170 THE CRETINIC DEGENERATION 



indeed in many cases an almost determining significance. The complete 

 setting aside of this factor, as we see in the works of H. Bircher and Scholz, 

 is not in my opinion correct. E. Bircher also surely goes too far when he 

 explains the striking influencing of the inhibition of growth, which was ob- 

 served in many cases of endemic cretinism under the thyroid medication, 

 simply through the evidence that also the normal cartilages react to the 

 administration of thyroid gland, and that Scholz and Zingerle favorably in- 

 fluenced the growth of rachitic dwarfs through thyroidin tablets. Such re- 

 sults, that are to be striven after in all cases, are not to be attained in all. 

 I quote examples of this in the chapter on infantilism, in which the inhibition 

 of the osseous growth behaves refractory to thyroid therapy. The cause 

 of the divergence of views I would especially see in the fact that up to the 

 present we have too little considered that a variable importance attaches to the 

 athyrosis components in different individuals and in different epidemics. So, 

 for instance, in the epidemic that Magnus-Levy described it stood entirely 

 in the foreground; it is not without significance in this respect that the 

 epidemic that Magnus-Levy described had lasted only for a short time. Also 

 in numerous cases of Kocher and v. Wagner is the athyrosis predominant. 

 However, v. Wagner states that the cases originating in Judenburg did not 

 react at all to the administration of thyroid. The same is true of the severest 

 forms of cretinism in the Steiermark that Scholz observed, and of the cases 

 of Bircher. It is therefore to be supposed that at different places the noxus 

 works with different intensity. Significant also is the fact as to whether 

 the population has suffered from the affection for a long time; finally it is 

 probable that bad living conditions, in-breeding, and many other factors 

 contribute to the intensity and the clinical symptoms of the endemic. 



How complicated the question is, is shown by a communication of v. 

 Wagner's as to marine cretinism. It is known that the seacoasts are almost 

 free from goiter and cretinism. Now v. Wagner observed on the island 

 Veglia, belonging to the Guarneric Islands, fifteen dwarfs, mostly about 

 100 cm. tall. The closure of the fontanelles was delayed; in most, but not 

 in all, the root of the nose was retracted, there existed more or less distinctly 

 well-expressed myxedema of the skin, high voice; there was absence of hair on 

 the pubic and in the axillary regions ; the genitals showed high-grade infantil- 

 ism, in men the mons Veneris was abundant in fat and, as is shown in the 

 photographs accompanying v. Wagners's publication, was limited above by a 

 horizontal line ; frequently there existed constipation, dentition was delayed, 

 the intelligence in some was only very slight, in others there existed only 

 slight apathy; many could not read and write; the hearing was well developed 

 in all. The thyroid gland was not palpable in all of them. v. Wagner 

 discusses the question whether these cases are to be classified under endemic 

 cretinism. As ground against such classification, v. Wagner adduces: the 

 complete freedom from goiter of the neighborhood, the marked dwarfism of 



