158 THE CRETINIC DEGENERATION 



more than that of the hearts of the control animals. The heart muscle 

 microscopically for the most part showed degenerative changes. Bircher 

 refers the cardiac damage directly to the goiter noxus ,and in agreement 

 with Minnie h sees in it a disease sui generis. 



According to a personal communication from Prof. Scholz also the endemic 

 cretins usually have bad hearts, but no hypertrophy ; this fact may hang to- 

 gether with the gradually and long-continued action of the goiter noxus, per- 

 haps also with the slight "expressions of life" [Lebensausserungen] of such 

 individuals. 



3. Endemic Cretinism 



Symptomatology. The habitus of endemic cretinism shows a much 

 greater multiformity than that of sporadic cretinism. Dieterle compares 

 the photographs of seven youthful cretins of eighteen years of age from Bern 

 with that of sporadic cretins from fourteen months to twenty-one years of 

 age, and shows that despite the fact that the latter come from different 

 countries, they show much similarity to one another, while the others re- 

 semble one another less strongly although they come from the same family. 

 Dieterle cites the doctrine of Majfeis, that there is no cretinic prototype. 

 The skulls, too, in endemic cretinism show greater differences; in many 

 endemic cretins the skull is small, the forehead low and receding; in others the 

 skull is abnormally large. Regularly the root of the nose is retracted, al- 

 though never to so great a degree as in chondrodystrophy; for the most part 

 the eyes stand wide apart, the throat is short and thick, the lips are cushiony, 

 the facial expression morose. Ordinarily the skeleton shows abnormalities 

 ankyloses, scolioses, etc. Scholz describes flattening of the head of the 

 femur. The pelvis is often narrowed in all dimensions, and the bones are 

 provided -with swellings [Wiilsten]. Also there is difference in the degree of 

 dwarfism. v. Wagner observed individuals under 90 cm., although there 

 are full cretins over 150 cm. in body length. E. Bircher of Aarau has kindly 

 provided me with Figs. 18-22. Fig. 18 shows the multiformity of the facial 

 expression and the shape of the skull in endemic cretinism. 



The duration of life of the cretins is in most cases shortened, yet some 

 cretins attain a very high age. Kocher reports about seventy-year-old and 

 even one-hundred-year-old cretins. 



The figure is awkward, the gait inelastic, the muscles are poorly developed ; 

 individuals with completely developed forms can indeed not walk, but can 

 only creep. This depends, however, not as much on the muscular weakness 

 as on the want of every fine coordination. The skin of the face is often very 

 lax, numerous transverse wrinkles traverse the forehead and lend to the 

 face an old appearance. The development of the myxedema is very diverse. 

 Magnus-Levy and v. Wagner found in many cases typical supraclavicular 

 pseudolipomata, and also on other places of the skin very evident pad-like 



