THE CRETINIC DEGENERATION 471 



thyroid extract in simple thyroid adenomata. Probably a standardized 

 dosage of thyroxin will become the medical treatment of choice in future. 



Various intestinal antiseptics have been recommended by McCarrison 

 in the treatment of endemic goiter. (See same below.) It would seem 

 favorable from the results achieved to make a trial of this treatment com- 

 bined with dietary measures. 



Roentgenological treatment properly controlled may be recommended 

 before resorting to surgery. 



The mortality of thyroidectomy has now been so reduced in skillful 

 hands that selected cases may be advised operation with propriety. Very 

 large, cystic, indurated or calcined goiters do not yield to medical treat- 

 ment. In such instances or when pressure symptoms intervene, surgery 

 is indicated. Great improvement in the operation of thyroidectomy has 

 been made since Kocher's development of the operation by Halsted, C. H. 

 Mayo, Crotti and other operators. The mortality in skilled hands is low. 

 It is well, however, to bear in mind that postoperative cachexia strumipriva 

 is still met with. Such postoperative hypothyroidism usually develops so 

 slowly that it frequently escapes the observation of the attending surgeon 

 and fails to be noted in surgical statistics. One of the interesting facts 

 brought out by recent basal metabolism studies is the detection of greater 

 numbers of such cases, particularly those of a mild type. In spite there- 

 fore of the splendid results of modern thyroid surgery, it seems justifiable 

 in all suitable goiter cases to try the effect of medical treatment before 

 recourse to thyroidectomy. 



Thyroid Treatment of the Cretinic Degeneration. Thyroid therapy 

 is productive of less certain results in the cretinic degeneration than in 

 in sporadic hypothyroidism. This may be fairly expected in view of the 

 general character of the disease. The more typical hypothyroidism is de- 

 veloped, the better results can be expected. It is likely that failure to 

 properly select and control the cases together with the uncertain quality 

 of the thyroid preparations then in use were responsible for the statements 

 in the older literature as to the inefficiency of thyroid therapy in cretinic 

 degeneration. In many instances the results of treatment have been satis- 

 factory. Thus v. Kutschera (a), who carried out this mode of treatment on 

 a large scale in Austria, reported in a series of 1011 endemic cretins marked 

 improvement in 42.8 per cent, definite improvement in 48.6 per cent. A 

 small minority failed to be benefited. High-grade idiots and deaf-mutes 

 were excluded from this series. It is unfortunately just such individuals 

 who are least benefited by thyroid treatment. In these instances, atrophic 

 and sclerotic processes have determined actual irreplaceable tissue loss, as 

 the thyroid factor is small or perhaps at times entirely absent. For thy- 

 roid preparations and dosage, see section Treatment of Hypothyroidism. 



No comprehensive reports of the control of treatment of cretinic de- 

 generation by basal metabolism determinations are known to the writer. 



