cases are treated with ice bags, and the swelling subsides and only some discharge from the ear is left, which may continue for years and finally the patient dies of some intercurrent affection, or is carried off by a cerebral abscess or a sinus infection, the death certificate, however, giving no inkling of the real cause of death. Such cases, after destruction of the membrana tympani in whole or in part, do drain into the middle ear, but do not get well except in very rare instances.

Coming to the matter of chronic suppurative inflammations of the middle ear, the question of medical treatment is quite limited, the application of medicinal substances to the middle ear in destruction of the membrana tympani may do much toward the bettering of the morbid condition and in certain cases, with the help of thorough cleansing, the discharge may cease, as far as can be seen, and the comfort of the patient be very much enhanced. The best of all medicines in my experience have been nitrate of silver and chromic acid; other things do good, but nitrate of silver carefully applied does more than all other medicines together. It is true that it is hardly fair to speak of the application of these substances as medical treatment, since such methods would ordinarily be classed as surgical. The insufflation of boric acid and such other like measures are followed by improvement in some cases, but it is questionable if the boric acid is ever an important factor in the change of condition; it is more probable that the process of cleansing which usually accompanies the use of these powders and instillations, benefits more than the applications do harm.

Ossiculectomy is advocated by many, but is not, I think, the best remedy for a suppurative process, which, I believe, always involves the antrum. It is in many cases insufficient. The removal of dislocated or carious ossicles, or parts of the membrana tympani, or the opening up of sinuses in the middle ear space, by bettering the drainage conditions must needs do great good, and in some cases cure, but there is left a certain unknown quantity of uncured cases, even after a couple of years of trial, that is most discouraging, and resort must be had at last to radical measures, and these do cure, if suffi

,.ciently radical, and the after-treatment is as it should be. An operation which involves not only the removal of the remains of the membrana tympani and ossicles, but also the posterior bony wall of the external auditory canal together with the ablation of the mastoid process and obliteration of the antrum is radically curative, and if all diseased tissue be removed and the wound properly treated afterward, why then, you will have cured your patient and have bettered his hearing.

It seems rather remarkable to the onlooker, sometimes, that the patient after a radical operation for chronic purulent otitis media, should come out with fairly good hearing, not normal, of course, but enabling him to hear the watch at a foot and ordinary conversation at six or ten feet.

One cause of failure, in the radical operation, after the first cause, i. e., incompleteness of the operation itself, must not be forgotten. It is insufficient after-treatment. All authorities are agreed that only a competent aural surgeon should be entrusted with the after-treatment of these cases. Pus pockets form, granulation tissue fills the middle ear space, contractions of the canal are constant, new areas of bone become affected and the conditions are not far different from those prevailing before the operation.

To sum up, in the first place very active treatment directed to the general condition, in acute otitis media, is often successful if begun in time, but is not frequently so begun. Secondly, cleanliness. In the third place surgical interference to meet an imperative call for relief, and, lastly, a rational surgical procedure for the removal of morbid conditions which can not be otherwise reached.

CRETINISM, WITH REPORT OF CASE.

DR. G. H. MESKER, OLIVIA, MINN.

Cretinism is a peculiar type of mental and physical degeneracy, either congenital or developing in childhood, due to absence or disturbance of the function of the thyroid gland.

The etymology of the word "cretin" is shrouded in obscurity. Nearly every locality has its special name for cretins. Some of the synonyms of cretinism are infantile myxoedema and cretinoid idiocy.

Cretinism may occur in any part of the world, but there are certain limited districts in which it is an endemic disease affecting a large percentage of the population (endemic cretinism). Isolated cases of the disease (sporadic cretinism) have been observed in many widely separated places that are far removed from foci of endemicity.

As stated in the definition, the cause of cretinism is absence or disturbance of the function of the thyroid gland. This applies both to the endemic and sporadic form of the disease. The proofs of the thyroid theory, as we may call it, are as follows:

1. The most constant lesion in cretinism is that involving the thyroid gland. In the case of the endemic form, there is generally goitre; in the sporadic, the gland is either atrophic or absent.

2. The occurrence of operative cretinism, that is, the development of the cretinoid state after the removal of the thyroid gland.

3. Animal Experiments.-The removal of the thyroid gland in young, growing animals, if the animals survive for any length of time, is generally productive of an arrest of growth, and a state comparable to cretinism in man.

4. Therapeutic Results.-The use of thyroid gland extract in the treatment of cretinism has brought about remarkable

results. It is true that these have been more brilliant in the case of sporadic than in that of endemic cretinism, but it has not been systematically tried in the latter, and there are other factors of influence in the development of the disease. The successes obtained are, however, a strong confirmation of the view that cretinism is consequent on disturbance or absence of the thyroid function.

If it be accepted then as proved that cretinism is due to absence or disease of the thyroid body, the next question to arise is, “What influences bring about the morbid condition in the gland?" The cause of its absence, poor development or goitrous state in sporadic cretinism, we do not definitely know. A number of reasons have been assigned; consanguinity of the parents; conception during alcoholic intoxication; fright during pregnancy; tuberculosis, and a neurotic taint, but the frequency of these conditions compared with the rarity of cretinism indicates that they possess little real importance.

In the case of endemic cretinism, our knowledge is less meagre, although still far from complete. The fact that endemic cretinism and endemic goitre are in a large measure co-extensive in distribution suggests a relationship between the two. The common cause is to be found in the drinking water.

There are, however, certain predisposing causes:

1. Locality. It occurs especially in sheltered, damp and imperfectly aired valleys.

2. Geologic Formation. McClelland, in his Himalayan studies, found goitre most common in places in which the soil was rich in lime and magnesia, there being one goitre in every thirty-three, and one cretin in every thirty-two persons.

3. Social Conditions. Endemic cretinism prevails among people eking out a meagre existence under unfavorable conditions.

4. Consanguinity. In-breeding and consanguineous marriages are an important factor in the perpetuation of cretinism.

5. Heredity. When the parents are goitrous, even if the

thyroid disease is slight, the children are very apt to develop cretinism, and this is particularly true if the parents are related.

Nothing is more characteristic than the physiognomy of a cretin. The typical cretin is short of stature—a stunted, dwarfish being, with a large head resting almost on the shoulders or sinking forward on the chest. As a rule, the hair is short, coarse and abundant, though sometimes long and silken, and grown well down over the low forehead. The skin is pale, thick, dry, rough, at times scaly, and has a tendency to form thick folds or waddles. The face is stupid, expressionless, and repulsive. The eyes gaze vacantly, seldom fixing objects. The nose is short, thick, with a deep-lying root and flaring nostrils. The mouth is large; the lips are thick and fleshy and constantly open, permitting the swollen tongue to protrude and the saliva to drool. The teeth are few in number, large, wide apart, badly formed, usually decay early. The ears are usually pale, often deformed and stand out. A short, thick neck, at times deformed by the presence of a goitre, joins the head to the thorax.

The thorax is disproportionately short, flattened irregularly at the lower level of the sternum, and often scoliotic or kyphotic. The breasts in females are usually smaller than normal, or are very large and pendulous. The abdomen is protuberant and inclined to hang downward, often a hernia, either umbilical or inguinal, is present. In both sexes the genitalia are usually small and infantile, with absence of hair in the pubic region, but in rare cases, the external organs of generation are excessively developed. The extremities are short, fleshy and grooved by deep furrows; the feet and hands are large; the nails roughened. Often there is a tendency to bow-leg or knock-knee. Many cretins cannot walk; some cannot even stand unless supported. Intellectually, the cretin, as a rule, presents a degree of degeneracy that is on a par with that of his body. His wants are confined to the most rudimentary desires, such as hunger and thirst, and to these even, he gives expression in ways that are intelligible only to those who are constantly about him.