mus, local distension, attacks of constipation on account of valve like obstruction, a passage of much glairy mucus and fæces bringing some relief, until a favorable condition for tthe phenomena of obstruction occurs.

I wish here to report a few cases to illustrate some of the types above mentioned.

Case I. R. B., age twenty-one, American. Butcher, very fleshy and of phlegmatic temperament. Family history of tuberculosis and epilepsy; personal history of attacks of epilepsy (grand mal) and recurrent appendicitis-during the last five or six years; the last year the attacks were very frequent. The attacks of appendicitis were invariably accompanied by convulsions, obstruction and extreme pain. There would be fullness and hardness at the seat of the appendix, and, in a few days, a profuse discharge of mucus, with fæces, bringing relief. I was called February 26, 1893 and found the patient suffering as above. The attacks continued at varying intervals. An operation was decided upon. On May 25, 1893, on opening the abdomen. over the region of the appendix, a mass of adhesions was found, involving the coecum, ascending colon and omentum. The appendix was not found nor was any pus present. Some of the adhesions were broken up, the bowel straightened out somewhat and the wound closed. The patient was considerably better, for six or eight months, when his old trouble began to return. He was referred to Dr. Murphy, of Chicago, who operated on him before several members of this Society, which met in Duluth, in 1895. About the same condition was found as at the first operation. More of the adhesions were separated, but the patient died, a short time after, from shock.

Case II. Mrs. M., age twenty-nine. Irish. Tubercular family history. She called at my office July 7, 1896. Was very anæmic, and weak. Complained of great pain in the abdomen which was much distended. She had not menstruated for over a year, never had been pregnant. On examination I found a large cyst in the pelvis. Next day at the house found her in a worse condition with signs of obstruction. With three or four days treatment she was no better; her symptoms of obstruction becoming alarming. we operated on July 11, 1896. A large cyst of the broad ligament, extensively adherent to the bladder and intestine was found, filled with three gallons of cystic fluid and blood. To have dissected all the adhesions would have been to sacrifice the life of the patient. We removed all of the sack possible, stitched the remaining portion to the abdominal wall and kept packing. with gauze each day until the cavity was obliterated. The patient is now well, has no pain, bowels regular and does her own work.

Case III. Miss P., age forty-one. Domestic. Irish. Was called March 16, 1897. Found the patient suffering with agonizing colicky pains, also vomiting, fainting and chills. Upon examination could detect a possible soft mass in the lower right abdomen. She was taken at once to the hospital. She continued to suffer from marked constipation, frequent attacks of colic and vomiting. An operation was decided upon and performed March 24, 1897. A vaginal examination under the anæsthetic revealed nothing of importance. Upon opening the abdomen a cyst about the size of a walnut was found arising from the left ovary and firmly adherent to a loop of the small intestine. The ovary and cyst were separated from the bowel and removed, and the peritoneum carefully stitched over the raw surfaces. The patient made an uneventful recovery. The symptoms of headache, nausea, vomiting, fainting, extreme constipation and dyspepsia for which she had been treated for months before all disappeared.

The treatment of this form of disease is preëminently surgical, when any treatment is necessary, but the method to pursue in each individual case diagnosed, will suggest itself at the time of operating and needs no particular consideration here. An operation is seldom required when the adhesions surround solid or fixed organs, but when the bowel becomes united to such movable organs as the ovary, tube, bladder, stomach, omentum, etc., troublesome symptoms usually occur.

Maurice Richardson and others believe that when long continued disabling abdominal pains, though doubtless at times of nervous origin, are present, an exploratory operation is neces

In conclusion I wish to emphasize the fact that adhesions of the intestines do occur oftener than is supposed, that they are frequently unrecognized and mistreated and that they often follow laparotomies.

The recognition of these facts has been the writer's excuse for this paper, hoping thereby to bring before you the surgical importance of these adhesions, to urge a thorough examination in every case of abdominal disease, a guarded prognosis, conservative treatment and a careful operation in all abdominal sections; thus the future will doubtless establish more cures from this malady, and more of the criticism and reflection often cast upon our profession and skill will be avoided.

CRETINISM, WITH A REPORT OF A CASE OF THE SPORADIC VARIETY.*

By Christopher Graham, M. D.

Rochester, Minnesota.

Thyroid therapy has found a stable and scientific basis. The experimental physiologist, the physician and the surgeon, each may claim a share of the honors.

The physiologist ranks first, for his deductions were established by method and fact. The surgeon taught through operative errors; the physician profiting by the directed labors of the former and the well meant operations of the latter and in part by his personal observations, drew conclusions that hastened this advanced doctrine.

Wolfstein says that "among the many great achievements of this great century may be surely ranked the benefits which humanity has received from the recognition of this doctrine," organ therapy, and further: "None of the internal secretions, the seminal fluid excepted, ranks the thyroid in potency."

In cretinism thyroid treatment finds a fruitful field of usefulness; has already accomplished much and promises everything. Cretinism, with which I propose chiefly to deal, has been so modified through this therapy that its most frightful aspects have been well nigh lost.

Two forms of cretinism are recognized, the endemic and the sporadic. The former finds mention in the sixteenth century, the latter was first clearly distinguished by Fagge in 1871.

The endemic form has occurred in various parts of Europe and Asia, especially in the valleys of the mountainous regions.

*Read in the Section of Obstetrics and Diseases of Children of the Minnesota State Medical Society, June 17, 1898.

Hirsch states that it is also found in Vermont, Massachusetts and California, but Osler, who has carefully studied cretinism in America, fails to corroborate such statement.

The sporadic form, however, has been reported from various parts of the United States, and these reports have rapidly multiplied since 1893, at which time Osler made a collective report of eleven cases. In the two forms the characteristic symptoms are so nearly alike that Osler's definition, embracing both, is a good one:

"A chronic affection characterized by disturbance of the growth of the skeleton and soft parts, a remarkable retardation of development, an extraordinary disproportion between the different parts of the body, a retention of the infantile state, with a corresponding lack of mental prog

ress.

There are however, differences which have led some observers to class these two affections as independent.

The endemic form is usually accompanied by goitre, the sporadic is much more rarely so accompanied. In fact, absence or atrophy of the thyroid is the rule. Morel, Curling and Fagge, as well as many later observers, agree that goitre is the first of a series of degenerations leading to cretinism.

Bircher says that thyroid feeding has less or perhaps little effect on the myxedematous condition of the endemic type, but this has not been fully established. However the goitrous condition is relieved if calcareous degeneration has not taken place, and doubtless further observations will show that the myxedematous condition will likewise yield. Dentition is more delayed in the sporadic. The endemic arises in certain localities and seems to have something of an infectious nature, said also to be due to drinking water which possesses some organic or inorganic poison or is lacking some virtue which otherwise would prevent such abnormal development. Again the skeletal development shows differences. The long bones are less or more slowly developed in the sporadic; the sutures and fontanelles are slower to close, being often open as late as the tenth year.

There are other minor differences as shorter life and gentler disposition of the sporadic, but despite all these it is generally conceded that the same cause or causes act to produce both forms.

The function of the gland is variously discussed. Horsley says that it is a blood forming organ. Schiff, that it secretes a substance that influences the nutrition of the nervous system. Kinnicutt says that we must accept one of two theories:

First, that it secretes a substance which enters the circulation through the lymphatics and which is essential to the chemistry of metabolism and for proper nutrition of the various tissues.

Second, that it produces an antitoxine to neutralize or destroy poisons that are developed during tissue change and by collecting in the blood produce autointoxication. Whatever the nature of the secretion, development, mental and physical, is largely dependent upon it.

As to the pathology of the disease little is positively known. There are, in the sporadic, three conditions of the gland noted by various observers. One, where the gland is absent congenitally or wasted in early life. A second where. the gland is atrophied or perhaps functionless. The third, those cases in which goitre éxists along with cretinous symptoms.

The pathology is, however, closely allied or identical to myxedema, operative or idiopathic. Post mortem cases of natural myxedema have always shown an atrophied gland. The walls of the vesicles are infiltrated with embryonic tissue and chronic thyroditis is evident; connective tissue increases throughout the body; fat usually develops subcutaneously; epithelial cells block the tubes of the sweat glands; blood and skin show excessive mucin.

Whatever may be the true pathology of the cretinous state certain it is that a functionless thyroid, or a perverted secretion is back of it all.

The symptoms usually appear appreciably from six months to five years after birth. In the developed state they are striking and repulsive. Mental and physical development retarded; a head large for the body growth, misshapen, scantily covered with a coarse, yellowish growth of hair; a bloodless yellowish green complexion, low forehead, eyes apparently small, with swollen lids and oedematous surroundings; nose flat and broad between the eyes with nostrils dilated; thick lips, lolling tongue, dribbling saliva; perhaps toothless; ears deformed and protruding and a short, bull like neck make up a distressing and often absolutely expressionless countenance.

Subcutaneous fat is abundant and supraclavicular deposits frequent. Muscles soft and flabby; limbs often crooked and the ends of the long bones enlarged; protruding abdomen increased by lumbar lordosis; when able to walk the gait it tottering and awkward; fingers and toes short and stumpy giving broad hands and feet; skin is dry and perspiration scanty; special senses poorly developed; speech comes late or is not at all attempted, and the voice is coarse and rasping. Puberty is delayed; circulation poor as shown by cold, blue hands and feet and subnormal temperature. All movements slow and apathetic and often they sit for hours oblivious of surroundings.

The diagnosis offers but little difficulty in a case well developed. He who has read the ordinary text-book descriptions and has seen the cuts usually accompanying, will rarely fail to make

a correct diagnosis. Small stature; disproportion of parts; the peculiar facial expression; stupid manner; fatty deposits; subnormal temperature and poor circulation are quite sufficient to permit a diagnosis.

Putnam says that there may be disorders of nutrition or irritative nervous symptoms unaccompanied by myxedema due to deficient or perverted thyroid action, and that we may yet. learn to recognize affections that lie between myxedema and health, as well as the disorders of development and nutrition for which the thyroid is now known to be more or less responsible.

Regarding the primary causes that destroy the gland or pervert its function, we have little or no understanding. Whatever these primary causes may be this is common agreement. that the condition is due to maldevelopment of the thyroid gland, its absence, atrophy or hypertrophy, perverted or abolished secretion; the trouble manifesting itself either in early embryonic life, appearing at birth or soon thereafter or delayed until late childhood. Bircher lays blame chiefly to drinking water. Ewald, however, savs that water alone is not the sole cause of the disease, but that certain hereditary tendencies together with bad hygienic surroundings and poor social conditions combine to produce or aid greatly in its production.

Kocher says, both goitre and cretinism mav be inherited from parents who show no thyroid disease but the function of whose gland has undergone some change. Judson Bury and Munson emphasize intermarriage as a fruitful cause. while Langdon Downs considers alcoholism a strong causal factor, especially if active at the time of the procreative act.

Treatment: As in idiopathic myxedema, cachexia strumapriva, infantilism and the like. so in cretinism thyroid therapy has wrought marvelous changes and demonstrated the value of experimental therapeutics. Through the number of cases treated and reported it has been clearly shown that thyroid treatment offers the greatest good to the suffering cretin.

The capabilities of treatment are: First, removing the myxedematous condition; second, quickening physical development; third, awakening the intellect. The myxedematous condition is rapidly and often fully reduced, thus removing the most unsightly symptoms which mark these unfortunates.

Dr. H. C. Wood, in discussing the loss of body weight in the allied conditions through thyroid action, says: "The various researches are sufficient to warrant the conclusion that thyroid treatment decreases body weight in part by causing waste of nitrogenous tissue, but to a greater extent by wasting the carbohydrates." Physical development is rapid and perhaps the

most marked and remarkable effect of thyroid feeding. This is seen especially in the long bones, and so profoundly does treatment affect the tendencies of growth, though years have elapsed since growth was manifest, it is again remarkably quickened.

Telford Smith points out the tendency to bending of the bones, especially the long, during thyroid treatment, and urges care in overtaxing the limbs at this period, or advises the use of splints to avoid such deformity. Food is giyen in quantity and quality to meet the demands of increased growth, and sunlight and air in abundance.

The mental condition is slowest to respond and it is difficult to say how far we may reasonably expect such development to obtain. However, cases are reported where improvement has been apparently complete and many where comparison with the normal is favorable.

Speech also is favorably affected. Where the language consisted of harsh rasping grunts, words and sentences were gradually acquired, while some report cases where speech became distinct and even fluent.

It is a common observation that the shorter course this disease has run and the younger the patient toward whom treatment is directed, the more nearly perfect the final result. Therefore the plea of Koplik for early diagnosis and treatment is pertinent. Other effects of treatment are softening of the skin, abundant and silky growths of hair replacing the coarse and scanty, and the rapid progress of delayed dentition.

Treatment must be continued throughout the entire life of the individual, otherwise relapses occur. It is sufficient in most cases to give a large weekly or bi-weekly dose after distressing symptoms are relieved. The dose for a child varies from one-half to one grain, at the beginning, gradually increasing to five or more, keeping track of any untoward symptoms and decreasing the dose or discontinuing it for a time, then resuming with less amount. Cretins bear thyroid better than adult myxedematous patients, but the effect is the same, therefore treatment is safer in the former than in the latter.

Danger signs are increased temperature, rapid pulse, insomnia, restlessness, digestive disturbance, dyspnoea, muscular twitchings and tremor. Early signs of improvement are lessened stupidity, gain in myxedematous condition, mental and physical awakening and attempts at speech.

Report of Case. John M., born October 13th, 1891. Saw him first June 9, 1897, aged five years, eight months and twenty-six days.

Family History: Parents both born in Germany, of healthy stock, medium size, average mental ability. No hereditary taints obtainable,

Labor reported normal and easy, lasting little more than one hour. Nursed the child six months, then fed him milk from a spoon as he refused the bottle. From the sixth to the ninth month the mother began to notice that the child was not right, that the tongue protruded, lips thick and child slow intellectually.

Had a very poor appetite, refusing everything except milk and bread; appetite continued poor well into the first year of treatment. This child has had measles and whooping cough, the latter especially severe, being in a hopeless condition several days. The mother says that he took not

even a swallow of milk for nine days, and what surprised her most was that he kept fat the whole time. He was always constipated; sweated but little. Cut first tooth at nine months, and slowly developed more, until after treatment when it was much more rapid, cutting the last baby teeth in May, 1898.

When first seen, June 9, 1897, the following was noted:

Child had never attempted walking, limbs not deformed but short and thick; diet had been little else but bread and milk; constipated; teeth few and decayed; fontanelle widely patulous; thyroid gland could not be palpated; head large and square; face swollen and expressionless. The forehead seemed low, eyes small and widely separated. Nose flat at roof, turned up at end and nostrils dilated, Lips thick and tongue protruding, hair thin and bristling. Abdomen markedly protruded and lumbar lordosis greatly exaggerated, skin dry and scaly, anæmic and greenish yellow.

Appetite poor and digestion capricious, head could not be held steady, muscles weak. Sweat but little, temperature subnormal, always cold and seems sensitive, taking cold easily. Νο speech, not even words, harsh cries the only language.

Diagnosis of cretinism made and powdered thyroid given, one-half grain three times a day. At no time has the dose been more than three grains daily, because the child living at a distance could not be under observation. Had the child been carefully watched and larger doses provided, I am confident the results would have been much more nearly perfect and rapid, if not more marvellous.

Three weeks after treatment began, the child returned markedly improved at which time picture number one was taken.

During the later winter the child began to walk some and said several words, but owing to bad weather the parents did not return for medicine and the child relapsed in so far that walking and talking ceased and myxedema began to show. On returning the dose was increased to three grains per day, and rapid improvement followed.

Present condition: Fontanelle almost closed. hair thick, soft and normal, skin smooth and soft, eczema of head, face and lids nearly gone, eyes apparently larger and brighter. Nose improved, lips thin, tongue normal and wholly within the mouth, first teeth all present but very much decayed, temperature normal and child sweats easily. Myxedema almost disappeared, lumbar lordosis slight, abdomen normal. To use the mother's words, "John was always so bloated, now he is like other children." Walks everywhere unassisted, and is difficult to care for as he

often runs away. Is again saying a few words. Appetite excellent, eating all ordinary food and digestion perfect.

Spleen and liver not enlarged, constipation overcome. The most marked feature is growth. The first loss in weight so often noticed was scarcely manifest in this case, and I attribute it to the small initial dose so that the loss in the myxoedema kept pace with the natural gain due to the good effect of the drug. The child has gained ten pounds in weight and but a fraction less than six