466 NELSON W. JANJSTEY 



bronchial catarrh and cough. The so-called "goiter asthma" usually 

 comes on at night, is characterized by profound dyspnea and may end 

 fatally. It^nay be induced by pressure on the recurrent laryngeal nerves. 

 Woelfler reported paralysis of vocal cords in 10 per cent of his series, 

 Kronlein, vocal disturbances in 62 of his 191 cases. Other cranial and 

 spinal nerves are rarely compressed giving corresponding symptoms, es- 

 pecially pain in head and neck. Dysphagia is most common. Goiter heart 

 of the respiratory type may develop. 



Bacterial inflammations of goiters may ensue after trauma or treat- 

 ment by injections resulting in acute thyroiditis, even necrosis and gan- 

 grene. 



Myxedema, even in older subjects, is generally less commonly present 

 than in sporadic hypothyroidism. According to Bircher, 60 per cent of 

 endemic cretins do not exhibit myxedema, This, as do all the clinical fea- 

 tures, appears to differ in different localities and epidemics. Scholz found 

 it rarolv among Steiennark cretins; v. Kutschera frequently in his series; 

 McCarrison in his Indian cases describes a. myxedematous type of endemic 

 cretinism. 



Anomalies of dentition and the jaws are described by Kranz, who 

 failed to find similar changes in thyroidectomized animals and described 

 them therefore as characteristic of cretinic degeneration. In spite, how- 

 ever, of this experimental evidence similar lesions, delayed and irregular 

 dentition, liypoplasia, defective enamel, and liability to wear down pre- 

 maturely, are characteristic hypothyroid symptoms. 



The nervous system suffers more severely and sometimes more fre- 

 quently than in sporadic hypothyroidism. This is evinced by the great 

 prevalence of idiocy and feeble-mindedness in endemic localities. Quite 

 characteristic is the development of idiocy without accompanying marked 

 subthyroid stigmata such as always occur when the mentality is severely 

 affected in sporadic cretinism. On the contrary, the body may be greatly 

 stunted showing various degenerative changes and yet the mentality be 

 but slightly affected, an excellent example of the multiformity of the clin- 

 ical picture. Physical defects, however, are usually present to a certain 

 degree. 



A peculiar type of cretinism with cord symptoms has been described 

 by McCarrison in India and later by Crookshank in England. It is 

 not known in America. The following is taken from McCarrison (a.), who 

 describes it as: 



''A condition of cretinous idiocy with associated cerebral diplegia and 

 tetany due to congenital fibrosis of the thyroid and parathyroid gland. 

 One third of all cretins in endemic localities of the Himalayas belong 

 to this type." Such afflicted children are helpless and of defective men- 

 tality. There may be nystagmus and strabismus and facial grimaces. 

 The knee jerks are increased, the spasticity may be so great that affected in- 



