Volume 71
Number 3
8. Simonson, E., Alexander, H., Henschel, A.,
and Keys, A.: The effect of meals on the
electrocardiogram in normal subjects, Am.
Heart J. 32: 202, 1946.
9. Simonson, E., and Keys, A.: The effect of an
ordinary meal on the electrocardiogram--
Use o/the band
refractometer in, determining
total serum proteins of
infants and children
Jess G. Thoene, r
James L. Talbert, M.D.,
S. Subramanian, M,B., ~ and
Gerard B. Odell, M.D.
BALTIMORE, MD.
K N o w • E D O E of the circulating levels of
plasma proteins can provide valuable as-
sistance in the diagnostic and therapeutic
management of children, particularly in
small infants. With the introduction of the
hand refractometer, measurement of the
plasma refractive index has become a simple,
reliable procedure. Wolf and others have
demonstrated that a high degree of correla-
tion exists between the plasma refractive in-
dex, venous total serum solids, and venous
plasma proteins. 1-~ Application of this same
method to the assessment of plasma proteins
From the Division of Pediatric Surgery of the
Department of Surgery and the Department of
Pediatrics, The Johns Hopkins University
School of Medicine.
Supported by United States Public Health
Service Grant No. HD 01941 from the National
Institute of Child Health and Human
Development, Bethesda, Md.
eAddress, GMSC 7-110, Johns Hopkins Hospital,
Baltimore, Md. 21205.
e'~Fetlow in Surgery, The Johns Hopkins University
School o[ Medicine.
Brie[ clinical and laboratory observations 4 13
normal standards in middle aged men and
women, Circulation 1: 1000, 1950.
10. Simonson, E., and McKinlay, C. A.: The
meal test in clinical electrocardiography,
Circulation 1: 1006, 1950.
in capillary blood samples would extend its
usefulness in pediatric patients. The present
studies were undertaken to establish a cor-
relation between capillary serum refractive
index and venous plasma proteins, and to
confirm the applicability of this determina-
tion in the treatment of infants and small
children.
MATERIALS AND M E T H O D
A hand refractometer ~ was used for alI
determinations of total serum solid. This in-
strument is calibrated to read directly in
grams per cent of serum solids rather than
in refractive index, and is temperature com-
pensated to give accurate readings over the
range of 70 to 90 ~ F. An additional scale
allows its use in determining urine specific
gravity on extremely small aliquots.
Patients included in this study were chosen
from the infants' and childrens' wards of The
Johns Hopkins Hospital. Paired venous and
capillary blood samples were drawn simul-
taneously in each instance.
All serum protein determinations were
done by the Biuret reaction using the re-
agents described by Gornall2 A microtech-
nique was employed. A 20/zL serum sample
was mixed directly with 780 ~L of reagent,
After 15 minutes, the optical density of the
resultant sample was read against a reagent
blank at 540 m~,, in a B. & L. spectronic 20
photometer.'~ This value was converted to
protein concentration directly from a stan-
dard calibration curve established previously
with crystalline human albumin, the concen-
tration of which was determined by Kjeldahl
analysis. 6 Working standards of Versatol A
~TS Meter, The American Optical Company, Instrument
DMs~on, Buffalo, N. Y.
tBausch & Lomb, Inc., Rochester, N. Y.
4 14 Brief clinical and laboratory observations
correspond to this standard curve and were
used for reagent checks. The supernatant
fluid from a microhematocrit determination
was found to provide ample serum for the
measurement of proteins by this microtech-
nique, as well as for determination of total
serum solids with the hand refractometer.
RESULTS
The data in Fig. 1 confirm the high de-
gree of correlation between total serum pro-
tein and total serum solids in venous blood.*
The correlation between total serum protein
and total serum solids of capillary blood
samples is demonstrated in Fig. 2. Fig. 3
illustrates the linear relationship between
concentrations of venous and capillary pro-
teins. The capillary protein values were
slightly higher than those obtained in the
corresponding venous samples, when values
of capillary protein exceeded 4 Gin. per 100
ml. Fig. 4 illustrates the excellent correla-
*The computations in this paper were done in the
Computing Center of the Johns Hopkins Medical Institu-
tions, which is supported by Research Grant FR-00004,
from the National Institutes of Health and by Education
Contributions from the International Business Machines
Corporation.
I0-
9-
8-
7-
oEr -
0 IE,
E 5-
"4-
>
5-
/
/
2-
/"
/"
/"
o
o i i. 4 ;
VTSS ( g m / I 0 0 ml )
Fig. l. Venous total protein (VTP) vs. v e n o u s t o t a l s e r u m solids ( V T S S ) .
The Journal of Pediatrics
September 1967
tion between venous total protein, as mea-
sured by the Biuret method, and capiIIary
total serum solids, as measured by the TS
meter (r = 0.94).
DISCUSSION
Serial determinations of total serum pro-
teins may be useful in a number of clinical
situations in pediatrics, but the absence of a
simple, reliable method for obtaining this
information has restricted the frequency with
which such measurements have been prac-
tical. In many laboratories, the size of the
blood samples necessary for such studies is
excessive, particularly in tiny infants; and
the time interval required before the value
is available to the physician limits its clinical
usefulness.
The hand refractometer provides a means
for simple, yet quick and accurate deter-
ruination of the refractive index of various
body fluids. The present study confirms the
usefulness of this instrument for the deter-
mination of total serum proteins in pediatric
patients. Other investigators have proved
the reliability of such measurements when
employing samples of venous blood. In the
/
/
/
/
eeo ee 9 9
9 9 ooee 9
/ 9
/
/
VTP : . 8 2 4 VTSS - 1.08
n:38
CORREL. COEFF.: 0.86
; i ; ,b
Volume 71 Brief clinical and laboratory observations 4 15
Number 3

I0"

9" /
/
/
8" ,/

7"
A

06"
0

E5-

E'4-
I.-

3-
/
/
2- ,," CTP =.759 C T S S - 0.28
/ n=71
/ CORREL. COEFF. : 0 . 9 0

0
o i i i i ; ; + ; ; ,b ,'~ ,~
GTSS (gm/lOOml)
Fig. 2. Capillary total protein (CTP) vs. capillary total serum solids (CTSS).

10- /
/
9-
/
/
/
8- /
/
/
7-

o
o ee e e
... 5-
E 9

~4-
/
>3" /
/
/
2- /
/ "VTP=.903 CTP + 0 . 5 5
n.:36
/ CORREL. COEFE = 0 , 8 9

0 I I I I I
I0' Ii '
12
GTP ( gm / I 0 0 rnl )
Fig. 3. V e n o u s total protein ( V T P ) vs. capillary total protein ( C T P ) .

present study, a similar high degree of cor- The proved reliability of capillary samples
relation was established between the plasma allows a far wider application of this tech-
refractive index of capillary blood and the nique to the routine care of infants and chil-
total serum protein content of venous blood dren. Clinical situations in which serial de-
when paired samples were measured simul- terminations of serum proteins have particu-
taneously in the same patient. lar application are encountered in babies
4 16 Brie[ clinical and laboratory observations
I0-
"9-
8-
7-
A
E 6-
0
0
"" 5"
E
v
n 4-
I-
3-
/
/
2-
/ VTP=.852 GTSS-I.26
/ n =36
/ GORREL. GOEFF.= 0 . 9 4
0
CTSS ( g m / l O O m l )
Fig. 4. Venous total protein (VTP) vs. capillary total serum solids (CTSS).
with hyperbilirubinemia and in infants and
young children with either significant losses
or limited intake of proteins.
In the evaluation of the risk of toxicity of
hyperbilirubinemia to the newborn, a knowl-
edge of serum albumin concentration is par-
ticularly important# Since there is very little
variation in the concentration relationship
of albumin and globulin in the neonatal
period, one can calculate the serum albumin
from the total protein determination de-
rived by refractometry.
Serial monitoring of serum protein levels
combined with an index of effective intra-
vascular volume, determined by central ve-
nous pressure measurements, allows consider-
able precision in regard to volume as well as
to composition of ideal replacement therapy
for patients who have suffered significant
losses of body fluids? Such situations are en-
countered frequently in pediatric patients
with medical and surgical disorders and are
often compounded by associated restrictions
in oral intake. The maintenance of a satis-
factory level of circulating proteins also pro-
vides a useful measure of adequacy in the
The Journal o[ Pediatrics
September 1967
/
/
/
/
/
S
e
/ 9
/
/
,i
management of smaI1 infants who require
prolonged parenteral feeding or suffer from
unusual nutritional disorders.
Exceptions to the reliability of this method
for monitoring total serum proteins may be
encountered in these clinical situations:
1. Patients in shock or vascular collapse:
In the presence of impaired peripheral
circulation, the close correlation be-
tween capillary and venous serum pro-
tein concentration may be alerted.
2. Patients receiving colloidal substances
such as Dextran: In these circum-
stances, the serum solid content may be
elevated without altering the amount of
serum proteins.
3. Patients with an elevation of circu-
lating serum lipids following ingestion
of a meal: Experience in infants and
children has indicated that significant
postprandial lipemia is relatively un-
common as opposed to the adult. The
only example of this type of inter-
ference encountered in the present
studies involved a child with severe
nephrosis. In actuality, pMents who re-
Volume 71
Number 3
quire serial m o n i t o r i n g of p l a s m a pro-
teins also frequently have limitation of
oral feedings.
SUMMARY
T h e present study has confirmed the re-
liability of total serum protein d e t e r m i n a -
tions as measured by the quick, simple tech-
nique of h a n d refractometry. T h e applic-
ability of capillary blood samples for this
purpose provides a means by which deter-
m i n a t i o n of total serum proteins becomes a
rapid, bedside procedure, p e r f o r m e d easily
by either physician or nurse.
REFERENCES
1. Wolf, A. V.: In Wolf, A. V., editor: Aque-
ous solutions and body fluid, New York, 1966,
Harper & Row, Publishers.
2. Remp, D. G., and Sehelling, V.: Relations
between total solids and total proteins of se-
rum as measured by refractometry, Clin.
Chem. 6: 400, 1960.
A clinical variant of tic
con vu hif
Percy Barsky, M.D.
"~VINNIPEG, CANADA
U N i Q u E in the annals of p e d i a t r i c litera-
ture, is the s y m p t o m - c o m p l e x k n o w n as "tic
convulsif de Gilles de la T o u r e t t e . " T h e hail-
m a r k s of this disorder are i n v o l u n t a r y
movements, b e g i n n i n g in childhood, a n d their
association w i t h t h a t p h e n o m e n o n referred
to as " c o p r o l a l i a ''1 (an irresistible use of
obscene lang'uage). F o r u n e x p l a i n e d reasons,
reference to the s y n d r o m e diminished after
From the Department of Pediatrics, Faculty
of Medicine, University o[ Manitoba, and
Children's Hospital o[ Winnipeg.
Brief clinical and laboratory observations 4 17
3. Rubini, M. E., and Wolf, A. V.: Refracto-
metric determination of total solids and water
of serum and urine, J. Biol. Chem. 225: 869,
1957.
4. Barry, K. G., MeLaurin, A. W., and Parnell,
B. L.: A practical temperature compensated
hand refractometer (The TS Meter): Its clin-
ical use and application in estimation of total
serum proteins, J. Lab. & Clin. Med. 55: 803,
1960.
5. Gornall, A. G., BardawiI1, C. G., and David,
M. M.: Determination of serum proteins by
means of the Biuret, reaction, J. Biol. Chem.
177: 75i, 1949.
6. Hiller, A. J., Plazin, J., and Van Slyke, D. D.:
A study of conditions for Kjeldahl determina-
tion of nitrogen in proteins. Description of
methods with mercury as catalyst and titrimet-
tie and gasometric measurements of the am-
monia formed, J. BioI. Chem. 176: 1401,
1948.
7. Odell, G. B.: Kernicterus: Revised concept of
pathogenesis and management (A commen-
tary), Pediatrics 38: 543, 1966.
8. Talbert, J. L., and Haller, J. A., Jr.: Recent
advances in the postoperative management of
infants, J. Surg. Res. 6: 502, 1966.
1912. T h e disorder d i s a p p e a r e d almost en-
tirely from p r i n t until 1965, when Stevens
e n c o u n t e r e d a case in a 59-year-old F r e n c h -
C a n a d i a n male. -~
CASE REPORT
This is the history of a 9-year-old giri whose
parents had observed, during the preceding 12
months, an alarming increase in sudden, pur-
poseless, jerking movements of her body. These
wouId vary from sharp, repetitive head jerks, to
arm flexions, eye blinking, or leg kicking. Re-
cently the irresistible use of obscene language
(coprolalia), had manifested itselL She had been
repeating over and over again, "I swallowed a
piece of ." The child was aware that she
had said this, but could not refrain from re-
peating the phrase.
The girl otherwise appeared quite normal, but
the purposeless movements and the unique re-
petitive phraseology were becoming intolerable
and were responsible for keeping her out of
school.
Her past history was not remarkable, and the
family history seemed irrelevant. She was of