PEDIATRICS. UNDER THE CHARGE OF VANDERPOEL ADRIANCE, M.D., Consulting Physician to the New York Orphan Asylum and Pathologist to the Nursery and Child's Hospital. Intestinal Invagina- F. R. Kirmisson (Bull. de l'Acad. de Méd., Acute Articular Rheu- Kephalliaos (Wiener the early and inevitable involvement of matism, Chorea and En- Klin. Wchschrft., the heart applies to the girls alone, in docarditis of Children. No. 19, 1906). The the clinical material of the author. In a author reports 129 cases of acute articu- similar way polyarthritis could be demonlar rheumatism in children. His experi- strated as the etiological factor of chorea ence agrees with that of other observers only half as often in boys as in girls. to the effect that the disease is extremely rare up to the fifth year. No case was observed under one year of age. A suggestion which has been made to the effect that there exists a special predisposition for arthritis at the period of increased growth of the skeleton was not confirmed by the author's experience. The 129 patients observed by him included 64 boys and 65 girls. Hereditary tendency to polyarthritis could be demonstrated in 50.7 per cent. of the cases; a tuberculous heredity existed in 23 per cent. of these patients. The majority of the cases ran a milder course under salicylate medication than in the average adult case, whereas the disease is regarded as generally malignant in children by Bagius Ry. The joints which are most commonly involved (ankle, knee, hand, elbow) were also the first to be attacked, as a rule. About 70 per cent. of the cases were followed by a demonstrable involvement of the endocardium, this figure agreeing with the observations of other writers. It is noteworthy, however, that endocarditis developed in almost all the girls, but in only 45 per cent, of the boys. Hardly 5 per cent. of the boys, against over 20 per cent. of the girls, were attacked by chorea as a sequel of polyarthritis. The statement of Baginsky to the effect that the characteristics of acute polyarthritis in childhood consists in May, 1907). Almost all the cases of invagination of the bowel in children. come under surgical treatment when it is too late. In the 17 years of the author's practical surgical experience with these cases all the patients died, with the exception of a single one, who was operated upon six hours after the first symptoms had appeared. Statistics show that results improve with the accuracy of the diagnosis and the timeliness of the operation. All the cases which recovered, according to Clubbe's statistics, were operated upon in 23 to 28 hours after the onset of the disease, whereas in the cases with a fatal outcome surgical interference was delayed for from 48 to 68 hours. The diagnosis presents no difficulties whatsoever. Intestinal invagination is a disease. of early infancy. The most important signs consist in the bloody stools and severe colics. In this connection the following rules are laid down by the author: Invagination is the most common form of intestinal occlusion in little children. A baby which passes blood by the anus and at the same time presents severe colics, with signs of intestinal occlusion, is in all probability suffering from invagination of the bowel. With special reference to the treatment, operation should not be delayed after copious enemata have failed to promptly remove the invagination. Precisely as in a case of strangulated hernia, the physician must not leave the patient before the obstacle has been removed. F. R. Myocarditis Scarleti Pospischill (Wiener nosa (the Scarlet Fever Klin. Wch., No. 37, Heart.) 1907). A large number of children having scarlet fever present at the beginning of the disease a characteristic heart murmur, which consists in a splitting of the first sound, accompanied at the same time by a rough, scraping or grinding bruit. As a rule, this is heard most distinctly over the cartilage of the third left rib. The second sound may also be doubled. The author interpreted it as a pericarditic murmur, but convinced himself by autopsy findings of its occurrence with a normal endocardium and pericardium; for this reason he now regards it as the symptom of disease of the heart muscle. The murmur may be entirely absent in one epidemic and frequently present in another. In certain rudimentary cases, in which practically all the typical signs of scarlet fever failed, its presence permitted a diagnosis, confirmed by subsequent desquamation. The phenomenon is of variable duration. Exceptionally it may make its appearance at a later date, especially together with scarlatinous nephritis. Aside from its diagnostic value, this heart murmur does not seem to possess particular clinical importance. F. R. Macroglossia Congen- Delfino Archivio per ita Neurofibromatosa. le Scienze Mediche, Vol. 29, 1906). The patient was a child three years of age, who had presented an enlargement of the left half of the tongue since the time of birth. During the first year the tumor was so small that the tongue did not protrude from the mouth, and nursing was not interfered with. In the course of the second year the tumor began to grow, until the tongue constantly protruded from the mouth, even during sleep, and there was an uninterrupted discharge of the saliva. At the time of the patient's admission to the hospital the following findings were noted. at the examination. The child appeared perfectly healthy, well developed and of normal intelligence. The left half of the tongue was very much enlarged; the right half was normal, and the tip of the tongue was formed by the left half alone. The papillæ of the affected side were hypertrophied, and the surface of the tongue. was traversed by a number of furrows. There was some interference with speaking and chewing, also a profuse sialorrhoea. After a preliminary exploratory incision a wedge-shaped piece was removed from the anterior portion of the affected side, giving to the tongue its normal size and shape. The wound healed mal size and shape. promptly, speech and mastication gradually improving so as to become practically normal at the end of a year. The histological examination of the specimen showed no hypertrophy of the lymphatic vessels and no cyst formation, also no muscular changes, but there were innumerable nodules, enclosed by a capsule containing elastic fibres, and medullated nerve-fibers could invariably be demonstrated in the center. The disease accordingly consisted in a neurofibromatosis, as observed in general distribution over the entire body in von Recklinghausen's disease. In the author's opinion, this condition may possibly manifest itself at a later stage, as it invariably develops upon a congenital basis. Meanwhile, the condition present must be diag nosed as macroglossia neurofibromatosa, thor arrived at the conclusion that the primary factor must be regarded as a blood-dyscrasia, and that the leukocytosis (demonstrated in his cases) is the cause of the production of the uric acid as wel as the acid intoxication of the organism. In the former case the cyclic vomiting would have to be interpreted as the equivalent of an attack of gout; in the second case, as an effect of the acid intoxication of the organism. Based upon this hypothesis, the author endeavored to act directly upon the anæmia, and was enabled to observe in his cases of cyclic vomiting that good results followed upon reconstructive and invigorating treatment, with daily subcutaneous injections of soluble iron and arsenic. F. R. Brain Tumor. NERVOUS AND MENTAL DISEASES. UNDER THE CHARGE OF WILLIAM B. NOYES, M.D., Attending Neurologist, Demilt Dispensary. A case of brain tumor, of unusual type and interesting on account of its symptoms, its successful localization and operative results, is reported by Drs. J. L. Atlee, Lancaster, Pa., and C. K. Mills, Philadelphia, in the Journal A. M. A., December 28. The case was seen in consultation by several well-known physicians and was thoroughly studied in all its aspects. The patient was a physician, aged 43, with an excellent family and personal history. The important symptoms were headache, left unilateral laryngeal paralysis, localized left unilateral spasm with loss of consciousness, and later appearing left hemiparesis with loss of word memory and astereognosis. There was no true optic neuritis, though there was some indistinctness of the nerve margins. The visual fields were normal or nearly so. There was also nearly complete loss of voice. The left vocal cord showed adductor paralysis, and both it and the entire larynx were much congested, apparently due to the irritating cough. A triangular area of the skull, bordering the fissure of Rolando, extending upward along the line of the fissure for 13 inches and back an equal distance, with the base parallel to Reid's base line, was removed and a tumor 22x2x134 inches was shelled out. It was oval in shape and not adherent to the dura, but no pia was noticed over it. Microscopic examination. by Dr. W. G. Spiller revealed its structure to be epithelial in character, resembling that of the chorioid plexus, from which it was probably derived. The patient's memory for words and spelling returned immediately after the operation, and his improvement in other respects has been steadily progressive, with the exception of spasms occurring about three weeks after the operation, which were attributed to the use of faradism. The laryngeal paralysis, however, was still somewhat in evidence at the time of last examination. The authors quote from the recent work of Bielschowsky and Unger on the epithelial tumors originating from the chorioid plexus, and discuss more particularly the bearing of the case on the question of the cortical innervation of the larynx. Although the physiologic experiments of Krause, Semon and Horsley and Risien Russell would seem to indicate that a unilateral irritative lesion of the laryngeal cortical center should cause bilateral movements, and that a destroying lesion could only produce a bilateral paralysis of the vocal cords, this case and a similar clinical observation of Delevan's, to which the authors refer, point to the possibility of a destructive lesion of the cerebral center for laryngeal movements producing a persistent unilateral paralysis of the vocal cord on the side opposite the lesion. Children. Delusions of Grandeur Babon veit (Rev. in General Paralysis of Mens. des Mal. de l'Enfance, 1906-7). Paralytic dementia is of very rare occurrence in childhood and adolescence, and at this period chiefly attacks idiots and imbeciles. The course is a far slower one than in adults, but remissions are uncommon. The onset of the disease interferes with the physical and sexual development of the patient. While delusions of grandeur are not common in children, they are not as rare as usually stated; they occur in 12 to 14 per cent, of the cases of juvenile paralytic dementia. They are characterized, as a rule, by the silliness and childishness of the concepts. The patient will say, for instance, that he is enormously rich, for he owns 25 cents, or 500 monkeys. Outside of general pa phile reaction of the blood has not as yet been satisfactorily explained. There are certain cases which cannot be accounted for by Gabritschewsky's explanation of the phenomenon as dependent upon a hyperglycemia, nor by Kaminer's establishment of a relationship to leukocytosis. The author was enabled to demonstrate in the Children's Clinics in Florence the noteworthy fact that the iodophile reaction was present with remarkable frequency in the blood of children having some cerebral disease. The blood was examined and tested for the iodine reaction exactly according to the method prescribed by Ehrlich and Kaminer. The reaction existed in 21 of 30 cases, in which he was positive that this phenomenon could not have been produced by leukocytosis. A similar iodophile reaction in healthy children is extremely rare. It was observed by the author in one single instance among 20 cases. When pres ent it is very faintly marked under these conditions. The explanation of this phenomenon remains obscure. The author regards it as possible that in these cases of disease of the nervous system a stimulating influence may be exerted upon the glycogenetic function of the liver. F. R. C.H. Hughes, M.D., "La Phobie du Regard" St. Louis (Alienist and Neurologist). An abstract by W. C. Sullivan, M.D., in last July Journal of Mental Science of an interesting communication from Bechterew in the Archives de Neurologie for July on this subject calls to mind one of my own recent cases and one specially remote case. The remote case especially contributed to sustain the author's view that it frequently develops as an immediate sequence of sexual exhaustion, particularly when brought about by masturbation, while the present case rather controverts the sexual-exhaustion causation view, though the latter is markedly associated with other phenomena of morbid neurasthenic irritation, such as the phobia of blushing, though there was no inability to micturate before others, as the party having been profoundly prostrate after a period of neurasthenic delirium required catherization at times and the use of the urinal at the hand of a trained nurse. These cases in milder form are what we know as shamefacedness, sustaining about the same apparent relationship to the latter as ordinarily seen that settled and deep melancholia does to an ordinary fit of the blues, and, of course, are often encountered, in mild degree, in abandoned masturbaters and the otherwise sexually exhausted. The first case of our own here referred to was one of erotopathic insanity without furore of nymphomania. The young lady indited amorous epistles to the asylum superintendent, yet always naively veiled her face in the asylum to the superintendent, patients and attendants. To such an extent was this shamefacedness and erotism combined that it was deemed wiser to send the patient home than to keep her in the institution. Her mental condition was rather one of pure psychoneurasthenia than mania, she being one of those cases wrongly certified by the family physician as insane because of this peculiar and persistent phobie du regard and morbidly intensive erotism. The other case was markedly different, being a man of affairs, married satisfactorily and broken by overbrain strain in a large business enterprise which proved financially successful. The business required most disagreeable traveling through a woody country, both on horseback and afoot, causing him to break in brain on a final, forced and hungry tour, concluding with a last night and day without sleep. He broke down with psychoneurasthenia. This occurred more than 15 years ago. This experience with psychoneurasthenic delirium lasted nine months before he apparently regained his normal mental strength. But his convalescence was not then complete. It seldom is when the patient decides it is. The last acute attack was briefer in duration than the previous one, but he still has the phobie du regard remaining to some extent, though he can now take his meals at table when only his wife is with him or a few others. His phobia still embraces fear of wide expanses of country (space phobia), especially of wooded country, and fear of many people in a crowd (crodaphobia). if you will accept the term. He blushes readily on slight occasion in private conversation when speaking himself, especially when relating a story and the speech not being such as would cause a flush on the cheek of any ordinary person or upon his own when he has been quite well in his nervous system. In Beard's neurasthenia or cerebrasthenia this phobie du regard would appear as homophobia and gynephobia, but he has neither, so far as single individuals are concerned, though earlier in his malady he would blush and be halt of speech when speaking alone to me with no other auditor. This fear of coming under the observation of others, this dread of going into the presence of others, this aversion to |