468 NELSON W. JANNEY 



heart" thus came into use. This appellation in common with so many 

 others in thyroid terminology has been vaguely applied to describe the 

 cardiac changes in thyrotoxicosis as well as in hypothyroidism. The fol- 

 lowing remarks apply to cardiac lesions in the latter condition. There 

 seems no essential difference between the cardiac lesions of sporadic hypo- 

 thyroidism and the cretinic degeneration. 



1 Mitral insufficiency, which is not infrequent in these cases, may be 

 due to the hypertrophy and flabby myocardium, less frequently to vegeta- 

 tions of the mitral valve. The right heart may undergo dilatation and in- 

 sufficiency (Hose's goiter heart) due to the congestion in the pulmonary cir- 

 culation. Mechanical factors resulting from the weight and pressure of 

 a large goiter may embarrass the circulation and lead to the "pneumonic" 

 type of goiter-heart described by Kocher. It is certain, however, that 

 the mechanical factors in the development of cardiac lesions are of much 

 less importance than degenerations of the heart muscle. 



As to the Ilemaiology of cretinic degeneration, the only available 

 data seem those of McCarrison (a) Avho reports among 73 cases of endemic 

 goiter a decrease in the polymorphonuclear elements in 98.9 per cent 

 of cases, latest increase in the small mononuclear lymphocytes in 92.5 per 

 cent, eosinophilia in 88 per cent and mononucleosis in 23 per cent. En- 

 demic goiter is, however, the lightest manifestation of the endemic disease 

 under discussion. It seems then possible that the leucocytic formula of 

 endemic cretins might correspond more fully to sporadic hypothyroidism, 

 particularly in the more constant presence of mononucleosis. A certain 

 degree of anemia is common in endemic cretinism. 



Diagnosis 



The most important single factor in the differentiation of cretinic 

 degeneration from other conditions is its endemicity. In the absence of 

 cretinism and deaf-mutism, the occurrence of unusual numbers of goiters 

 suggests the development of the endemic disease. Sporadic cretinism, 

 however, may occur rarely in an area of endemic goiter. Simple goiters 

 are distinguished by small size, occurrence at puberty, during pregnan- 

 cy, etc. 



For reasons already given, the diagnosis from sporadic hypothyroid- 

 ism may be impossible. Endemic cretinism is distinguished by the fol- 

 lowing symptoms: the endemicity, frequency of struma, greater involve- 

 ment of the central nervous system, particularly the mentality, slighter 

 and disproportionate retardation of the ossification and in general the lack 

 of uniformity in the clinical picture. The failure of the thyroid therapy 

 in soino oases and the low tolerance to thyroid substance are further points 

 of differential value. 



