Speech he usually has not, and is able only to make monotonous, inarticulate noises and does not employ gestures. If he speaks at all, his voice is shrill and unpleasant.

The picture is not overdrawn, but characterizes the majority of cretins, but there are many in whom the disease does not reach such a profound degree, and in every locality in which the disease is endemic all graduations, from the fully developed to the mild type, are found.

Cretinism may be congenital; in such cases the child rarely lives any length of time. It is often still-born. More frequently it develops some months after birth in the endemic type, between the fifth and eighth months; in the sporadic, after the second year or later; according to Ord, it never develops in a child that is healthy up to the sixth year.

Endemic cretinism is more common in the male sex, while in the sporadic cases there seems to be a decided preponderance of females.

Differential Diagnosis.-But little need be said regarding the differential diagnosis of cretinism. The endemic form usually presents no difficulties, and the sporadic form, in its fully developed state, is also easily recognized. Occasionally it is necessary to distinguish between cretinism and dwarfism (nanosomia). In border-line cases the distinction may be impossible, but ordinarily we find that the dwarf does not present the typical skeletal changes nor the myxoedematous condition of the skin; there are likewise no deformities. The large tongue is absent, and the psychic defects, so prominent in cretinism, are not a feature of dwarfism.

Treatment. The treatment of endemic cretinism is primarily one of broad hygiene and sanitation. As the drinking water is mainly at fault, the first effort should be directed to its improvement.

In sporadic cretinism, remarkable results have been achieved by the so-called substitution treatment, substituting the deficiency in the activity of the thyroid gland itself obtained from animals, or preparations made from it. At the present time, numerous preparations of the thyroid are in the market. Some represent the gland in a dried state-the so

called desiccated thyroid; others are glycerin or etheral extracts in liquid form. As a rule the gland of the sheep or calf are used, but that of the hog also seems to be efficacious.

The dose of thyroid is more or less arbitrary and varies with the preparation. It is well to begin with small doses, increasing the dose with care. If the thyroid medication is too active, symptoms of intoxication may develop. These are tachy

Fig. 1.

cardia, pains in the limbs and elsewhere, slight fever and diarrhea. Under thyroid treatment some attention should be given to diet; meat should be restricted and the diet should be largely vegetarian. Under the treatment a wonderful change comes over the system of the individual. There is a growth in height and a general diminution in the bulk of the body; a disappearance of oedema of the skin and swelling of

the tongue and of the fatty tumors.

In the endemic, the

results of thyroid treatment are not so brilliant.

Case.-Male, born Jan. 24, 1893, being the first child; weighed at birth, nine pounds; was delivered with instruments. The family history is negative. He was bottle-fed, but has never had any sickness of any kind. He has one brother living and well. The first photograph was taken

Dec. 12, 1902, being nearly eleven months old; he weighed 41 pounds, and his height was 3 feet 2 inches. He showed all the general characteristics of a typical cretian, large, protruding tongue, flat nose, low forehead with coarse, reddishbrown hair; thick, short neck; the skin was dry, thick and dark brown. He also had some jaundice at that time. His gums were very much ulcerated from the many bad teeth,

always troubled with constipation and never made his wants known to his mother. He could not talk any, but showed some intelligence by being able to amuse himself in different

ways.

I began giving him thyroid extract in tablet form, two grains a day on the 12th of December, 1902, and he has taken it regularly ever since. He has at no time had any bad effects from the medicine, and his improvement began at once and continued, so after six months you would hardly know him to be the same boy. His hair has a better color and is softer; his face is intelligent; the waddly appearance has disappeared; he is beginning to talk as a baby begins.

He has every appearance of a healthy, normal child, were it not for his age and height.

NEEDED REFORM IN MODERN THERAPEUTICS.

W. S. FULLERTON, M.D., ST. PAUL, MINN.

Modern prescribing as exhibited by the medical profession to-day is a disgrace to the intelligence of a body of educated men. Prescription writing, as the scientific adaptation of therapeutic agents to the requirements of individual cases, seems to be a lost art. The young graduate enters on his career well grounded in bacteriology and scientific methods of diagnosis, but deficient in his knowledge of the action and application of drugs and materia medica. No drug or therapeutic agent should be used in any case without a definite understanding of its properties and a clearly defined object in view. This special knowledge can not be gained from the specious pamphlets and case reports of the proprietary medicine manufacturer. That too much credence is placed in this class of literature by the profession is a lamentable fact. We smile at the credulity of the laity which has given the patent medicine man his millions, while at the same time we allow ourselves to be humbugged by the equally meretricious proprietary medicine quack. Each year sees our materia medica "confusion worse confounded," through the accumulation of unnecessary and worthless fabrications. The medical profession alone, through its carelessness and indifference, is to blame for this condition. We can not shift the responsibility. Commercialism simply takes advantage of these qualities as it finds them in us. If there is no demand for an article that article ceases to be produced. The manufacturer of a proprietary medicine systematically creates the demand which he afterward supplies. That this is so, witness his methods. After he has chosen a name for his product, and organized a chemical company, he samples the profession through a corps of traveling men. That we then become his distributing agents can be proven beyond dispute by a visit to the druggists' prescription files in the wake of one of these samplers. Also that the demand is artificial is evident from the necessity