ENDEMIC CRETINISM 169 



cretinism, are either fully refractory, or that at least certain symptoms, 

 especially the disturbances of intelligence and speech, can remain uninfluenced. 

 The hypothesis that in such cases, in which the noxus has already done harm 

 at a former period, already definitive irreparable damage has been done, 

 especially in the central nervous system, can explain only a slight result, but 

 not the complete failure of the thyroid-gland treatment, as these conditions 

 also obtain in sporadic cretinism, and here thyroid-gland therapy is never 

 entirely without [good] results. 



We now take up the question as to what role the disease of the thyroid 

 plays in endemic cretinism. 



Pathogenesis. Kocher and v. Wagner identify sporadic and endemic 

 cretinism, referring all manifestations to a damaging of the thyroid gland. 

 Bircher, Ewald, and Scholz ascribe to the arthyrosis component only a cer- 

 tain signification, and see in it only one manifestation of cretinic degenera- 

 tion which is coordinated with other derangements. 



The following is a list of the factors that speak against the hypothesis 

 of a thyroid disturbance alone: 



1. The action of thyroid therapy is not so constant as in sporadic cretinism. 



2 . The myxedematous symptoms are wanting in many cases or are only very 

 slightly expressed. 



3 . The forms of the clinical manifestations of endemic cretinism are much 

 more manifold. To it belong the frequent association with mutism, 

 further the occurrence of mutism in cases that otherwise show only 

 few signs of cretinic degeneration. In endemic cretinism there is an 

 incongruence between the inhibition of the mental disturbances and 

 the other signs of the cretinic degeneration; cases that on the one 

 hand show struma and rather high-grade disturbance of growth are, 

 however, well developed mentally; on the other hand, cases that are 

 highly idiotic have remained behind in growth only a little. 



4. Further, there exists a quantitative and qualitative difference in the 

 disturbance in growth. This in endemic cretinism is only delayed; 

 even in the highest grades there occurs later closure of the most of the 

 epiphysial junctures; the disturbance in growth is disproportionate 

 (Breus and Kolisko). 



5. The hypophysis is often goitrously degenerated. 



I believe, therefore, that I shall have to concur in the opinion of those 

 authors who ascribe to the noxus of cretinic degeneration a direct deleteri- 

 ous influence on the central nervous system and other tissues, probably also 

 on the other ductless glands. Also the independent position that according 

 to the later investigations we must ascribe to goiter heart is embraced in the 

 confines of this view. 



On the other hand, the significant results of thyroid-gland therapy in many 

 cases of endemic cretinism force us to ascribe to the athyrosis components a greater, 



