2. Automatic centers, as sweat, respiration, cardio-inhibitory, accelerator, vasomotor, and spasm. These automatic centers are capable of sending out efferent impulses without afferent stimuli.

3. Central centers over respiration, cardio-inhibitory, accelerator, vasomotor, and sweat. You will notice that each automatic center has a corresponding control center which act as a check or control over any abnormal or disturbed action of the spinal centers presided over by the center in the medulla.

4. Tonic centers are such as exercise their influence in maintaining a continuous and uninterrupted rhythmical action of the higher centers.

SPORADIC CRETINISM-REPORT OF A CASE.*

BY ST. CLOUD COOPER, M.D.

FORT SMITH, ARK.

During the last four or five years numerous cases of this disease have been reported by various observers in this country. That so many cases have been recognized is largely due to the investigations and writings of Dr. Osler. In a paper published in the Amer. Jour. of Med. Sciences, November, 1893, Osler states that through his investigations he was enabled to report eleven cases of sporadic cretinism. In the same journal, October number, 1897, he states that the profession has learned to recognize the condition, and that he was able to make a further report upon sixty cases, including those already referred to.

Etiology. This disease is found in all countries. I believe could a collective investigation be made in this State (Ark.), a considerable number could be reported. The disease is especially frequent in mountainous countries. Heredity, interbreeding, pregnancy, alcoholism, syphilis, water, climate, have all been considered etiological factors. The disease may begin in uterine life or after birth. The congenital variety may be difficult to distinguish from rickets.

Read before Arkansas Medical Society, at Little Rock, May 10, 1899.

Symptoms. In describing the symptoms of this disease I will quote from Burr's article on Cretinism (Nervous Diseases -Dercum):

"In the sporadic type the symptoms usually begin about the fifth year. They are characterized by mental degeneration and physical retardation. Growth is stunted, the stature rarely reaching beyond five feet. The different parts of the body develop disproportionately, causing deformities. The limbs are crooked, the ends of the long bones enlarged, the trunk too long, and the chest large and flattened. There is lumbar lordosis, throwing the abdomen far forward; the head is brachycephalic, the vertex and occiput flattened; the hands large, flat, spade-like; the gait awkward, bear-like; the hair is a dirty brown, coarse, rough and thick. The body hair does not grow at all and is scanty. The face is large and square, the nose bridge much flattened and wide, keeping the eyes far apart, and the nostrils dilated. The eyelids are swollen and sometimes cannot be opened. The tongue is large and flabby, protrudes between the enormously thickened lips. The thick, viscid saliva dribbles constantly. The milk teeth decay early, and the permanent set may never appear. The skin is a dirty yellowish brown, coarse and wrinkled, or if myxedema be present it is pale. Subcutaneous fat is abundant, and there is apt to be local deformity, especially in the supraclavicular fossæ. The ears are malformed and stick out from the side of the head. The muscles are soft. The neck is bull-like, and goitre may or may not be present. The eyesight is usually good though there may be strabismus. Puberty is delayed, sometimes till the twenty-fifth year, and menstruation either is scanty or soon ceases. Respiration and pulse are slow, and the temperature subnormal. The circulation is poor and the extremities cold and blue. Red patches occur on the cheeks. The urine is thick, bad smelling, and quickly becomes ammoniacal. Speech is thick and the voice rough. Sleep is heavy. They are liable to curious attacks, in which they will sit for hours, the eyes opened and fixed, the body motionless, scarcely breathing, and showing almost no signs of life. It would seem as Maffei says,' that the soul had entirely left the body.' The amount of mental deterioration varies much. SomeVOL. XIX-17

times it is possible to educate them to fulfill many ordinary duties of life. One, for instance, who had but little schooling, keeps a news stand, supports himself, and knows the value of money. From this there are all grades down to absolute vacuity, in which the patient, though not paralyzed, cannot walk, nor talk, nor understand, nor even feed himself, being merely vegetative. Though ordinarily quiet, gentle, even affectionate, they sometimes are irritable and easily angered. All movements, all actions, mental or physical, are slow, not only in the initiative, but throughout the act. Many are deaf and dumb.”

Other observers mention enlargement of the liver and spleen. scanty or absent perspiration. Bowels obstinately constipated is another frequent symptom. Anterior and posterior fontanelle slow in closing.

Osler makes a clinical summary of sixty cases as follows: Sex-Males 24; females 36.

Age-Under two years, 6; from two to five years, 12; five to ten years, 12; ten to fifteen years, 10; fifteen to twenty years, 7; twenty to thirty years, 3; thirty to forty, 4; over forty years, 4.

Condition of the thyroid gland-Goitre was present in 7; gland stated to be normal in 12; gland small in 2; gland not felt in 16; no note in 20.

Treatment. Fresh thyroid gland of a sheep, or extract prepared by some reliable firm, is certainly a specific in this disease. Osler, in speaking of the result in thyroid treatment, says:

"No type of human transformation is more distressing to look at than an aggravated case of cretinism. It recalls Milton's description of the shape at the gates—

If shape it might be called, that shape had none
Distinguishable in member, joint or limb,'

or those hideous transformations of the fairy prince into some frightful monster. The stunted stature, the semi-bestial aspect, the blubber lips, retroussé nose sunken at the root, the wide-open mouth, the lolling tongue, the small eyes half closed with swollen lids, the stolid, expressionless face, the squat figure, the muddy, dry skin, combine to make the picture of