464 NELSON W. JANNEY 



tiating those cases in which the hypothyroid factor is marked and thus 

 enable a proper selection of cases for thyroid therapy. 







Symptomatology 



The clinical expressions are so varied that it was long before it be- 

 came generally recognized that endemic goiter, cretinism, idiocy, goiter- 

 heart and deaf-mutism belong to a single nosological entity. Even at pres- 

 ent, endemic goiter is occasionally still described as a disease sui generis. 

 This has in part come about through the prominence of this symptom 

 but also because an outbreak of goiter may be the only manifestation of the 

 disease in lightly affected areas. As the endemic increases, however, very 

 gradually cretins, deaf-mutes and idiots begin to put in an appearance 

 though never in numbers approaching those affected with goiter. As has 

 been emphasized by many writers, cretins are usually born of goitrous 

 parents. There is no necessarily sharp demarcation between the various 

 forms of the disease which merge into each other. Besides the typical clin- 

 ical pictures, many slight bodily and mental abnormalities occur in en- 

 demic areas which careful observers are prone to consider likewise mani- 

 festations of the disease. Among such may be included certain char- 

 acteristics frequently regarded as radical and familial by the laity, 

 viz., small statures, disproportionate development, ugly features, lack of 

 ambition, quarrelsomness, and the like. 



Griesinger quoted by Crotti aptly remarks in this regard, " Where the 

 endemic is very severe, the entire population is affected. Besides the true 

 cretins, the half-cretins, and goiter-bearers, there are innumerable weak- 

 minded, miserable and badly proportioned individuals; there are many 

 deaf-mutes, stutterers and stammerers and strabismus and deafness are 

 frequent. Through the entire native population runs a streak of physical 

 degeneration and mental dullness; even those individuals who pass for 

 healthy and intelligent are, on the whole, unlovely, narrow-minded and 

 sluggish and the country teems with mean-spirited philistines in whom the 

 qualities of heart are insufficient to compensate for the lack of intellect." 

 The clinical symptoms and signs of cretinic degeneration may in cer- 

 tain cases or epidemics be indistinguishable from those of sporadic cretin- 

 ism. In many descriptions this fact is but more clearly emphasized by 

 the forced attempts of the authors to bring out differential points. It 

 should be emphasized that the thyroid factor differs in various epidemics. 

 Some are characterized by greater numbers of typical hypothyroid cases 

 and cretins than others. The latter are less amenable to treatment than 

 the former. This has been the cause of much confusion. For the sake 

 of brevity, the reader is referred to the section on the symptoms of hypo- 

 thyroidism for a detailed description of such clinical manifestations. The 



