of life. As regards a cure meningocele is by far the most favorable. Many cases, especially those properly treated, pass through life with no other symptoms developing.

Some cases of meningomyelocele respond very nicely to treatment, but if accompanied by complete paralysis the outlook is exceedingly poor. Syringomyelocele with hydrocephalus is hopeless, usually dying in a few days.

Hydrocephalus and paralysis often follow either the aspiration and injection or surgical treatment, and is always fatal. We cannot expect to materially improve a coexisting paralysis by any form of treatment.

The diagnosis of spina bifida is not a difficult matter but to differentiate its varieties may be very hard-some diagnoses not being made until the sac is opened-however, the seat of defect, size of bony cleft, form of tumor-coverings and accompanying phenomena, will usually suffice.

Meningococele usually appears in the sacral region, rarely in the cervical, lumbar or dorsal, having a small bony cleft which is not palpable, the tumor is pedunculated, translucent, covered by normal skin and with no accompanying paralysis.

Meningomyelocele has a large palpable bony fissure, is sessile, translucent and freely fluctuating, the base only is covered by normal skin, there being a large central cicatrix, which is usually umbilicated at point of cord attachment. The cord may be seen as a shadow. This form usually appears in the lumbo-sacral region and is often accompanied by paralysis and deformities.

Syringomyelocele has a coexisting hydrocephalus, with accompanying paralysis of lower limbs, sphincters of bladder and rectum, and deformities elsewhere. Pressure on tumor causes bulging at fontanelles with symptoms of cerebral pressure.

Repeated aspirations are not very satisfactory and can only be called palliative.

Aspiration and injection of Morton's solution produces good results in some cases, but convulsions and sudden death may result.

Ligation or clamping of sac is to be condemned, as we may destroy any portion of cord, contained in the sac, thereby causing paralysis of extremities, sphincters, etc.

Electricity has been used with little if any succèss.

Plastic operations are without question the best mode of treatment in practically all cases and should be performed at the fourth or fifth month, unless indications for earlier treatment exist.

The operation consists of opening the sac, draining off excess of fluid, dissecting off all portions of cord substance and returning same to canal, if possible, closing cleft by suturing flaps and normal skin over same.

CASE: This little Italian girl, now aged ten and one-half months, came under my observation six and one-half months ago, with the following history: Father, laborer, aged thirty-seven years, moderate drinker and family history negative. Mother, aged thirty-four years, family history negative, two previous children, boy aged seven years, girl, aged nine years. Both normal and healthy; no children dead and no miscarriages-labors normal.

At birth this little girl had a slightly protruding soft area in the median line, sacral region-which increased rapidly in twentyfour hours, to the size of an egg-gradually increasing until at four and one-half months the tumor had assumed the size of a large cocoanut, and presented the following, characteristics: Situated in the median line, over the sacral region, with a broad firm base, measuring three and one-half inches in diameter and covered at that point by normal skin, the central cicatrix was rough and uneven, but not ulcerated, tumor fluctuating freely and transmitting light; bone fissure large and in first sacral vertebrae; fontanelles open; tendency to talipes equinovarus of right foot, no other deformities or paralysis.

Referred patient to Dr. W. R. Cubbins for surgical treatment, who did a plastic operation on same. A short time later what simulated a return of the tumor proved to be only an infected suture which soon disappeared leaving a perfect result as the case will show.

A CASE OF ARTHRITIS DEFORMANS IN A CHILD.*

BY DR. A. S. HERSHFIELD.

Bertha S.-10 years old.

Family History-Father was a farmer in Hungary, was always well and denies any venereal affection. Mother had five children, all alive but one, of which the little patient is the fourth. The pregnancies were all normal.

Previous History-The little patient had measles when three years of age, and up to time of onset of the present trouble had no other sickness.

Present Troubles-Onset-When five years of age, the little patient was playing in a garden, and towards evening fell asleep on the moist ground. Three or four days later the child began to complain of a pain in the left ankle. She had a slight fever at the time. Gradually the ankle began to swell, was red, and painful to touch or motion. This acute condition continued for about four weeks and gradually subsided but left the ankle enlarged and disabled. Soon after the right ankle went through the same state as the left. For nearly three years following, the inflammation would come and go, and as time went on the patient found that walking was becoming slightly more difficult. Two years ago she began having pains in both wrists, simultaneously, the inflammation being subacute and had with it but slight constitutional symptoms. During this period she had a slight inflammatory condition in the knuckle joints of both index fingers and middle finger of the left hand. It was also noticed that the little finger of each hand and second toe of each foot was becoming contracted. She further complained of pains in the knees and elbow joints, but in these regions there was no acute inflammation.

Examination-The child looks her age, is well nourished, has good color, is bright and of happy disposition. She shows

*Read before the Chicago Pediatric Society, Feb. 16th, 1909.

no deformity of the face and neck. The glands of the neck are not palpable. The shoulder joints are both normal and are freely movable. Elbow joints show enlargements of the heads of the ulna and radius, and the child complains of pain occasionally in both joints. The wrists are notably enlarged, and the enlargements are homologous. The wrist joints creak when

HAND POSED TO SHOW DEFORMITIES OF WRIST AND FINGERS. LATERAL AND FRONT VIEW OF ANKLE.

manipulated. The motion is limited laterally but can be fairly flexed and extended. When the hands are held out they assume the so called "seal fin" position. The knuckle joints of the index fingers are markedly enlarged as are the corresponding joints of the middle finger of the left hand. The joints of the thumb are greatly enlarged and that finger is longer in proportion to the

other fingers. There is some enlargement of nearly all the joints of the fingers and the little fingers show contracture. There is inability to completely close the hand, the forefinger and thumb being but slightly flexed. There is considerable atrophy of the muscles of the forearm. The vertebral column shows no in

volvement. The axillary glands are not palpable. The heart and lungs normal. No enlargement of the spleen. The inguinal glands are palpable. Hip joints freely movable. The knee joints are enlarged with some effusion and the child complains of intermittent pains in them. The muscles of the leg show some atrophy. The ankle joints are enlarged and correspond to the enlargement of the wrists. There is effusion on the outer side. of the ankle joints. The ankle joints are more freely movable than are the wrists, and creaking can be obtained upon manipulation. In walking the little patient assumes the attitude of a flat foot, not using the ankle joint in locomotion. Owing to this condition she is able to run but little and with difficulty. The large toe on each foot is enlarged and considerably elongated, out of proportion to the rest of the toes, the second toe is in state of extension. There is no enlargement of the other toes. Pulse rate between 90 and 100 and of moderate tension. Urine negative.

The subacute onset, the slow progress and the symmetrical distribution of the joints affected, strongly suggests that this case is one of nervous origin, corresponding to the disease occurring in the adult.

451 S. Center Ave., Chicago.