It appears that goitrous manifesta tions are far commoner in endemic than in sporadic cretinism, but goitre has been noted in several instances of the latter type of disease, and in all probability the presence or absence of goitre cannot be considered as a radical difference in the two affections.
Cretinism has a decided relation to goitre in this sense: that the same fac tors that produce goitre produce cre tinism. Cretinism may be present, how ever, in persons who not only have no goitre, out in whom all traces of a thy roid gland are absent. It appears, then, that cretinism bears a close relation to the abolition of function of the thyroid gland. The causes of endemic cretinism must be the same as those of endemic goitre. It is probable that this, is in fectious in nature and dependent upon some factor contained in the drinking water. Theodore Kocher (Dent. Zeit. f. Chir., B. 34, '92).
[Hofmeister (Fortschritte ruf dem Gebiete der Roentgen-strahlen, B. 1, H. 1, '97), studying a case of cretinism with the Roentgen rays, shows that the alter ations in the long bones in this condi tion are identical with those alterations produced in animals where the thyroid has been removed; such changes have been noted by him in guinea-pigs, and by Eiselsberg's experimenting with sheep, goats, and pigs. They both found that, if the thyroid be removed early, the bones grow slowly in length, and the epiphyseal plates remain present for a long while. Hofmeister calls the result ing condition, after Kaufmann, "chron drodystrophia thyreopriva." In this condition the epiphyses remain carti laginous long beyond the normal term. The rays show that, although the bones are otherwise normal in form, they are very small, and what appears most evi dent is lack of bony ends. In all the long bones only the diaphysis is to be seen—the epiphysis is either not present or there are only a few small nuclei of bone to be made out. The patence, al though they could be felt, were not seen with the rays. In concluding his paper he states that "between sporadic and endemic cretinism no absolute dif ferences exist which in an individual case make a differential diagnosis pos sible." Dolega (Verhandlungen des Congresses f. innere Med., Wiesbaden, '97) speaks of the autopsy of a cretin, aged 28 years, whose skeleton throughout showed the embryonal cartilaginous epiphysis and synchondrosis. Microscopical examina tion of the hones showed conditions which resembled fatal rickets, but did I not appear identical.
Langhans (Virchow's Archiv, B. 149, II. 1, '97) in an interesting paper, says: "Up to the present time no premature ossification of cartilage has been demon strated in any cretin. The bones first represented by cartilage grow very slowly in length, and the epiphyses remain flat, ossification procedes very slowly, the centres of ossification in the epiphysis appear very late, and the epiphysial plates remain a long time over the normal period. Remains of these even up to 45 years of age may still be demon strated. . . Periosteal growth is not
markedly disturbed. . . . An abnor mal thickness of the bones, such as Blebs describes, I have not been able to confirm." WILLIAM OsLEn.] In cretinism all autopsies agree in certain changes occurring in the histo logical development of bone quite dis tinct from changes occurring in rachitis, syphilis, or osteomalaeia. In the long bones the typical and almost geometrical arrangement of the rows of cells, always found where hyaline cartilage is ossify ing, becomes completely disordered. The rows of cells become irregular, the cap sules swell up, and many of the cartilage cells within shrink or disappear. The ground-substance itself may become liquefied in places, and all ossification which arises normally in such cartilage is checked, and growth in a longitudinal direction stops. The most marked change is at the junction of the epiphyses and shaft. In some of the autopsies fibrous connective tissue seems to appear around the epiphyses, forming soft, white de posits. Ossification of bone from mem brane, and especially from the perios teum, is exaggerated, and the bones may become abnormally thick. William B. Noyes (N. Y. Med. Jour., Mar. 14, '96).
As a result of the above-mentioned facts it is now shown to be impossible to separate cretinism from operative cachexia thyreopriva, as Bircher has done. Therefore we may conclude from our present knowledge that they are identical and that the former is, as Kocher first sharply and clearly stated, very probably caused by a lessened func tion of the thyroid during the foetal period as a result of toxic influences, either by becoming atrophic or entirely degenerating, or possibly by the forma tion of non-functioning struma-islets ("Strumaknoten") and the remaining portions of the gland being caused to disappear by pressure. . . . We should consider the development of the cretin in the following light: That cre tins in foetal condition develop normally, that only after birth does the absence of the normal thyroid make itself felt, and that the first signs of cretinism appear at the fourth or fifth month after birth, and in the course of the next years of in fancy make themselves more and more evident." From the examination of three speci mens of thyroid gland from adult cre tins, nothing especially abnormal is found in gross appearances of texture. Microscopically is noticed a deficiency of gland-tissue and excess of connective tissue, and adventitia of the arteries thickened. In one of the less altered glands there were small foci filled with leueocytes. The most perfect alveoli are small and have only a single layer of epithelium; the others show less and less epithelium, some showing none and being filled with leucocytes or colloid masses, or cellular debris. There was never wanting some gland-tissue capable of performing its function. This lends strong support to the theory of the de pendence of cretinism upon disordered function of the thyroid. A. Italian (Brit. Med. and Surg. Jour., Oct. 4, '90).