80 INTERNAL SECRETION 



1867, St. Leger mentioned forty-two different theories, propounded 

 by 378 different authors, concerning the genesis of goitre and of 

 cretinism. These possess at this date no interest other than a 

 historic one. 



The attitude which is now universally adopted towards the 

 results of thyroid insufficiency, finds its expression in the theory 

 advanced by Kocher and v. Wagner. They maintain that the 

 cause of cretinous degeneration is to be sought in a disturbance 

 of function of the thyroid gland, a chronic athyrosis ; or, in other 

 words, where the thyroid is normal cretinism is impossible 

 (Ewald). 



Whether, however, endemic cretinism is identical with athy- 

 rosis, and whether the pathological condition of the thyroid gland 

 is the primary cause of all the symptoms, or is itself the outcome 

 of other general degenerative processes, are questions upon which 

 opinions differ. 



W. Scholz adopts the view that cretinism and athyrosis are 

 not identical conditions. He bases his conclusion upon his find- 

 ing of active thyroid tissue in cretins, and upon the different 

 effects upon metabolism and general condition produced by 

 thyroid exhibition in cretins and in thyroidless subjects. In 

 Scholz's opinion, endemic cretinism is "a goitrous degenera- 

 tion, accompanied by cerebral disturbances of unknown origin, 

 to which the inhabitants of certain localities are subject." 



The demonstrable differences between the results of partial 

 and total thyroid insufficiency and those of endemic cretinism, 

 are commented upon with varying emphasis by different authors. 

 Ewald lays great stress upon the fundamental difference in the 

 growth of the bones. Athyrosis gives rise to a general and equal 

 retardation of endochondral ossification, which results in 

 dwarfism. In the cretin, however, skiagrams show that there is 

 unequal retardation of ossification and deformity of the bony 

 structure, which may be accompanied in isolated cases by pre- 

 mature synostosis. There is, moreover, an unmistakable differ- 

 ence in the clinical course, for cretins may live to old age, the 

 condition after a certain time remaining stationary; but myx- 

 cedema, in all its forms, is progressive and leads ultimately to 

 death. 



An even more important factor is that furnished by the 

 difference in the etiology of the two conditions. In endemic cre- 

 tinism, as the name implies, certain territorial factors are operative 

 and we have to assume the existence of an endemic noxa, the 

 nature of which is at present unknown. It is possible that this 

 harmful agent does not affect the thyroid gland only; it is even 

 probable that it does not affect it primarily. Ewald concludes that 

 endemic cretinism " is a condition of chronic physical and mental 

 degeneration, which is dependent upon local causes, in combina- 

 tion w r ith a more or less pronounced degeneration of the thyroid 



