ENDEMIC CRETINISM 1 71 



all individuals, the marked dysgenitalism, the normal development of hearing 

 and the relatively good development of speech, v. Wagner believes that 

 the in-breeding that exists on this island also albinism is indigenous here 

 perhaps plays a role in this, but that also the insufficiency of the thyroid 

 gland is the decisive factor. Very striking seems to me the circumstance 

 that in all individuals at first the development was entirely normal up to the 

 third, the fifth, indeed even the tenth year and the inhibition of growth did 

 not set in until this age ; the accompanying photograph shows, in addition to 

 the marked dysgenitalism, a form of obesity such as we are wont to find in 

 dystrophia adiposo-genitalis and to refer to the insufficiency of the inter- 

 stitial glands or of the hypophysis. The disturbance of growth seems to 

 me to speak decisively for the hypophysis. A strumous degeneration of the 

 hypophysis could perhaps have been demonstrated by an enlargement of the 

 sella on X-ray examination; in other cases there did exist, however, un- 

 doubted myxedematous alterations. Such an endemic degeneration of the 

 ductless glandular system with predominant involvement of the glandular hy- 

 pophysis occurring in earliest youth is, at all events up to the present, unique. 

 I cannot at first hand answer with certainty the question as to whether or 

 not a variety of cretinic degeneration exists in such a case. 



Surveying once more the field covered in the preceding observations it 

 seems to me that the separation of the cretinic degeneration from the chapter 

 of the pathology of the thyroid gland is indeed possible and desi fable, on the other 

 hand it would be a mistake to relegate too far to the background the intimate 

 connecting associations with the thyroid gland. The separate position depends 

 on the localization to certain territories, depending on the fact that the noxus 

 contained in the thyroid gland produces very frequently, perhaps even 

 regularly, alterations not only in the thyroid gland but also in numerous 

 organs such as the heart and the central nervous system. 



But there are other attempts at explanation that I have not as yet men- 

 tioned, v. Kutschera supposes an infectious noxus; he bases the assumption 

 on the following observation: dogs that have been brought up in the bed of a 

 cretin remained behind in development and became typically cretinic. Of 

 course it must be considered that these dogs were under the same external 

 conditions as human beings and drank the same water. Very difficult to 

 interpret is also the observation of v. Wagner that a dog with typical endemic 

 cretinism shows extensive retrogression of the cretinic symptoms after extirpa- 

 tion of the goiter, v. Wagner assumes that the manifold symptoms of en- 

 demic cretinism are produced by a poison emanating from the goiter, and 

 therefore, as previously mentioned, places the thyroid gland as the central 

 figure in the pathogenesis. 



Differential Diagnosis. The differentiation between sporadic and en- 

 demic cretinism is often difficult and in certain cases may be impossible. The 

 fact that the cretin comes from a locality in which cretinism is endemic 



