sinews and muscles; the tissue of the parotis and of the submaxillaris and found everywhere large quantities of mucine. He draws therefrom the conclusion that the thyroid gland in its normal state is a sort of regulator of the tissue change and specially controlled the transition of albuminates in their final products of decomposition, but with the extirpation of the thyroid this control is abolished, the regulating influences. ceases, the albuminates remain in their murcoid state and thus a constant state of irritation follows. The myxedema is only one symptom in the phenomenology of the disease, though it attracts our attention immediately by the bloated face, the heavy eyelids and lips, the bloatedness from the neck up to ears and the peculiar dull expression of the features. A kind of cretinoid state follows, the patients fail in strength, their movements are without energy, they look pale and anæmic, in fact we meet a whole series of changes in the central nervous system and especially in the activity of the brain, manifesting the character of depression and more and more gaining the habitus of idiocy. When such a person sits down, standing up is very difficult, he cannot keep himself erect, his head is bent forward as when one is falling asleep. For hours such patients remain in an extreme state of habitude in their chairs; having lost all interest in their surroundings they are in a full state of genuine apathy. When talked to or urged to speak, they respond slowly in an undertone as if their tongue. had lost its power. The answers are sensible enough, but correspond to a weakly acting brain, though still working in a normal direction. The question then arose, in what relation do the higher grades of myxedema stand to other lasting disturbance of a neurtic nature, especially as Horsley's monkeys after the extirpation of the thyroid gland, fell into such a cretinic state, squatting down in a bent form, and with the same apathetic state as human beings do. Studying his cases closely Horsley differentiates now three different stages of the disease. The first stage is the neurotic one, manifesting itself by manifold nervous disturbances; especially a peculiar tremor which is lasting, sometimes by spasmodic symptoms. The second stage he calls the mucinoid, the third the atrophic one. All his animals perished after a short time in a state of atrophy and cerebral exhaustion. For a long time observations have accumulated in relation to struma and cretinismus and it was accepted as a fact that endemic cretinismus nowhere exists where there is not also endemic struma. Vice versa, there are also sporadic cases of cretinismus and sporadic cases of struma standing in no relation to the other; still more the most exquisite strumous diseases are found in persons with perfect integrity of their mental functions or at least without any such disturbances which could be compared with cretinismus and again there are numerous cretin without much of a struma. Still there is quite a common form of cretinism which shows a great similarity to myxedema. In Italy the common people distinguish between cretins and marrons (chesnut) considering the former the leuco-phlegmatic, cretæcous ones whereas the marrons are more strongly pigmented rather brown lean and lank. This leucophlegmatic form of cretinismus shows much similitude to myxedema. Just as there may be a congenital cretinismus, so also a rachitis congenita has been observed, and many infants with congenital rachitis show not only disturbances in the growth of their bones on the extremities; but also remarkable changes at the base of their skull, corresponding to the changes found among cretins, namely synostosis of the basiler bones, sometimes also a remarkable narrowness of the sella turcica and a decided atrophy of the hypophysis. Curling described in 1850, several cases where the thyroid gland was wanting, and its place occupied by proliferating fatty tissue, which deserve more consideration than they received so far. Kocher described the cachexia strumipriva, those changes which follow the total extirpation of the goitres, and our surgeons are therefore now a days satisfied with a partial extirpation. We might well ask what are the relations of morbus basedowii, that cachexia exophthalmica with its reflex effects on the heart, the brain, the eyes, etc. What differentiate it from myxedema is already that in morbus basewodii the thryroid is in a hyperplastic state, whereas in myxedema its atrophy is essential. How much is yet to be done till light shines in all these questions; let every physician do his share in the work still before us, that is what that great teacher Rudolph Virchow requests us to do and listen to his earnest appeal.-Berlin Klin Werhenshrift. San Francisco, Cal., 100 Front Street. CONGENITAL HEMOPHILIA. BY DR. M. H. VAN TINE. HE case occurred in the service of Dr. Geo. B. Fowler and reported THE by Dr. Wendt in the Medical Record, Feb. 10, 1887. A male child was born at 4. A. M. Nov. 30, 1886. The mother, a primipara, was a remarkably well developed mulatto woman, twenty-five years of age. Both parents were apparently healthy: no history of syphilis was traced to either of them. Pregnancy progressed undisturbed to full term. Labor was easy and natural: the first stage lasted six hours and ten minutes; the second stage was rather precipitate, and occupied only ten minutes. The weight of the child at birth was nine pounds and eight ounces. The appearance of the child was normal with the exception of a purple hued swelling above and in front of the right ear. At about 7 A. M. on the following day, there was a severe hemorrhage from the umbilicus which was controlled at the time, by the usual remedies. Two slight attacks of epistaxis, and vomiting of blood ensued. Oozing of blood from the navel was again noticed at 11 P. M. This was most marked at the time of separation from the integument, although the blood appeared to come from several points. The hemorrhage continued with slight intermissions, until the death of the infant, which occurred on the following day—at 4 P. M. Dec. 2, 1886. Before death the tumefaction above the ear had perceptibly increased in volume and several purpura spots appeared upon the trunk and extremities. The child's weight was reduced to eight lbs and nine ounces. Death was attributed to exhaustion. The clinical record concludes by remarking, that "there was no post-partum hemorrhage, and that the mother passed through an absolutely normal child-bed, and that the placenta was healthy, at least, so far as gross appearances were concerned. A microscopical examination was not made." The autopsy performed twenty-two hours after death, revealed an apparently plump well nourished condition of body. The cadaveric rigidity was well marked. No petichiæ or ecchemoses appeared on the integument. A doughy tumour covered with skin of a purplish blue color, occupied the right post-aural region. The soft part of the umbilical cord was reduced to a hard shrunken mass, with adherent crusts of coagulated blood. A few superficial erosions were barely distinguishable at the time of junction with the integument. After being carefully prepared, the umbilical vessels were traced into the liver, and through the hypogastric arteries into the iliacs. They contained no blood, were patent on section, and quite normal. A small quantity of fluid blood, normal in color was collected from the different abdominal compartments. An accumulation of blood appeared between the layers of the omenUnder the diaphragm there was a large patch of extravasated blood and similar hemorrhagic effusions, less in extent, were found at other parts of the abdominal cavity. There was no blood in the stomach, The mucosa was bloodless, and all the contained organs were pale but not shrunken. The spleen was larger than normal and rich in blood, the liver pale, otherwise normal. A large hemorrhagic effusion was discovered beneath the fascia of the pectoralis major, which extended into 4 1 the substance of both pectoral muscles only one small, sub-pericardial The fact that no blood had escaped beneath the pericranium, Dr. W. considers "a note worthy departure" from the general rule in ordinary caput succedaneum. The fontanelles were large and quite soft. The substance of the brain was waxen in color and firmer than normal in consistence. The vessels of the pia were scantily supplied with blood, a clear serous accumulation occupied the sub-arachnoid space. In interpreting this case, the doctor finds himself confronted by the uncertainty pertaining to the subject of homophilia or hemorrhagic diathesis, as it has been called. The best literary authorities on the subject record but few cases of hemorrhages occurring during the first few days of extra-uterine life, and these children were the offspring of bleeder families. The question therefore arises, in considering all the attendant circumstances as to whether the assumption of homophilia is entirely. justifiable. In his opinion, there is but one disease that can possibly be thought of in this connection and that is syphilis. Death from uncontrollable hemorrhage after tying the umbilical cord is of rare occurrence. Nothing definite, he says is known of the true nature of homophilia. Investigation has been brought to bear upon the question as to whether the abnormality was dependent upon deficient blood composition, or upon an imperfect structure of the vessels or upon a combination of both conditions. This case in the absence of certain well marked anatomical lessons cannot be classed among the group of syphilitic affections pertaining to new-born infants. 23 Smith St., Brooklyn, N. Y. DENTAL ITEMS. W. IRVING THAYER, D. D. S., M. D. N our May communication we presented our observations in extracting cases where it is impossible to save the tooth. There is by far, too much of such mutilation practice in every community. Physicians of late years, do not have as many sins to answer for in this direction, as formally. They turn such cases over to the dentist. The latter may be nothing more or less than a "tooth carpenter," even unto a "falsifier of teeth." That teeth become carious there is no doubt. If permitted to remain in this condition, they must sooner or later "come out." It may not be uninteresting to consider some of the methods used to prevent their total destruction. However, if teeth never needed any repairing they would be much the better for all uses. But people will neglect their teeth in the face of stern facts, and invite some most disastrous consequences. "They have sown the wind, and they shall reap the whirlwind," and pay a tremendous price for their folly. Sound normal teeth are better than the most beautifully filled ones Hence, it must follow, that if a tooth is decayed, the sooner it is prevented from so continuing, the better. The more of the original tooth structure there is left, the better, provided there are no weak friable walls left standing to soon break down and crumble away. There are three different hard tissues in the construction of a tooth The enamel, the dentine and the cementum. The enamel has about 96 per cent of inorganic compounds. The dentine, 72. The cementum. 65. The latter tissue is buried beneath the soft, or gum tissues, in the alveoli, hence is not as liable to decay as are the other two parts of the tooth. The enamel covers all that portion of the dentine that is above the gums. There is a marked difference in the rapidity with which the enamel and dentine decay. The latter being softer, that is containing more of the soft solias, will disintegrate much faster than will the enamel. There may be but a small hole through the enamel, while the bone of the tooth will be severely gutted, even to the exposure of the pulp. This condition of affairs is anything but desirable. It is seldom, when a nerve becomes exposed that there is not more or less pulpitis. Before such a tooth can be filled it is necessary to get rid of all inflammation in the pulp. No nervous tissue in the body is more sensitive to outward impressions, than is the pulp of a tooth. The exposed nerve will need a topical application, or dressing to exclude the air and foreign substances and reduce |