450 NELSON W. JANNEY 



rison, de Quervain, Knopf elmacher, Siegert, et al). These authors cham- 

 pion the so-qalled Unitarian conception. Opposed to this theory is the so- 

 called dualistic conception, according to which endemic cretinism and its 

 accompanying conditions are regarded as a general process of degenerative 

 nature affecting various tissues and organs including the thyroid. Among 

 the "Dualists" may be mentioned H. and E. Bircher, Pineles, Scholz, 

 Wieland, Dieterle, v. Kutschera, Falta, Crotti, etc. 



The Unitarian hypothesis was strongly supported by Kocher as early 

 as 1892. It emphasizes the frequency of goiter and cretinism in the 

 endemic disease and regards deaf-mutism, idiocy, goitrous degeneration 

 of the thyroid and infrequency of myxedema merely as deviations from 

 the typical picture of hypothyroidism due to the influence of heredity 

 and endemicity. The excellent results obtained in extensive series of 

 cases treated by thyroid extract lends further support to this theory. In 

 spite, however, of these data and of much ingenious explanation by the 

 supporters of this theory, it seems difficult to include under hypothy- 

 roidism all clinical forms of cretinic degeneration. For example, the 

 nervous type of endemic cretinism of India described by McCarrison 

 presents spastic diplegia which is not met with in hypothyroidism. 



The earlier supporters of the dualistic view maintained that the 

 cretinic degeneration differed fundamentally from sporadic hypothyroid- 

 ism and even went so far as to deny any relationship between these two 

 conditions. Of late, however, there has been a tendency to give proper 

 importance to the prominent role played by the thyroid in endemic cre- 

 tinism and allied disorders. The dualists emphasize, however, a number 

 of differences, which render it impossible to regard the cretinic degen- 

 eration simply as an endemic expression of hypothyroidism. These points 

 of divergence as contrasted to sporadic cretinism are as follows: 



1. The usually later onset of endemic cretinism speaks for a different 

 causation of exogenous nature. 



2. Variability and indefmiteness in the clinical symptoms as con- 

 trasted to the exceptional regularity and definite nature of the manifesta- 

 tions of hypothyroidism. 



3. Failure of parallelism between the severity of the clinical symp- 

 toms and the thyroid pathology. 



4. Less delay and marked irregularity in the ossification processes 

 of cretinic degeneration as compared to the skeleton in sporadic hypo- 

 thyroidism. 



T>. Special clinical characteristics. Such are the frequency of deaf- 

 mntism, idiocy, goiter-heart, and large degenerated goiters. 



fi. Absence in endemic areas of cretins with typical sporadic signs 

 and symptoms. Absence or slight expression of myxedematous symptoms 

 in many cases, 



