himself to any diagnosis, draws attention to the analogy his own request, was allowed by the professor to de presented by this case with acute spinal paralysis. The liver a lecture in his place, in order to demonstrate the case, however, seems to differ in some respects from peculiarity of his mental state. The patient is a highlyordinary cases of this disease, more particularly in the educated man, of exceptional intellectual endowments, fact of the pain sensation being altered. but for many years he has been the subject of so called "circular" insanity. The recurrence of the disease pre vents his pursuing for any length of time any occupation in which his natural abilities and acquired accomplishments would in happier circumstances have enabled him to gain distinction. In the maniacal phase of his illness he shows an astonishing wealth of ideas, and with his manifold knowledge and his readiness of exand even brilliant in his language. Thus, in the lecture pression (he has lately been a writer) becomes witty he delivered, on the mental condition of the maniac in

NOTES: AND ITEMS

Pasteur's Remains Removed.-The remains of Prof. Louis Pasteur, who died September 28, 1895, were removed December 26, 1896, from the Cathedral

of Notre Dame to the Pasteur Institute, where they were received by a gathering of distinguished men, in cluding Premier Meline, William Rambaud and Bris

son and several well-known men from Great Britain.

President Faure and Gen. Billot, the Minister of War, were represented at the ceremony. Speeches were made at the crypt of the Institute by M. Rambaud, M. Bodin, President of the Municipal Council of Paris, and Dr. Evans, Dr. Rice Buckworth and others.

The Western Surgical and Gynecological Association. - The annual meeting of the West ern Surgical and Gynecological Association closed at Topeka, Kan., December 30, 1896, with the election of the following officers: President, Jose Eastman, Indianapolis, Ind.; Vice-President, D. S. Fairchild, Clinton, Iowa; Second Vice President, B. B. Davis, Omaha, Neb.; Secretary and Treasurer, Herman E. Pearse, Kansas City, Mo. Executive Committee, Lewis Schooler, Des Moines, Iowa; Milo B. Ward, Topeka, Kan.; C. Lester Hall, Kansas City, Mo.; John P. Lord, Omaha, Neb. Denver was chosen for the meeting on December 28 and 29, 1897. The Association comprises all of the Middle and Western States.

The Treatment of Warty Growths of the Genitals.-Wm. S. Gottheil, in a paper on "Epithe lioma of the Penis," read before the Society for Medical Progress, November 14, 1896, concludes as follows (International Journal of Surgery):

1. Warty growths of the genitals, more especially in the male, are always to be suspected of malignancy, no matter how innocent they seem.

2. They should either be left entirely alone, or be thoroughly removed by knife or cautery.

3. Imperfect attempts at destruction, as with nitrate of silver, carbolic acid, etc., are especially to be avoided; there being many cases recorded in which they have apparently stimulated a benign growth into malignant

action.

A Lunatic on Lunacy.-A curious occurrence took place recently in Professor Krafft-Ebing's clinic, says the British Medical Journal, where a patient, at

periodical attacks of madness, he puzzled his auditory by the brilliant and exact form of his speech, and on a lay person or a junior student might even have made conclusions logically drawn, though, in fact, they were the impression that his statements were correct and his all nonsense. He spoke for nearly an hour, holding the attention of his audience the whole time. His look and bearing, which are those of a scholar, helped to keep up the illusion.

PUBLISHER'S DEPARTMENT.

practitioner of medicine, it has always been a difficult Quiniline, or Tasteless Quinine.-To the matter since the introduction of quinine into the phar does not disturb the digestive functions. The mooted macopa to obtain a liquid preparation of this drug which question has been solved in introducing this preparation, Quiniline, to the medical fraternity. In this form, it is a pleasant, palatable and harmless preparation, and while on the one hand quinine in large doses has a very irritant action on the mucous membrane of the stomach, and in continued large doses has been known to cause a severe gastritis on the other. Quiniline may be given in equally large doses and is positively non irritant in its action. In small doses, Quiniline acts upon the stomach and intestines very much as a simple bitter, and in moderate doses, it stimulates digestion and increases the appetite. In administering quinine in cap. sules or pills, its action is very uncertain, as in many cases the gastric and intestinal juices are unable to dissolve the hard coating of the pill or the gelatine of the capsule. The mass passes through the intestinal tract and is ejected with the feces without accomplishing its purpose. In cases of enteric fever it may even do considerable harm. The hard mass acts as a foreign object and may cause perforation of the diseased mucous membrane. Quiniline, on the contrary, is easily assim ilated by the gastric and intestinal secretions. Pamphlets free. THE EVANSVILLE DRUG Co., Evansville, Ind.

MEDICAL REVIEW,

VOL. XXXV.

A WEEKLY JOURNAL OF MEDICINE AND SURGERY.

ST. LOUIS, MO., JANUARY 9, 1897.

ORIGINAL ARTICLES

Report of a Case of Sporadic Cretinism,
With Presentation of the Patient.1

BY GEORGE M. TUTTLE, M.D., ST. LOUIS,

Attending Physician, St. Luke's Hospital; Martha Parson's Hospital;
Bethesda Foundling Asylum, and Missouri Baptist : anitarium.

Before taking up my report in detail, I beg to ac knowledge my indebtedness to Dr. M. F. Engman, of this city, for his courtesy in enabling me to have the care of this patient. He first recognized the character of the case, and but for his interest in another line of medical investigation, the skin, should be its reporter.

NO. 2.

well, but from infancy has been obstinately constipated. Twice a week regularly her mother gives her a large dose of castor oil; as she has discovered that this is the most satisfactory way of relieving the bowels.

Her mental condition is infantile. She understands a good deal that is said to her, and has a small vocabulary in which she makes known her wants and answers questions. Her enunciation, though, is very thick and peculiar, and consequently it is difficult to understand her. She shows decided appréciation and interest in many things, members of her family and friends, and is always a little reserved in the presence of strangers. She is well trained as regards her urinating and going 10 stool, as she never soils herself. She amuses herself easily and will sit quietly for a long time contented with some simple plaything as a diversion. Her dispo. sition is fairly affectionate and friendly, although at times her temper is aroused and she gets somewhat violent during which she has her crying spells like any child. The special senses, sight, hearing and taste, are all well developed.

The parents of this child are healthy, and of normal The bony system is that of a child of two to four build. The father is English, the mother Irish. The years in size. All the bones are small and decidedly mother has a small, but very distinct thyroid enlargement, involving both lobes. She had never noticed this herself, her attention having first been called to it by Dr. Engman. There is one other child, a perfectly nor mal man, now 22 years old.

infantile. The anterior fontanelle is widely open, and the posterior can still be made out. Teeth are present, but in a very bad state of decay, and this, combined with lack of information from the mother, makes it hard to identify to which dentition they belong. There The subject of our report is a girl, now 17 years old. is a distinct lateral curvature of the spine with its con. At birth, her mother says, she was in no way different vexity to the right, which is said to have been present from other children, and it is hard to fix on the age at from early childhood. Both legs are somewhat bowed. which she was first noticed to have any peculiarity. The child can stand with slight support, but is unable The first thing that gradually attracted the mother's to walk alone. Her characteristic attitude is squatting attention, was her failure to grow and develop properly. with feet crossed and hands together.

She was taken to some doctor for advice, but he made

no special comment about her, although he quieted the mother's apprehensions. Later the mother noticed that she always kept her mouth open, and that her tongue protruded continually, seeming too large for her mouth. Thus slow and gradual, bodily and mental, development

has been characteristic from the first.

She has had measles and whooping cough, at 2 years of age, but otherwise has been free from disease. Her bodily functions are, all but one, well performed. She eats well, has no difficulty in swallowing, and sleeps

1Read before the St. Louis Medical Society, Saturday Evening,

November 28, 1896.

The skin and appendages are absolutely typical of the myxedematous condition. The skin itself is pale, glossy, shows the normal markings in an exaggerated way, while the subcutaneous tissues are universally much thickened. The lips are very thick and protruding, especially the lower. The nose is flat, markedly "pug" Above and behind the clavicles are the always mentioned pads of soft fat. The hair of the head is sparse and thin, but what there is has evidently grown fairly long, as the mother has twice cut it, and there is a respectable length still left. There is absolutely no sign of hair in the axillæ or on the pubes. The skin feels dry and cool, although the mother says she sweats freely in the summer time.

Its Relief.1

BY HANAU W. LOEB, A.M., M.D, ST. LOUIS, Professor of Diseases of the Nose and Throat in the Marion-Sims College of Medicine; Fellow of the American Laryngological, Rhinological and Otological Society, Etc.

Her general aspect is very characteristic, with the Mouth-Breathing Caused by Adenoids and open mouth, enlarged protruding tongue, thick everted lips, and short full neck. The subcutaneous tissues of the neck being so thick there is no chance to make a sure examination and statement as to the presence or absence of a thyroid gland. The most that can be said positively is that it is not enlarged and gives no evidence of its presence. The heart, lungs and kidneys are negative. Her pulse is in the seventies, respiration The most important of the functions of the nose is rather slow, and rectal temperature about 99°. She the respiratory, the one perhaps least considered by the weighs 34 pounds, and in 34 inches in height. A few laity; and yet from the earliest childhood to old age, other measurements I have put down mainly for future abnormality of this function asserts itself in no unmean comparisons:

Meatus to meatus

Front of nose to occiput
Circumference of chest
Circumference of abdomen

ing terms. Symptoms referable to this condition are

11 inches. present whether the interference be slight or so great that nasal respiration is wholly or almost impossible.

19 inches.

17 inches.

12 inches.

12 inches.

25 inches.

25 inches.

The necessity for nasal breathing is easily understood, for without it the pharynx, larynx and lungs themselves are subjected to experience which are, to say the least, detrimental to their physiological action.

Is not the air warm one day and cold the next? Is it not at one time dry and at another saturated with moisI do not intend to go into the history or etiology of ture? Is it to be expected that a kindly nature would these cases in general but simply to mention the fact permit so uncertain and variable a circumstance to burthat recent researches in cretinism, myxedema and den the lungs in the performance of their respiratory cachexia strumpipriva, have proved all three diseases function? Far from it; for we have a mechanism which closely related, and each due to some lack of function so influences the changing conditions of the air that in the thyroid gland. In some cases the gland is con- when it reaches the alveoli, in summer or winter, in dry or genitally absent, in others it atrophies, in others it is wet weather, there is that degree of uniformity that obremoved and in others it is enlarged, but such enlarge-viates any strain upon the lungs or any departure from ment means the replacement of the proper glandular tis- their normal physiological action. sue by fibrous or cystic hypertrophy. At any rate, these nutritional changes follow when the physiological function of the gland is destroyed.

Indeed the nose is the great governor of respiration. Through its beautiful supply of blood, whatever the temperature of the inspired air and however slight an amount of moisture is present, when it reaches the rhino-pharynx, its temperature is about that of the blood and its moisture is almost at the saturation point. This has been amply proved by the experiments of Aschenbrandt, Kayser, Greville, MacDonald and others. It therefore follows that the air under normal condi

tions reaches the pharynx, larynx and lungs uniformally warm and moist and therefore proper for the uninterfered interchange which takes place between the alveoli and the pulmonary capillaries. But what will result from the presence of some obstruction to nasal respira

Later it was experimentally found that by leaving a portion of the thyroid behind in operative work, or by transplanting some thyroid tissue from some other animal, the condition of cachexia strumpiprava did not develop. This led to the trial of subcutaneous injections of thyroid gland, and this to feeding the glands by mouth. Each produced the desired beneficial effects, not even the process of digestion destroying the efficacy of the gland, whatever it is. The step to using the gland for therapeutical purposes was naturally next in order, and we are all aware of a large amount of literature on this subject during the last few years. Among tion? Primarily mouth breathing results, the air passthese results are a number of successful results from the use of the thyroid feeding in cases like this, of sporadic cretinism. My plan is to begin at once with her with daily doses of one grain of thyroid extract in dry powdered form, as prepared by Parke, Davis & Co., of Detroit, Mich, which I shall gradually increase to tolerance, as conditions suggest, and I hope at some future date to have the pleasant opportunity of presenting her to you in a much improved condition.

A Physician of Cincinnati recently sent a dunning card to a delinquent patient and was fined one hundred dollars for his enterprise.

ing through the mouth, pharynx and larynx without the beneficial influence of the nose.

In the next place in accordance with a well-known physical law, the air will abstract the heat and moisture from these organs as it passes through them, and while it may be of the proper temperature and moisture, by the time it reaches the lungs, it has become so at the expense of the pharynx and larynx. Since these organs are not supplied with the tissues which gives the characteristic heating and moistening function to the nose, the result of this abnormal action is to produce a path.

'Read before the St. Louis Medical Society, Saturday Evening, December 28, 1896.

the lymphoid tissue so abundantly found in the rhinopharynx. As long as the growth is so small that it does not occasion nasal or Eustachian obstruction, its symptomalogical significance is small. But as the tissue be comes more manifest, and while many of the results are remote, it is surprising how speedily they will develop. In many cases the growth produces no obstruction to nasal respiration but when the mucous membrane cov. ering the adenoid tissue becomes inflamed, by reason of its many folds, the additional swelling suffices to produce partial or complete mouth-breathing. Such is the condition of many children, who under ordinary cir

ological change in the tissues below the nose. Thus on account of the constant call for moisture from the pharynx, the common condition of dryness of the throat may supervene and pharyngitis, laryngitis and bronchi tis may result. Not only this, but since nasal obstruc tion is frequent in children in whom the skeleton is not so firm that it may not be modified, it is common to observe certain well-authenticated changes in the conform ation of various parts of the body. Thus the pigeon breast so frequently found in children may be ascribed to mouth-breathing; the heavy jaw, high arched palate and broad nose are often ascribable to this condition. In addition, stunted growth, malassimilation, anemia, cumstances are nose breathers, and yet who become enuresis, anorexia, cough, nasal discharge, fretfulness, restlessness at night, snoring, croup, deafness and im pairment of mental functions are frequent concomitants of oral respiration.

I have considered these in a general way for they may result from mouth-breathing from whatever cause. Yet as mouth breathing in childhood especially results from adenoids more frequently than from any other cause, these symptoms and conditions may be taken as natural consequences of this disease.

mouth breathers whenever they have a "cold." Successive attacks of coryza predispose to an increasing hypertrophy of this adenoid tissue.

Hypertrophy of the palatal tonsils is frequently associated with this condition and not uncommonly is the latter overlooked in the enthusiasm of treatment of the former. It has been the experience of every laryngol. ogist to meet patients, unrelieved of mouth-breathing, upon whom tonsillotomy has been performed by one who failed from negligence or ignorance to treat the adenoid growths.

being of the child that the disease should be early rec. ognized and relieved in order to secure a re establishment of normal nasal respiration.

Before considering the pathology of this affection, it will be well to glance at certain anatomical peculiarities To the growing child these adenoid growths are of great of the nose and throat. It seems that these organs have importance, for their presence prevents restful sleep, ocbeen bountifully supplied with a large amount of casions continuous mouth breathing and encourages the lymphoid connective tissue, resembling the lymphatic development of chronic inflammation of the upper res. nodes in other portions of the body. The distribution | piratory tract. It is, therefore, necessary for the wellof this tissue is different in different individuals; while it is scattered more or less throughout the pharynx it finds a lodging place especially wherever there is an unfilled space. Thus the vault of the pharynx, the space between the two palatal pillars and that between the epiglottis and tongue are most inviting and therefore are the seats of the greatest deposits. Whence we have the rhino pharyngeal or Luschka's tonsil, the palatal or faucial tonsils and the lingual tonsil. These collections constitute the "lymphoid ring" which has recently come into prominence; it has been strongly advocated that this lymphoid ring exerts a protective influence over the respiratory tract whereby the ingress of pathogenic bacteria is prevented. Its constant presence in childhood and its comparative absence in adult life still remains one of the unsolved questions for future physiologists to answer.

The method of treatment more frequently depends upon the operator than upon the case, for anyone may become expert in his own manner of procedure. In my earlier experience I was accustomed to use forceps, but since the introduction of Gottstein's curettes, I am more partial to their use. Whereas, formerly I operated without anesthesia, nipping off a small portion only at one sitting, I now almost invariably complete the operation at one sitting under chloroform. Since the patients are generally children, and since the time of anesthesia is seldom longer than half a minute, the danger of such practice is reduced to a minimum. When the child is anesthetized and the mouth gag inserted, it is a question of a very few seconds to cut out the larger portion with the curette and then to follow this up with a thorough disintegration of the mass by forcibly pressing the growth against the base of the skull with the palmar surface of the finger. In this manner it is possible to remove the hypertrophied tissue in its entirety, and so expeditiously that before the resultant blood has an opportunity to flow down into the trachea, the operation is completed, the patient's head is hanging over the table and the blood is passing through the nose and mouth, while the anesthesia is disappearing. For this reason I place the patient in the recumbent position, From a pathological standpoint, adenoid growths | feeling sure that no blood will enter the trachea and represent, as is well known, a simple hypertrophy of thereby produce suffocation. Other methods contem

From an embryological standpoint the rhino-pharyngeal tonsil is the earliest to appear, the palatal next and the lingual the youngest of all. In like order do those undergo atrophy, so that under normal conditions the rhino-pharyngeal is insignificant in children of ten years of age, the palatal at fifteen and the lingual is present much later in life.

4

When these organs persist later than the time speci fied and when they interfere with the action of the nose, throat or ear, by reason of their presence or enlargement, they then indicate abnormality.

plate the use of forceps, the fingernail, or the artificial mouth-breathing and its effects which he could in no nail, but to me they are by no means so inviting or so wise prevent. satisfactory as the plan which I have detailed. The after treatment is simple; some efficient and pleasant antiseptic, like Pasteurine (the best of all, I think) is all that is required. It should be used as a gargle and mouth-wash; and, if necessary, as a post-nasal spray. Thus far, out of the many hundred cases upon which I have operated, I have observed no unpleasant results. In but one case did a middle ear inflammation result, due, however, to the unwarrantable exposure to which the patient subjected himself immediately after the operation.