about ten pounds more than it does now. At present it weighs in the neighborhood of thirty pounds. It is about thirty and a half inches in height. It is difficult to measure the child accurately on account of its restlessness and its inability to stand The child has the appearance of low mentality; a broad nose, thick lips, protrusion of the tongue, large head, and lack of intelligence in the eyes. The skin at the time it came under observation was rough, and had the characteristic doughy feel of the cretin. The so-called fatty pads were present; and the reduction in weight is due probably to the disappearance of those fatty pads. The abdomen was pendulous, large, and at present it shows very plainly diastasis of the recti, with a tendency to umbilical hernia. The hair is thin, dry and coarse. The fontanelle is closed. The occipital protuberance is very well marked The hands are characteristic, although they are losing some of their characteristic points. They have a spade-like appearance, with stubby, short fingers. All of the long bones are relatively short and thick. The neck of the child is thick and short; and if there is any thyroid gland present, it is hard to make it out.

The child, when it was first seen, was placed on specific treatment. It was given a little too much of the thyroid extract. I considered the dose for a nine-year-old child, without thinking of the small stature, and for that reason a too large dose was administered, which induced marked nervous symptoms, with elevation of temperature. The rectal temperature, when the child was first observed, was 961⁄2 degrees F. Restlessness and increased temperature were manifest in a day or two after the beginning of the treatment. The child got up to about one grain of thyroid extract at a dose. This was reduced until finally it was taking one-half grain of the thyroid extract three times a day, after which it showed very little tendency to restlessness. The mother of the child informs me that the thyroid extract was reduced to one-quarter of a grain for a little while, after which the dose was increased again. The skin was dry and rough, but now assumes more the characteristic of the skin of a healthy child. It is soft now and has lost that markedly dark color it had at the beginning. In general, the child is improving. Its voice, which you hear, is not nearly so hoarse as it was when treatment was first instituted, although at times it has been better than it is at present. The child cries more lustily than it did. It had difficulty in swallowing, but after about four weeks' treatment the appetite improved markedly until now it seems to be hungry all the time, and there is no difficulty apparently in swallowing. The tongue protrudes at present; but the mother tells me that most of the time the child keeps the tongue in the mouth. The lips are not so thick as they were. The child shows more intelligence than it did. On the whole, it has improved markedly under thyroid extract in two months.

So far as the prognosis is concerned, we do not know just exactly how much more the child will improve, but it has reacted so well under this treatment that we can hope for considerably more improvement. It has already begun to say such words as mamma and papa, which I think speaks well for a good result.

TYPHOID FEVER IN A CHILD OF FOURTEEN MONTHS, WITH PATHOLOGICAL FINDINGS.-Drs. Alfred C. Cotton and William J. Butler reported jointly this case. Dr. Butler, in reporting the case, said: This child was fourteen months old and was admitted to the Presbyterian Hospital on the 5th of January.

As to the family history, the parents are both living and well. This was the only child. It had always nursed; had never been sick and was considered healthy. The child's illness began on a Thursday afternoon, at which time the mother, on returning from a visit to a neighbor's house, found the child crying. It refused to nurse. That night it vomited frequently, was restless, and slept very little. The condition remained about the same Friday and Saturday, save for a higher temperature and greater restlessness. The child continued to vomit spontaneously after nourishment or water. The vomitus was said to have a foul odor and to be of a brownish color. Did not cough. Had a constipated stool on Thursday; since that tiime stools were liquid, brownish in color, and of a very foul odor. There were three or four movements in the twenty-four hours. Patient entered hospital Saturday at 7 P.M. Examination gave the following:

Child appeared to be well-nourished. It was restless; rolled its head from side to side, but made no noise. The hands and feet were cold. The eyes rolled upwards, but were negative. The neck and chest were negative, except for some fine moist and crepitant râles, heard posteriorly and below, suggestive of edema of lungs. The abdomen was slightly distended, but soft. The spleen and liver were not palpable. Lower extremities presented slight edema. After entrance the child had a temperature between 105.2 degrees and 106 degrees, until death, which occurred the following morning about two o'clock. Respiration was between 50 and 60 per minute. The bowels moved three or four times during the time the child was in the hospital. The pulse was very rapid and feeble.

The following is a report of the post-mortem examination, made by Dr. Bassoe, pathologist to Presbyterian Hospital:

REPORT OF PATHOLOGIST.-F. M., aged fourteen months. Clinical diagnosis, open. Attending physician, Dr. Cotton. Anatomical diagnosis, typhoid ileocolitis. Acute mesenteric lymphadenitis; acute splenitis, slight. Acute degeneration of liver and kidneys. Slight edema of the lungs and subcutaneous tissues. Patent foramen ovale.

The body is that of a well-nourished and well-developed female child. The length of the body is 75 cm. There is con

siderable edema of the subcutaneous connective tissue, which is most marked in the lower extremities. The peritoneal cavity is empty. The small intestines are distended with gas. The ileum hangs over the brim of the pelvis and is very hyperemic and dark in color. Both pleural cavities are empty and free from adhesions. There is no change in the pericardium; the thymus covers the upper half of the pericardium, and measures 6 cm. from above downward; 5 cm. from side to side, and 8 mm. anteroposteriorly. The thyroid gland is small and its cut surface normal. The larynx and trachea are not changed. The largest cervical lymph glands are 4 mm. long. The tracheal and bronchial glands are of similar size. The left lung crepitates. The cut surface is grayish-pink, and contains a moderate amount of blood and frothy fluid. The right lung resembles the left. The heart weighs 45 grams. The endocardium is everywhere smooth. The cavities of the right side of the heart contain clotted blood. The foramen ovale is patent by a large slit at its margin. The myocardium is of a uniform grayish-red color. The spleen measures 6.5x3.5x1.5 cm. The cut surface is mottled, dark red and gray. The Malpighian bodies are very distinct. The tongue and pharynx are not changed. Each tonsil measures 15x7 mm., and contains a grayish nodule, 2 mm. in diameter. The esophagus is smooth. The stomach is empty, and measures 8 cm. from side to side. The mucous membrane is smooth and thin, with slightly developed rugae. In the upper portion of the small intestine there are no changes. In the upper portion of the ileum Peyer's patches are moderately swollen. This swelling gradually increases from above downwards. Necrosis of the swollen patches appears within 40 cm. of the ileocecal valve; 25 cm. above the ileocecal valve is a greatly swollen patch which is partly necrotic. The mucosa below this patch is everywhere hyperemic; both Peyer's patches and the solitary follicles are swollen and partly necrotic. Just above the valve is a patch 4 cm. in length, from which the necrotic tissue has partly sloughed away. The ileocecal valve itself is swollen and partially ulcerated on its proximal surface. The mucous membrane of the appendix is smooth, but hyperemic, and has a distinct, shavenbeard appearance. The mucous membrane of the ascending colon is also swollen and the solitary follicles are very prominent. Throughout the mucosa scattered dots the size of pin points are seen; these are identical in appearance, but much less numerous than those which give the shaven-beard appearance to the mucosa of the appendix. There are no ulcers present in the large intestine. The mesenteric glands, especially those closest to the ileocecal valve, are enlarged and soft. The largest of these glands are 14 mm. in length, and the cut surface is grayish-red in color. The liver weighs 245 grams. It is smooth externally and rather soft; the cut surface is grayish-red, and the markings are rather

indistinct. In places the cut surface has a mottled appearance, on account of the presence of very pale areas. The gall-bladder contains dark bile. Its lining is smooth. The pancreas and adrenals are not altered. The right kidney measures 6x3.5x2.5 cm. The capsule strips off easily, leaving a smooth surface. The cortex is 4 mm. in thickness, and is rather pale. The relation of cortex to medulla is as I to 3. The markings are not distinct. The left kidney answers to the same description. the urinary bladder there is no change. The uterus is 2 cm. long. Each ovary measures 18x7 mm. The spinal meninges and cord show no changes; the cerebro-spinal fluid is clear. The brain could not be examined.

HISTOLOGICAL DESCRIPTION.-Sections from the intestine show marked hyperplasia of Peyer's patches, the lymphoid tissuc in the submucosa constituting over half of the thickness of the bowel wall. The overlying mucosa is thin, hyperemic, and in places it is absent, leaving the submucosa exposed. In the interior of the lymph follicles considerable hyperemia is present, and proliferation of large cells (endothelial). Many polymorphonuclear leucocytes are seen among the larger cells. The muscular and serous coats are not involved. In the spleen the lymph follicles forming the Malpighian bodies are also prominent, and resemble those of the intestine in appearance, being largely made up of large cells. The pulp is greatly engorged with blood. In the kidneys the epithelium of the convoluted tubules is somewhat swollen and granular. The glomeruli are not altered. Aside from hyperemia, no change can be made out in specimens from the liver prepared in the usual way. The heart muscle. thymus, thyroid and pancreas are not altered.

BACTERIOLOGICAL EXAMINATION.-A bacteriological examination was made of the bile and spleen. The culture media remained sterile.

Clinically, this patient was sick about sixty hours, prior to which time the child apparently showed no special disturbance of any kind, so far as the parents noticed. It is not improbable, however, that the child had been ailing for some days, or had presented some symptoms which were unnoticed by the parents. The course it pursued clinically simulated that of a case of gastroenteritis; but the pathological findings were accepted at once as those of typhoid. Many other conditions than typhoid may result in hyperplasia of Peyer's patches, that is, other infections. than typhoid. But the hyperplasia, with ulceration, however, is not a common finding in other conditions than typhoid. We have in this case hyperplasia most prominent in the lower part of the ileum, especially in the region of the ileocecal valve. Although the diagnosis in our case will never be accepted as absolutely certain, on account of negative cultures, still the postmortem findings, the hyperplasia, the beginning necrosis, and

ulceration of Peyer's patches, together with hyperplasia of the adjacent mesenteric glands, form the typical anatomical picture of typhoid in a child in whom the hyperplasia predominates over all other features. While ulceration is more characteristic of adult life and late child life, hyperplasia of Peyer's patches is most commonly to be found in infants. Rilliet and Barthez, when pointing out the difference between typhoid in children and in adults, called attention to that fact. They spoke of typhoid in infants and in younger children as being characterized chiefly by hyperplasia of Peyer's patches, which in the majority of instances in young children, instead of proceeding to ulceration, terminated in resolution, and drew attention to this as one of the striking differences between typhoid in the infant and typhoid in the adult. While we do not wish to be placed on record as making a diagnosis positively of typhoid in this case, we cannot see what other diagnosis could be made anatomically. On the other hand, it is not improbable that there were bacilli in the bile and spleen, but that they were few in number and escaped detection.

Dr. Butler called attention to a point that seems to be a symptom of gravity in typhoid in children, and that is vomiting at the onset, which continues into the course of the disease. He has the record of another case, six or seven years old, in whom among the first prominent symptoms at the onset was vomiting, which persisted throughout the course of the disease. The child died on the seventh day, with a temperature of 106 degrees, and a pulse of 170 just before death.