BISMUTH IN THE TREATMENT OF INTERSTITIAL KERATITIS.

611 As is well known, though seldom stated, it is impossible and iodides has been very disappointing, and if to make any very great difference in the prevalence of Dr. Kleefeld’s favourable experiences with bismuth recessive characters like mental deficiency by segre- are confirmed, the outlook for this class of patient gating those in whom they are manifest; disastrous should be much better than it has been in the past. combinations of unrecognisable heterozygotes would go on producing a supply for a very long time, even if all mental defectives were killed at sight. But a MENTAL DEFECT IN EARLY CHILDHOOD. deliberate and concerted attempt by college graduates ALTHOUGH the literature dealing with mentally to furnish a due supply of proper persons is a much better heeding proposition because the failures, who defective children of school ages is abundant, little has been written about mental defect at an earlier period, are not exceptionally gifted, will, in nearly all cases, be at least tolerably good citizens. We would commend at the time when these children are brought to the his doctrine to eugenic propagandists. His discussion practitioner for diagnosis, and when appropriate of the insoluble negro problem suggests that increasing treatment might yield the greatest benefit. The urbanisation and decolorisation, with a birth-rate subject of the symptoms, diagnosis, and treatment of falling faster than the death-rate, may soon lead to a mentally defective children was therefore chosen by decline in their numbers in America, and possibly Dr. John Thomson for the course of Morison lectures on mental disease, recently delivered in the Hall of the to their practical extinction. The paper on mortality draws attention to the curious fact-not, of Royal College of Physicians of Edinburgh. The course, newly observed-that whooping-cough is the clinical material on which the lecturer drew consisted in the notes of 1200 cases, 952 of which had been under one cause of death which kills more girls than boys. Males are the frailer sex. In early foetal life there is a 5 years of age. In the matter of classification, Dr. great excess of males which at birth is reduced almost Thomson holds that of Dr. A. F. Tredgold to be the to equality, and in the first few years of life changes best of those which attempt to combine pathology to a preponderance of females. Some of the essays with clinical findings. Cases are divided into two are slight-e.g., those on sexual selection and the large groups : (a) Primary amentia, in which there is effect of birth control on fertility. None is veryian original incapacity of the cerebral neurons for proper development; (b) secondary amentia, which deep, but none is meant to be. The book intended for general reading, and people with very are due to an arrest of development of the brain, varied interests will read it with profit. usually at a later stage from some extraneous or accidental cause. Dr. Tredgold, dealing with children of school age. or older, includes 85-90 per cent. of the cases in the primary group and 10-15 per cent. in the BISMUTH IN THE TREATMENT OF Dr. Thomson’s figures, referring to secondary. INTERSTITIAL KERATITIS. younger children, are : Primary, 57 per cent. ; IN a paper headed " Is Parenchymatous Keratitis secondary, 43 per cent. The difference would appear Curable ? " Dr. G. Kleefeldl has drawn attention to ’, to be due to the fact that many cases of primary amentia are not recognised till they go to school, and the modern high standard by which complete from interstitial keratitis is judged, improved illumina- many of the secondary cases die in infancy. The tion and the corneal microscope betraying permanent recognition of mental defect depends on two thingsflaws which more primitive methods of examination information from the mother and the doctor’s examinafail to disclose. Even when vision has been restored tion. The mother may give valuable information to normal, Dr. Kleefeld has never failed to demonstrate about the labour, about other children, or miswith the corneal microscope persistence of white carriages, or about the family history. On examinain severe cases, some abnormality of patches and corneal blood vessels formed during the tion, especially acute stage of the disease. At least this was the case appearance or behaviour may be noticed, such as an before he began giving injections of bismuth. In abnormally small head or a too early closed fontanelle. The signs of an easily recognised disease such as one of his cases, given bismuth, the patient came under treatment in the early stage of oedema of the mongolism, cretinism, or microcephaly may be present. Regarding behaviour, unnatural gestures and grimaces, cornea. Vision was already reduced to finger-counting, such as rolling of the eyes, may betray mental defect. the duration of the three disease was although only natural curiosity or abnormal emotional weeks. Injections of bismuth were given without Lack of are morbid signs. A series of epileptiform displays but after the cedema of any great hopes, eight days the cornea had largely disappeared, only two or three attacks without apparent cause is probably an small vascular bundles having succeeded in pene- indication of the presence of mental defect. The recurrence of attacks of petit mal is ominous, trating the cornea. The treatment was continued, persistent and the oedema disappeared so completely that when as it is often accompanied by arrest in the normal the patient was examined three months later even growth of the cranium. In these severe cases the the corneal microscope failed to show any lesion. prognosis is very grave. In dealing with the milder prolonged study of the child under various It is probable that complete recovery can be effected may be necessary before the extent of by specific treatment only before or during the stage circumstances of oedema; when this has passed off the patient’s damage can be estimated and suitable training fate is settled for better or worse. In a second case, selected. The normally developing child first of all in which one eye after the other was involved, the exhibits aimless movements of the limbs, which gradually become purposive as they become stronger. injection of bismuth aborted the evolution of the The instinctive movements, such as crying, swallowing, keratitis in the second eye after several injections had saturated the body with bismuth. In a third and sneezing, although they are purposive, unlike the are at first equally involuntary. case, in which sulpharsenol had been given for a long random movements, time without any relief, and there were signs of In time they become clearly intentional, and the baby glaucoma on the left side, the injection of bismuth can be observed making efforts to turn his head and to reach objects. After the first three months he begins was followed by the complete disappearance of ocular to balance his head. Later he struggles to sit up, a return the intra-ocular of congestion, pressure almost to normal, and by diminution of the corneal turning his head to look about him, and practising opacity. Dr. Kleefeld gives little information as to convergence of the eyes. Still later, he exerts his will the dosage of bismuth adopted in these cases, but he in learning to crawl, to stand, and at length to walk. sounds the warning that bismuth may prove toxic In the same way the use of senses is gradually acquired to the optic nerve, and he therefore advises caution and perfected. Another sign that the baby’s brain is in the dosage till more is known of the affinity of developing is the increasing gratification derived from bismuth for the nervous system. Hitherto the treat- the normal functions of the body. If for any reason ment of interstitial keratitis with mercury, arsenic, these are interfered with, as from blindness or deafness, the growth of the intelligence is appreciably retarded. Later he learns to guide his movements more by the 1 Le Scalpel, Jan, 26th.

infantile

isI I

recovery 1 I

cases