LETTERS TO THE EDITOR 973
from dietary trials whether due to “allergy” or
“intolerance,” but only if given the
opportu-nity.
JAMES P. KEMP, M.D.
Assistant Clinical Professor of
Pediatrics (Allergy) and Co-Director
Pediatric Allergy Clinic and
Training Program
University of California, San Diego
San Diego, California
REFERENCES
1. Crook, W. C., Harrison, W. W., Crawford, S. E.,
and Emerson, B. S. : Systemic manifestations due to allergy: Report of fifty patients and a
review of the literature on the subject (
some-times referred to as allergic toxemia and the
allergic tension-fatigue syndrome )
.
PEDI-ATRICS, 27:790, 1961.
2. Speer, F. : The allergic tension-fatigue syndrome.
Pediat. Clin. N. Amer., p. 1029, 1954, and
Intern. Arch. Allerg., 12:207, 1968, and Ann.
Allerg., 12:168.
3. Rowe, A. H. : Elimination Diets and The
Pa-tient’s Allergies. Philadelphia: Lea and
Fi-biger, 1944.
To rrm EDITOR:
Stone and Barbero made a careful study of a
number of children with abdominal distress
and arrived at the diagnosis of irritable bowel
syndrome. However, a more comprehensive
en-tity was probably involved. Abdominal
symp-torn is only one of many symptoms
encoun-tered in this syndrome. As the authors also
stated there is headache, pallor, syncope,
ver-tigo, and poor appetite. Certain circulatory
symptoms also belong to this same syndrome. I
described them in 1956.1
I see this syndrome as an entity which can
be entered under the heading of
neurovegeta-tive dystonia. It is a syndrome caused by an
adaptation deficiency and may emit symptoms
from any organ as the vegetative nervous
sys-tem innervates all the organs of the human
body. Although European textbooks deal with
neurovegetative dystonia in childhood, it
ap-pears to have been completely overlooked in
the American literature. In adults this
syn-drome is readily regarded as neurosis, coming
in the domain of psychiatry. A child with
neu-rovegetative dystonia readily tends to become neurotic, but primarily the disease is not
neuro-sis. This syndrome has been called by many
different names in the literature of internal
medicine and pediatrics, and it is time we
agreed on a standardised name for it. The
di-agnosis of neurovegetative dystonia indicates
the basis of this matter: the tonus of the
vege-tative nervous system is not optimal for every
situation, but produces unpleasant sensations
when the child is subjected to different
envi-ronmental changes. I have submitted an article
on this matter to the editorial board of Clinical
Pediatrics, hoping to stimulate discussion on it
also in the American forum.
TUOMAS PELTONEN Professor in Pediatrics
Department of Pediatrics
University of Turku Turku 3, Finland
REFERENCE
1. Peltonen, T. : Uber die sogenannten
funk-tionellen Storungen im Schulalter. Ann.
Paediat. Fenn. ( Suppl. 7), 1956.
To THE EDITOR:
It has indeed been a pleasure to have
re-ceived such a range of letters to PEDIATRICS on
the experiences of various physicians with
re-current abdominal pain. It does appear that
one can really open Pandora’s box with such a
common symptom as recurrent abdominal pain
in childhood.
It is obvious that there is a great variety of
diagnostic and therapeutic possibilities, such as food allergy, urinary tract disease, periodic
dis-ease, lactase deficiency, abdominal epilepsy,
duodenal ulcer, and others. Admittedly,
recur-rent abdominal pain is a symptom with many
possible diagnoses. On the other hand, it is
sur-prising how frequently no traditional organic
lesion is demonstrated, suggesting that some
disturbance not readily identified by our
com-mon diagnostic tools may be present. I assume
the words functional versus organic, indicated
by our correspondents,. do not in this day and
age refer to the fact that there is a nebulous
“mind” without structural and
pathophysiolog-ical tissue components, but refer instead to our
lack of specific diagnostic tools or
understand-ing of basic metabolic pathways. In this
con-text, one can consider the comment regarding
the term “irritable bowel syndrome” for these
cases of recurrent abdominal pain as
tanta-mount to replacing “unknown” by
“idiopathic.” Although it is quite clear that we
ill-974 LETTERS TO THE EDITOR
ness, it is important in Virchowian tradition to
identify sites of involvement as a step in the
direction of diagnosis and etiological definition.
Kopel, et al.1 earlier indicated some objective evidence that patients with this picture showed
increased rectosigmoid activity following
para-sympathomimetic stimulation. Such evidence
and that of Lumsden, et al.2 in adults would
lend some support to the thesis that the
intes-tine is of some significance in the abdominal
pain. Hence, the term “irritable bowel
syn-drome” may be applicable. In moving one
notch back from this point, one can argue that
two alternatives exist: (1
)
body sites to avan-ety of stimuli or; (2) that a specific cause is
producing a variety of responses in the host. As part of this, it is exceedingly difficult to interpret the importance of food allergy, since
our current major diagnostic model of
evalua-tion is as subjective as any psychosomatic
ques-tion may be. As stated in the paper, some of
the patients were on diets and had persisted in
their symptomatology. What are needed are
more careful controlled studies following these
base line descriptions. Long-term follow-up
without specific dietary or other manipulations
would be of great importance. We are
summa-rizing a large group in follow-up at present.
Our impressions are most favorable; many of
these children can move to and hold a real
state of well being. One of the points made by
some of the correspondents was that there was
a good response to elimination diets, and recur-rence with readministration, thereby suggesting
an allergic etiology. Nevertheless, some
pa-tients with recurrent abdominal pain
spontane-ously subside; others seem to respond to
ma-nipulations accompanied by emotional support
and reassurance. It would, thus, be exceedingly difficult to evaluate the results of any therapy within the limits of such a patient design.
Another feature of importance in pediatrics
is how our therapeutic management in the
young might, by implying some defect,
pro-duce a graft of a sick outlook as an adult. It appears to us that this is a significant question for pediatrics to examine in its comments,
diag-noses, and therapeutic manipulations to
pa-tients and parents. Long-term studies would be
of great interest in this regard.
The meaning of the electroencephalographic findings of soft nature in this study would
stand parallel to the observations described for
a control and recurrent abdominal pain popu-lation reported by Apley, et al. No difference
in incidence of EEC findings from a random
well group of children were observed.
Further-more, Apley reported a drug study of placebo
and diphenylhydantomn with no difference in
response to both, thus making the specificity of
EEC and drug response much less of
signifi-cance.
We would agree that hospitalization is not
vital for most patients with a period of
abdomi-nal pain; however, it is equally true that some children are hospitalized because of sufficient
impact on their lives and are “studied.” It
would appear to us that these patients have
been willing to undergo such a stress rather
than the chronic and pervasive fear which they
and their families often earlier exhibited. In
these cases we are as deeply concerned about
the long-range impact of such fear as we are of
radiation and hospitalization. In fact, the
meaning of hospitalization in pediatrics as a
therapeutic and diagnostic tool needs consider-able reexamination.
Of course, hospitalization can vary all the
way from incarceration in bed, to life in an
open unit with many recreational, school, and
family participation aspects; so that, in
discuss-ing hospitalization, it may be necessary to
de-fine the setting more clearly.
Finally, it has since come to our notice that
our condition has been described under the
name of Neurovegetative Dystonia by T.
Pelto-nen and L. Hirvonen5 in Finland.
Perhaps our correspondents and ourselves
can further the understanding by developing
new approaches to investigate this fascinating
syndrome of which we all seem to be the
pro-verbial blind men feeling parts of the elephant
as yet, all mixed up with our biases.
GIuLI0
J.
BARBERO, M.D. Pofessor of PediatricsHahnemann Medical College and Hospital
Philadelphia, Penn.sijlvania 19102
REFERENCES
1. Kopel, F., Kim, I., and Barbero, C. J.:
Corn-parison of rectosigmoid motility in normal
children, children with recurrent abdominal
pain and children with ulcerative colitis.
PEDIATRICS, 39:4, 1967.
2. Lumsden, K., Chaudharv, N., and Truelove,
S. C. : The irritable colon syndrome. Quart.
J.
Med., 31:123, 1962.3. Apley, J., Lloyd, J. K., and Turton, C.
LETTERS TO THE EDITOR 975
4. Apley,
J.:
The Child With Abdominal Pains.Philadelphia: F. A. Davis Company, 1959.
5. Peltonen, T., and Hirvonen, L.: The symptoms
of vegetative dystonia in children. Ann.
Paediat. Fenn., 7:309, 1961.
Black Tongue Moniliasis
To THE EDITOR:
The usual description of oral moniliasis is,
“Superficial, streaklike lesions which become
confluent and form pearly-white, elevated
patches which resemble milk curds.” I have
recently seen a strikingly different form.
CASE REPORT: The patient was a 5-year-old
Negro boy who became sick November 11,
1969, complaining of abdominal pain and next
day of throat and ear pain. His tongue was
getting dark. He was seen November 13th by
an ear, nose, and throat specialist, who said
the child had an abscess of his tonsil for which
he prescribed Declomycin syrup, 1 teaspoon
four times a day for 3 days. On referral from
that physician, I saw the patient 2 weeks later,
November 26th. The mother was worried
be-cause the tongue had become black before the
Declomycin was started. When I examined the
patient his tongue was heavily coated black
except the tip of the tongue. His throat and
soft-palate looked inflamed. He did not have
otitis media, bronchitis, or heart murmur. His
submandibular glands were a little enlarged.
His abdomen was distended but no organs or
masses were palpable. He had no oral
bleed-ing.
CULTURE: I took a Mycosel Agar culture. In
a few days this was strongly positive for
Can-dida (Monilia) Albicans, which confirmed my
clinical diagnosis even though the tongue was
black-not white like milk curds.
TREATMENT: Because the patient had an
in-flammation of his throat and soft palate, I
prescribed potassium phenoxymethyl
penicil-lin (Ledercillin VK) 80 cc, 125 mg 4 times
per day, started him on a sample dose of
erythromycin 400 mg from the office, and
also prescribed nystatin
(
Mycostatin)suspen-sion 24 cc 1 cc orally t.i.d., applied to the
tongue.
COMMENT: I checked the patient 5 days
after his initial visit and my treatment with
Mycostatin was effective. My diagnosis was
accurate even though I had never heard of
black tongue thrush. The tongue was not black
any more, only minimally inflamed looking.
The inflammation of the soft palate and throat
had cleared. I instructed the mother to finish
the penicillin orally and Mycostatin suspension.
Two months later, during another upper
re-spiratory infection, the tongue appeared
corn-pletely normal.
In view of this report, if any physician finds
that a Negro patient has a black tongue, he
should take a culture to determine if
Monilia-sis or other fungus infection is present.
I.
J.
WOLF, M.D.Department of Pediatrics (Allergy)
Albert Einstein College of Medicine
231 East 31st Street Paterson, New Jersey 07504
REFERENCE
1. Nelson, W. E., ed. : Textbook of Pediatrics, ed.
8. Philadelphia, London: W. B. Saunders Co.,
p. 680, 1964.
Treatment of Hyperkinetic Child with Dextroamphetamine and Ephedrine
To ns EDITOR:
The following case may prove interesting to
readers who treat hyperkinetic children.
The patient, a 7-year-old boy, was noted to
be hyperactive at school. He was easily
distrac-tible during group activity, easily frustrated,
and under achieving despite above average
in-telligence. He also had a cough for several
days.
Physical examination revealed a quite hyper-active male unable to sit still or concentrate on
tasks for more than 15 to 20 seconds. Other
than this, neurological examination was within
normal limits. He also had wheezes in both
lung fields. Our clinical impression was
hyper-activity syndrome and bronchial asthma. We
elected to try dextroamphetamine 5 mg/day
for his behavioral prol)lem plus Verequad
Sus-pension#{176} (theophylline 65 mg, ephedrine 12
mg, phenobarbital 4 mg, glyceyl guaiacolate
50 mg/5cc) for his asthma. The latter drug
was given for 1 week. When it was stopped
and Dexedrine was used alone, the child
com-plained of severe headaches, both frontal and
occipital, which stopped when
dextroampheta-mine was withheld.
He was seen again March 12, 1970 in
con-sultation with Dr. Jordan Joseph, Chief of
Neu-0 Knoll Pharmaceutical Company, Orange, New
