THE CKETINTC DEGENERATION 465 



following remarks are limited to the distinguishing features of cretinie 

 degeneration. 



This endemic disease is characterized by its multiformity whereas all 

 sporadic cretins bear a general resemblance to one another. Endemic 

 cretins correspond to no fixed type. A visit to the endemic areas of 

 Switzerland or Austria, or observation of the photographs of groups of 

 endemic cretins clearly demonstrate this. It may be mentioned that the 

 following characteristics are usually present : a pale or pasty complexion, 

 a stupid or sullen facial expression, the root of the nose retracted, a large 

 tongue and a short neck. The growth is stunted but in general less so 

 than in sporadic hypothyroidism. The skeletal changes are distinguished 

 by their irregularity and lack of symmetry (see Pathology) and are usu- 

 ally not proportional to the severity of the mental and other symptoms. 

 Breus and Kolisko call attention to the shortening of the upper extremities. 

 A disproportionate length of trunk as compared to the limbs is frequent. 



The Thyroid Gland. Goiter. The thyroid gland undergoes hyper- 

 trophic or atrophic changes in the cretinic degeneration. The former give 

 rise to endemic goiter, a very common manifestation of the disease. The 

 atrophic glands are the cause of the lean necks with prominent sterno- 

 cleido-mastoid muscles and larynx that are met with in high-grade cretins. 

 A goiter may be the only sign of the cretinic degeneration. In certain 

 affected areas, notably those in the United States, this holds quite true. 

 Goiters are much more prevalent among endemic than sporadic cretins. 

 Among Osier's American sporadic cretins, 12 per cent showed goiters. 

 Among McCarrison's endemic cretins, 40 per cent were goitrous. In 

 certain communities, endemic goiter becomes so frequent that practically 

 all the inhabitants, as well as domestic animals, are affected. 



Although endemic goiters are in the great majority of cases eminently 

 chronic, they may develop acutely in newcomers to a goitrous locality 

 ("acute" or "summer goiters"). The degree of enlargement is very vari- 

 able. It may be so slight as to remain unnoticed by the patient, become 

 the usually moderate cervical enlargement, or rarely develop into an enor- 

 mous growth lying on the anterior surface of the chest reaching down- 

 ward even to the waist. With regard to the anatomical location, thyroid 

 tissue, wherever located, may become goitrous. Thus submaxillary and 

 lingual and intralaryngeal goiters are known. The substernal type is of es- 

 pecial surgical importance. The neck may show no enlargement in such 

 cases. For further details surgical works may be referred to. 



Pressure symptoms due to goiter often occur when the growth is large. 

 Of Kronlein's 191 patients 62 gave a history of paroxysmal dyspnea. 

 Congestion of the face and neck is common in goitrous individuals due to 

 venous compression, respiratory embarrassment or goiter heart. The 

 trachea may become compressed particularly by the intrathoracic type. 

 Consequent to this compression may develop stridor, dyspnea, tracheo- 



