complicated genetic problems.
PARTIAL THYROXINE-BINDING GLOBULIN DEFICIENCY IN A FAMILY
Authors: Moloshok Ralph E. , Hsu Lillian Y. F. , Seal Ulysses S. , Hirschhorn Kurt
Published: December 2021

Deficiency of thyroxine-binding globulin (TBC) has been previously described in several families, and the mode of inheritance in most families has been interpreted as X-linked. The hemizvgous affected males have an absence of TBC, while the heterozygous females have wide range of TBC values (low to normal). A family recently studied by us presents a different form of TBG deficiency. The proband, who was born with ambiguous external genitalia and raised as a female, was found to have a testis on one side and a streak gonad on the other side. Her chromosome constitution showed a mosaicism of XYY/XY/XO. After a low PBI level was obtained, she was found to have reduced but not absent TBG activity. Similar reduction of TBC was found in her brother, who also had congenital hypothyroidism, and her normal male first cousin. The observation of the reduction of TBG levels rather than a total absence in the hemizygous affected individuals in this family suggests a variant of TBG deficiency, although it still appears to be due to an X-linked gene and is most likely due to an allele of the same gene.
CONGENITAL ASYMMETRY: REPORT OF 10 CASES WITH ASSOCIATED DEVELOPMENTAL ABNORMALITIES
Authors: Parker David A. , Skalko Richard G.
Published: December 2021

Ten patients with total congenital asymmetry were found in a review of the charts of some 860,000 admissions to The New York Hospital-Cornell Medical Center over the interval 1932-1966.

Associated abnormalities described include two instances of adrenal neoplasm, one case of bilateral medullary sponge kidneys, and a possible case of Beckwith's syndrome. Six of the 10 patients had abnormalities of the genitourinary system. An oncogenic-teratogenic relationship and a possible biologic system for the study of such a relationship are suggested.
Letter to the Editor
Authors: Daly Richard F.
Published: December 2021

Considering the phenotypic variability in Down syndrome and other extensively studied syndromes due to chromosomal abnormalities, it would be surprising indeed if no variation in signs or symptoms of the XYY condition was found. I have recently found the XYY condition in a 6 ft, 13-year-old boy (unpublished). His height has been at or above the 90th percentile since age 5 years. Data on his earlier growth are not available. I first examined this boy about 4 years ago, prior to the report by Jacobs, et al.
Infektionskrankheiten, Vol. II/2, edited by O. Gsell and W. Mohr. Berlin/Heidelberg/New York: Springer-Verlag, 1968, 1034 pp. (In German), $61.25
Authors: Eichenwald Heinz F.
Published: December 2021

The present two volumes represent the second of a three-part publication whose aim (in the words of the editors) is "to summarize existing knowledge" in the field of infectious disease. The series is intended to be useful to "the practicing physician, the clinician, and the academician." The two previously published volumes dealing with viruses succeeded admirably in these aims. However, Part II of the series, devoted to bacterial disease (except pneumococcal illnesses, unaccountably exiled to a future volume dealing with nickettsiae, protozoa, and deep mycoses) is less successful, and, in some ways, represents a distinct disappointment.
PEDIATRIC PRACTICE IN THE UNITED STATES
Authors: Yankauer Alfred , Connelly John P. , Feldman Jacob J.
Published: December 2021

This is a report of a mail survey undertaken on behalf of the Subcommittee on Pediatric Manpower of the Council on Pediatric Practice of the American Academy of Pediatrics. Its purposes were: (1) to collect information about how practitioners of pediatrics utilize their own time and that of other health workers for the performance of specific tasks carried out in the course of ambulatory pediatric care; (2) to ascertain the degree to which practice characteristics, including task delegation, were related to characteristics of the physician, his practice arrangement and his practice load; and, (3) to sound out general pediatric opinion concerning task delegation in ambulatory pediatric care.

The genesis of this survey and its relationship to current health manpower shortages have been discussed elsewhere.1 Prior to this survey no information on a national basis had been available concerning the extent and nature of task delegation in pediatric office practice or the opinions of pediatricians about this subject. Although most American children receive preventive and therapeutic health care from physicians in private office practice, extraordinarily little information about the characteristics of this system of care is available.

A structured, precoded questionnaire was designed to collect the desired information. In the summer of 1967, the first version was pretested on 273 Regular Fellows of the Academy of Pediatrics residing in Massachusetts and a 2% random sample of Fellows residing in the other 49 states and the District of Columbia. The results of this major pretest have been described elsewhere. Slight modifications were made in the original version of the questionnaire and the revised version was mailed in the late fall of 1967 to 6,820 Regular Fellows of tile American Academy of Pediatrics residing in the United States.
Letter To The Editor
Authors: Johnson Roswell D.
Published: December 2021

It is with deep satisfaction that I note the article on marijuana in the contributors section in the January issue of Pediatrics.

As an Academy member and now as a full time Director of a university health service, I have found it necessary to devote a great deal of time to the literature, and to community and regional programs on "drugs," and an extensive day by day as well as night by night dialogue with students of all persuasions on the problem of behavior alterants, particularly marijuana.
Letter To The Editor
Authors: Dohner V. Alton , Ott JOHN E.
Published: December 2021

The Commentary by Nader and Haggerty Pediatrics 45: 1, 1970) initially appears almost as biased anti- as they insinuate Bates is promarijuana. They refer to marijuana as a "chemical ‘escape to nowhere’" or as "a precursor to chronic usage" as though all users become social dropouts, chronic users, and "drug bums who expect to sponge a living while offering nothing in return." This is no more objective or realistic than some prohibitionists who believe one drink of alcohol will lead to chronic alcohol dependence.
Letter To The Editor
Authors: Nader Philip , Haggerty Robert
Published: December 2021

Dr. Haggerty and Dr. Nader write:

We are pleased to have stimulated at least some pediatricians to a consideration of their own views on the marijuana issue. On Dr. Gleason's letter we have no comment. We hope that Drs. Dohner and Ott reread our commentary and note we are quoting others' views, not expressing our own in the introductory paragraph they refer to.

We are encouraged by the responses and also agree with Dr. Milman that all available data should be considered.
Letter To The Editor
Authors: Yankauer Alfred
Published: December 2021

Second, Dr. Yankauer:

"Disgraceful and totally unacceptable" are inflammatory adjectives. They stir up uncomfortable feelings of personal guilt and blame. It would be reassuring if the differences between infant mortality rates in the United States and those of several small European countries with relatively homogenous populations and stable traditions could be explained away as statistical artefacts.

Unfortunately the differences cannot be explained away. Clear evidence for their substance is the fact that infant death rates after the first month of life are three times as high in the United States as in Sweden.
Whose Trudeau Now?
Authors: Joven I. B.
Published: December 2021

This is in reference to the article on tuberculin reactors by Drs. Burchak and Turner and Ann Robson from Toronto in the December 1969 issue.1

I did not realize that the American Trudeau Society (ATS), if ever there was such a one, had as one of its activities the production of a culture media designed to allow the growth of M. tuberculosis.

I wonder if the authors (if they were canadian) meant this as a compliment to their colorful prime minister, Pierre Elliot Trudeau.
INBORN ERRORS OF METABOLISM: SOME THOUGHTS ABOUT THEIR BASIC MECHANISMS
Authors: Howell R. Rodney
Published: December 2021

The question of whether, in the inborn errors of metabolism, genetic information is absent or coded incorrectly (structural mutations), or whether the gene itself is normal but is not activated (regulatory defects) is extremely important in the directions taken for the future consideration of such problems. The problem of introducing new, well defined, genetic information into a human cell which is either lacking such information or has abnormal genetic information appears formidable at the current time. However, the existence of regulatory defects would imply that the correct information to make the deficient enzyme (s) is available to the cell, and we need only find ways of activating (inducing) this genetic information.
HYPERBILIRUBINEMIA AND KERNICTERUS IN SMALL PREMATURE INFANTS
Authors: Ackerman Bruce D. , Dyer Geraldine Y. , Leydorf Mary M.
Published: December 2021

Serum bilirubin levels above 15 mg/100 ml occurred in 7 of 54 infants with a birth weight of less than 1,500 gm. Definite or probable kernicterus occurred in five of these seven infants. The maximum level of indirect serum bilirubin in the five infants with kernicterus varied from 18.5 to 20.4 mg/100 ml in three infants and from 22.2 to 23.2 mg/100 ml in two. Exchange transfusions were performed in four of the five infants at levels of 18 to 22 mg/100 ml but were ineffective in preventing kernicterus. Skin hemorrhage appeared to be one of the etiologic factors causing the hyperbilirubinemia in the five infants with kernicterus. Exchange transfusion must be performed at levels of indirect bilirubin below 20 mg/100 ml if death or neurologic damage are to be prevented in the small, critically ill premature infant.
ON HOW TO BECOME A MODEL PARENT ACCORDING TO BERNARD SHAW
Authors: C. T. E.
Published: December 2021

My parents took no moral responsibility for me. I was just something that had happened to them inevitably and had to be put up with and supported. They did not worry themselves uselessly about my character and my future. I suffered nothing from the intolerable meddlesomeness of the conscientious parents who are so busy with their children's characters that they have no time to look after their own. I cannot remember having ever heard a single sentence uttered by my mother in the nature of moral or religious instruction.

My father made an effort or two. When he caught me imitating him by pretending to smoke a toy pipe, he advised me very earnestly never to follow his example in any way; and his sincerity so impressed me that to this day I have never smoked, never shaved, and never used alcoholic stimulants. He taught me to regard him as an unsuccessful man with many undesirable habits, as a warning and not a model. In fact he did himself less than justice lest I should grow up like him; and I now perceive that this anxiety on his part was altogether admirable and lovable, and that he was really just what he so carefully strove not to be: that is a model father.

Many of us who are parents go through agonies of hypocrisy to win a respect from our children which we do not deserve. In our virtuous resolution to do our duty as parents we become humbugs, and when our children are old enough to find us out, as they do at a very early age, they become cynical and lose the affectionate respect which we have destroyed ourselves morally to gain.
CLINICAL EVALUATION OF ABNORMAL ENZYME CONTENT IN THE PANCREATIC JUICE OF CHILDREN
Authors: MCDOUGALL CLARICE
Published: December 2021

One hundred and sixty-five children were intubated and the enzyme activity of their duodenal juice studied. Seventy-six patients showed normal potency of all the pancreatic enzymes and had clinical conditions apparently unrelated to pancreatic secretions. The other 89 patients were included in this study and grouped as follows:

Group I: Twenty-three children had minimal pancreatic enzyme activity and presumably were suffering from fibrocystic disease of the pancreas.

Group II: Two children with minimal enzyme activity may have had a pancreatic deficiency of different etiology from that of Group I.

Group III: Four children had transitory partial suppression of trypsin, lipase and amylase. In three, after recovery, repeated studies showed that their enzymes were normal. The fourth child died without the enzyme studies having been repeated. A fifth child had complete suppression of enzyme activity while ill with a respiratory infection. She is included in this group because, coincident with her clinical recovery, there was an appreciable return of enzyme activity. Clinically, these five children had nothing in common.

Group IV (a): Twenty-five children had suppression of lipase activity in conjunction with a normal level for trypsin and amylase. Most of them had some type of gastrointestinal disturbance. Four had diseases of the respiratory system. Sixteen of these children were restudied. The return of lipase activity coincided roughly with a return to health: those who were studied at a time they were clinically well had normal enzyme activity, while those who were not well still had a reduced secretion of pancreatic lipase. None proved to be early cases of progressive pancreatic deficiency.

Group IV (b): There were no children with deficient trypsin activity in the presence of normal lipase and amylase.

Group IV (c): Sixteen children were deficient in amylolytic activity in conjunction with normal trypsin and lipase. Most of these children had gastrointestinal symptoms. Six of them had celiac disease.

Group V: Eighteen children with extreme malnutrition had normal enzyme activity.
THE PRESIDENT'S COLUMN
Authors: SHAW EDWARD B.
Published: December 2021

The President and the Executive Board send their greetings to the membership of the Academy of Pediatrics for the new year.

This column will appear irregularly from time to time in an effort to keep the membership apprised of developments which affect the Academy and which must be considered by the Executive Board. The President and the District Chairmen are elective officers of the Academy and in the true sense of democratic representation can only attempt to interpret the opinions of the membership in their action on problems which arise. American medicine is now confronted with many problems upon which neither the individual nor the organization can avoid taking a position. The action of your executive officers must be predicated upon the expression of opinion by the membership. It is hoped that you will keep your officers informed of individual and group opinions upon controversial issues in order to guide their action. The columns of Pediatrics IATRICS are open to the membership in "The Pediatrician and the Public" but it is most desirable that you communicate with your officers directly for their information.

The San Francisco session was astonishingly well attended considering the handicap which distance imposed upon many of the members. I should be remiss in not expressing the pleasure of the local Fellows that so many should have come so far and contributed so much. Dr. Edgar E. Martmer and his Program Committee are to be congratulated not only because of the excellence of the program but also because they were able to effect last minute substitutions for participants who, because of illness, were unable to attend, without impairing the structure of the meeting.
LOUISIANA'S PROGRAM FOR THE CARE OF THE PREMATURE INFANT
Authors: CHIPMAN SIDNEY S. , TREUTING WALDO L.
Published: December 2021

Louisiana's program for the care of the premature infant has been discussed in terms of the need for such a program and of its component parts.

Little effort has been directed towards expansion of case finding since all facilities available for the care of the prematures are already overtaxed.

Hospital placement at the present time centers around the unit constructed in the Charity Hospital in New Orleans, where facilities have been planned to accommodate 80 to 100 infants. Because of the large numbers involved many problems have arisen regarding construction and organization.

A system of home investigation and follow-up has been well developed in the New Orleans area.

Plans for the training of nurses and physicians in the care of the premature are complicated by the need for minimizing the number of contacts with these infants. Members of the house staff and undergraduate nurses participate in the activities of the unit. Courses for graduate nurses will begin shortly and a more comprehensive training progam will be developed.
OBSERVATIONS ON ACUTE LEUKEMIA IN CHILDREN TREATED WITH 4-AMINOPTEROYLGLUTAMIC ACID
Authors: MILLS STEPHEN D. , STICKNEY J. M. , HAGEDORN ALBERT B.
Published: December 2021

THE RECENT publications of Farber and co-workers dealing with the treatment of acute leukemia in children have awakened widespread interest. Their investigations have stimulated hope for the amelioration of symptoms of this fatal disease and indicated the possibility of provoking remissions that lengthen the lives of those patients affected by it, while making them more comfortable at the same time.

In investigating leukemia and allied conditions of a neoplastic nature, Farber and co-workers noted what they termed an "acceleration phenomenon" in the blood and bone marrow of leukemic children treated with folic acid or its conjugates such as diopterin (pteroyldiglutamic acid) or teropterin (pteroyltriglutamic acid). There was marked hyperplasia of the marrow as well as of other sites of leukemic involvement at postmortem examination. They reasoned that if folic acid or its conjugates speeded up the leukemic process, an antagonist to folic acid might be devised in order to retard the progress of the disease or stop it altogether. Through co-operation with the research division of one of the major pharmaceutical firms, a series of folic acid antagonists was soon developed. One of these was aminopterin (4-aminopteroylglutamic acid). It differs from folic acid only in the substitution of the NH2 group for the OH radical in the fourth position of the pteridine group. Of several compounds synthetically made, it has been the most effective and yet most toxic agent in its action on the leukemic process.

Farber and co-workers first employed aminopterin in the treatment of acute leukemia of children in December 1947.
CRANIO-FACIAL DYSOSTOSIS OF CROUZON
Authors: FLIPPEN JAMES H.
Published: December 2021

A case of cranio-facial dysostosis of Crouzon occurring in a 4 year old girl is described. The family tree of this patient is of particular interest because the deformity is known to have been present in 10 members of four generations, thus demonstrating the hereditary nature of the malformation. Because 10 of the 21 progeny were afflicted, the pedigree is interpreted as meaning that the disorder is the expression of an heterozygous, dominant trait. The patient was considerably benefited by the operation advocated by Faber and Towne for premature cranial synostosis, as modified by Ingraham.
PENICILLIN REGIMENS IN PEDIATRIC PRACTICE
Authors: HILDICK-SMITH GAVIN , MCNAIR SCOTT THOMAS F. , WHITLOCK COLEMAN M.
Published: December 2021

A study was made of the blood levels and the clearance rates of penicillin that follow different doses and routes of administration of penicillin, in normal children from 2 to 11½ years with normal kidney function.

Following intramuscular injection of aqueous penicillin, optimal bactericidal levels (cf.Eagle and Musselman) were obtained with a daily dose of 5000 u./lb. if given every three hours, or 10,000 u./lb. given every six to eight hours. If adequate doses of oral caronamide were added to the latter dosage scheme, the above levels could be obtained for 8 to 12 hours.

Procaine penicillin of the large particle size (procaine penicillin A) used in this study, when given in doses of 6000 u./lb., provides optimal bactericidal levels for 24 hours or more in some instances. Furthermore, the same dosage scheme using preparations of a smaller particle size (procaine penicillin B), which did not sustain bactericidal levels for quite as long, resulted in successful therapy on clinical trial. Caronamide added by mouth does not increase the initial height of the blood levels appreciably, but does delay the plasma penicillin clearance rate.

Oral penicillin is variable in its action. It appears to be more reliable if given in a buffered form and the addition of caronamide improves the levels obtained.

The therapeutic application of these different regimens is discussed.
OBSERVATIONS REGARDING ARTIFICIALLY INDUCED SUBCUTANEOUS NODULES IN RHEUMATIC FEVER PATIENTS
Authors: MASSELL BENEDICT F. , COEN WILLIAM B. , JONES T. DUCKETT
Published: December 2021

Subcutaneous nodules indistinguishable from spontaneously occurring nodules have been artificially induced in rheumatic patients by the subcutaneous injection of blood.

The frequency, size and duration of the induced nodules correlated closely with the severity and duration of the rheumatic process. Only infrequently could nodules be induced in control subjects suffering from conditions unrelated to rheumatic fever.

Although citrated blood obtained from patients with highly active rheumatic fever seemed to be more effective in inducing nodules in quiescent and mildly active rheumatic patients than did the patient's own blood, the active rheumatic blood was not more effective than blood obtained from healthy young adults.

The daily injection of convalescent rheumatic serum into the site of the nodule test did not interfere with the induction of nodules.

Saline, as well as blood, effectively induced nodules in certain patients, provided that it was injected with the standard traumatizing technic.

It is concluded that the development of nodules results from injury to the subcutaneous fibrous tissue, the reactivity of which is altered by the rheumatic process, and that the hypothesis of a nodule-stimulating substance present in the blood of active rheumatic patients is untenable.

Nodules have been induced in some rheumatic patients by the subcutaneous injection of hyaluronidase. These observations, together with the observations of others that trypsin is also an effective nodule-inducing agent, suggest that enzymes may play a role in the mechanism of nodule formation. However, it is also possible that these substances act in quite a nonspecific way and set off the nodule reaction merely by injuring the subcutaneous fibrous tissue.
ROCKY MOUNTAIN SPOTTED FEVER WITHOUT A RASH
Authors: WARTHEN ROBERT ORR , BURDICK WILLIAM FOSTER
Published: December 2021

An unusually severe case of Rocky Mountain spotted fever that failed to develop a rash by the eighth day of fever in spite of the delay in beginning specific chloramphenicol therapy until that time is reported.

Due to the absence of a rash the diagnosis was of necessity only presumptive when chloramphenicol therapy was begun. It was not definitely established until later, when the agglutination and complement fixation tests became positive.

Chloramphenicol effected a recovery within 48 hours of its initiation.

This is the first reported case of severe tick fever to survive eight days of symptoms without specific therapy and yet fail to develop a rash.
DEGENERATIVE CHANGES IN YOUNG DIABETIC PATIENTS IN RELATIONSHIP TO LEVEL OF CONTROL
Authors: JACKSON ROBERT L. , HARDIN ROBERT C. , WALKER GLENN L. , HENDRICKS ATLEE B. , KELLY HELEN G.
Published: December 2021

The level of control, as well as the duration of the disease is an important factor influencing degenerative changes and good control will delay and possibly prevent degenerative changes.

Our present knowledge makes it not only possible but practicable to maintain a high level of control of diabetes in children living in a well adjusted home.

Until more knowledge concerning the treatment of childhood diabetes is available, a high level of control appears to offer the best means of averting or delaying chronic degenerative changes.

Additional knowledge is needed to understand the pathologic physiology of various levels of noncontrol.

An optimistic rather than a pessimistic outlook is warranted.
NATURAL HISTORY AND PATHOGENESIS OF MILIARY AND MENINGEAL TUBERCULOSIS IN CHILDREN
Authors: PERRY THOMAS L.
Published: December 2021

In preparation for a program of treatment of miliary and meningeal tuberculosis with streptomycin and other antituberculous drugs, 163 consecutive cases admitted to the Los Angeles Children's Hospital in the 15 years between 1933 and 1948 were analyzed.

Twenty-one infants and children had miliary tuberculosis, 58 had tuberculous meningitis and 84 had both diseases. Of 145 patients who received only symptomatic treatment, all died.

The usual frequency of these diseases in the spring was not observed in this series.

Anergy to tuberculin was uncommon; only 2% of the patients reacted negatively to 1.0 mg. O.T.

Forty-eight per cent of the cases occurred before the age of 2 years, and two thirds before the age of 4 years. There was pathologic evidence that tuberculous meningitis occurs commonly within a few months of the primary infection; 82% of the autopsied cases showed evidence of fresh primary tuberculosis.

Vague symptoms such as vomiting, fever and lethargy were most common in early tuberculous meningitis and rarely stimulated a prompt diagnosis. Headache was a frequent complaint in children over 4 years, but was uncommon in those under 4 years. The average duration of life of patients with tuberculous meningitis from onset of symptoms to death was 20 days; the duration of symptoms until a correct diagnosis was made averaged over 11 days.

Caseous tuberculous foci antedating the meningitis were demonstrated in the central nervous system in 27 out of 70 cases in which careful pathologic examination was made. Thirty-five per cent of the autopsied cases of tuberculous meningitis had no acute hematogenous dissemination elsewhere in the body.

Hydrocephalus was found in 25 out of 80 brains examined and tended to appear early in the course of the disease.

Possible precipitating factors were found in the histories of 15% of the 163 patients.

Suggestions are made as to possible means of preventing the development of miliary and meningeal tuberculosis in infants and children and the need for prompt diagnosis and treatment is stressed.
THE WORRIES OF A GRIEVOUSLY ILL ENGLISH FATHER AS WRITTEN TO HIS CHILDREN IN 1794
Authors: C. T. E.
Published: December 2021

The quotation below is an excellent example of the anxieties once faced by seriously ill parents in the days long before the existence of child welfare programs.

The thoughts of a hard usage which some poor, friendless children meet with from unthinking and unfeeling people, cannot but be matter of concern to every parent, under the prospect of leaving a family of dear infants in such a melancholy situation. They cannot but be under some concern for them, respecting things pertaining to their comfort in this life, in things that are only of a temporal nature; but still greater must be the concern of every pious and religious parent, respecting things of a spiritual nature! Where shall the dear children now find a friend who will watch over them in things that have reference to futurity? Since real religion, and the fear of God, is so very unfashionable, that people who are in real concern about it, are, with St. Paul, thought to be beside themselves. Who will be so singular as to take the pains to shew (sic) them their danger from sin, and their remedy a Saviour? Who will shew them the necessity of holiness, and carefully instruct them in all the branches of it? Who will direct them in the choice of their company with a parental tenderness and anxiety; kindly reminding them, as occasion requires, that "he that walketh with wise men shall be wise; but a companion of fools shall be destroyed." Who will diligently observe, and tenderly check in them the beginnings of bad habits, and considering that "the beginning of sin is as the letting out of water," which, if not early stopped, will soon prove unconquerable?
EFFECTS OF FRESH PLASMA OR WHOLE BLOOD TRANSFUSIONS ON PATIENTS WITH VARIOUS TYPES OF MUCOPOLYSACCHARIDOSIS
Authors: Dekaban Anatole S. , Holden Kenton R. , Constantopoulos George
Published: December 2021

Repeated fresh plasma or whole blood transfusions were given to five patients with either Hurler, Hunter, or Sanfilippo types of mucopolysaccharidosis. Clinical observations and total 24-hour urinary AMPS and their composition and molecular weight distribution were determined before, during, and after transfusions. The two patients who received plasma transfusions showed no noticeable change in the amount of AMPS excreted; of the three patients who received whole blood transfusions, two had slightly less excretion of AMPS while the third showed no difference. The AMPS in the CSF were measured in one patient before and after blood transfusions and found to be unchanged; likewise, the determination of molecular weights in the isolated AMPS was virtually identical. In the patients studied, the transfusions caused no demonstrable difference in the patients' clinical condition.
INEFFICACY OF FRESH FROZEN PLASMA THERAPY OF MUCOPOLYSACCHARIDOSIS II
Authors: Erickson Robert P. , Sandman Robert , Robertson William van B. , Epstein Charles J.
Published: December 2021

Patients with Mucopolysaccharidosis II (Hunter's syndrome) were given short-term treatment with large infusions of fresh frozen plasma to evaluate recent claims of clinical and chemical improvement by such therapy. Clinical behavior, urine glycosaminoglycans, and skin, serum, and urine acid hydrolases were evaluated by single-blind techniques. There was no noticeable effect of fresh frozen plasma infusion on the performance of these patients. The total urinary excretion of glycosaminoglycans was not altered by the infusions and there was no change in the size of the glycosaminoglycan fragments.

The abnormal skin activity levels of β-galactosidase, β-glucuronidase, and N-acetylglucosaminidase were unaltered three days after fresh frozen plasma infusion and, similarly, the abnormal levels of these enzymes in the serum persisted without significant change during the ten days of evaluation.
ABO Hemolytic Disease, Complement, and Phagocytosis
Authors: Gordon B. D.
Published: December 2021

The first reference for the letter "ABO Hemolytic Disease, Complement, and Phagocytosis" by Dr. B. D. Gordon (Pediatrics, 50:169, 1972) should read as follows:

1. Wang, M. Y. F. W., and Desforges, J. F.: Complement in ABO—hemolytic disease of the newborn. Pediatrics, 48:650, 1971.
SITE OF ACTION OF EXFOLIATIVE TOXIN IN THE STAPHYLOCOCCAL SCALDED-SKIN SYNDROME
Authors: Lillibridge Clinton B. , Melish Marian E. , Glasgow Lowell A.
Published: December 2021

The purpose of this study was to demonstrate morphologic correlates of exposure of skin to exfoliative toxin derived from live phage group II staphylococci. Human infection with these staphylococci has been associated with scarlatiniform rash, generalized exfoliation, or bullous impetigo.

Histologically, the skin lesions in patients and animals injected with the exfoliative toxin appear indistinguishable. The characteristic change is an intraepidermal cleavage through the granular cell layer. Electron microscopically, this cleavage appears to result from disruption of otherwise normal attachment structures (desmosomes) through their intercellular contact area. This disruption may be related to disappearance of extracellular globules which are proposed possibly to contain proteolytic enzymes.
Letter to the Editor
Authors: DeHaven Kenneth E.
Published: December 2021

We referred these questions to Dr. Kenneth E. DeHaven, Orthopedist of the Cleveland Clinic, Cleveland, Ohio, and to Mr. Creighton J. Hale, Vice President, Little League Baseball, Williamsport, Pennsylvania. Excerpts from their answers follow:

The risks of serious or permanent injury to the elbow are the same as for pitchers of any age, namely, medial tension overload, lateral joint compression syndromes, and extensor overload. In addition, the preadolescent pitcher runs the risk of medial epicondylar epiphysitis.
Letter to the Editor
Authors: Hale Creighton J.
Published: December 2021

Because of the great numbers of boys playing in Little League, we receive thousands of reports of injuries through our Insurance Division. In examining these reports from the doctors, we find that the injury to the elbow from pitching is infrequent. We have found that this specific injury increases with age and it occurs more in our 13-15-year-old groups and 16-18-year-old group than in the 8-12-year-old group. This seems logical in that the older boys become the greater their strength, the harder they throw and, consequently, the greater the stress placed upon the medial epicondyle.
Behavior Modification by Drugs: The Need for Definitions
Authors: Johnsen Stanley D.
Published: December 2021

Dr. Conners is to be credited with the initiation of a study into the clinical evaluation of the beneficial effects of various stimulant drugs used in the treatment of minimal brain dysfunction. Of particular value appears to be the comparison of the psychometric tests done before and after treatment. One, however, has to question critically the value of many of the statements that were made in evaluating a patient's response to drugs.

The author does not precisely define various terminology used in the study.
Avoiding More Than Pediatric Pathogenesis
Authors: Haddock Samuel T.
Published: December 2021

I enjoyed reading the superb article in which Drs. Carey and Sibinga discussed avoiding pediatric pathogenesis in the management of acute minor illness. They gave the subject much thought and clearly analyzed the problems as scientifically hard-nosed but sensitive practitioners. However, I am sure many physicians who see the infant with minor illness may, nevertheless, think of SDS (crib deaths) while others may be concerned for the patient's satisfactions and financial security. I would, therefore, like to recommend Dr. Comfort's discussion of "What is a Doctor?" which explains the unique position of death today as faced by the practitioner.
Bacterial Infecfions: Changes in Their Causative Agents—Trends and Possible Basis (Bayer—Symposium III), edited by M. Finland, W. Marget, and K. Bartmann. New York/Heidelberg/Berlin: Springer-Verlag, 1971, 231 pp., $15.00
Authors: Nelson John D.
Published: December 2021

Almost two years ago a group of eminent international authorities in the field of infectious diseases gathered near Cologne, Germany, for a week of reflection and discussion concerning the changing patterns of bacterial infections in recent decades and the possible reasons for the changes. The United States was represented by Drs. M. Finland and E. H. Kass of Boston, F. Daschner of Los Angeles, and A. von Graevenitz of New Haven. Other scientists were from Germany, France, Sweden, Great Britain, Switzerland, and Denmark.
Brain Hypoxia (Clinics in Developmental Medicine No. 39/40), edited by J. B. Brierley and B. S. Meldrum. London: Spastics International Medical Publications, 1971, 320 pp., $20.00
Authors: Koenigsberger M. Richard
Published: December 2021

This group of papers presented at the Carshalton Symposium on brain hypoxia is remarkable in being quite different from its sister volumes in the splendid British series of Clinics in Developmental Medicine. The papers are grouped under sections concerned with cerebral blood flow, electromicroscopy, biochemical approach to brain hypoxia, post-hypoxic brain swelling, atmospheric decompression, hypoglycemia, and epilepsy.

The result is a mixed bag; most of the papers do not deal directly with the effects of permnatal hypoxia, the subject of greatest interest to the pediatrician, neurologist, and pediatric neurologistxsx.
Changing approach to neonatal hepatitis and biliary atresia
Authors: Landing Benjamin H.
Published: December 2021

Recently advanced ideas on the pathogenesis and interrelationships of neonatal hepatitis and biliary atresia, and on newer methods of surgical treatment of the latter, have generated renewed interest in the prognosis of these conditions, and in factors which influence it. In the past, those who believed that the operative curability of biliary atresia, by "conventional" enteric anastomoses, was very low (under 5% in most series), and who believed that surgical procedures, such as open liver biopsy and cholangiography employed to determine whether a patient had neonatal hepatitis or biliary atresia, significantly worsened the prognosis of neonatal hepatitis, could even wonder whether exploration of a patient who might have either disease was really warranted.
On alcohol burners and paper clips
Authors: Nelson Nicholas M.
Published: December 2021

Those readers who tend to be titillated into reading articles whose titles include such eye-catching phrases as "a simple method" may well, at first, be disappointed in the contribution of Lister et al. elsewhere in this issue of Pediatrics. Surely, one feels appendices which assault our senses with such polysymbolic multiple equations as these must relate to a method more accurately described as formidable and, at best, academic-certainly not practical!

Now, a paper clip is, indeed, simple in concept and design-its functional application is self-evident. Yet, the engineer's calculations and mechanical drawings of the machinery which enabled production of such a basic instrument of civilized living are, no doubt, a good deal more complicated than Listers' illustrations and appendices.