SPORADIC CRETINISM 127 



The dose was reduced to three tablets and after some days, when the pulse had become 

 entirely regular again, five tablets were given continuously. 



Jan. 8. Leucocytes, 4800, of which: 



Polymorphonuclear neutrophiles, 61.5 per cent. 

 Lymphocytes, 20.5 per cent. 

 Large mononuclears, 12.5 per cent. 

 Eosinophiles, 5.5 per cent. 



Jan. 19. The examination of the hearing now shows certainly that the patient reacts 

 to loud noises. Distinct lid-reflexes. 



March 29. Thyroidin medication has now been continued in the large doses without 

 producing manifestations of poisoning. The hearing is still better, the enlargement of 

 the liver has essentially diminished in size; otherwise there is no change. 



December, 1910. The nuclei of the os magnum and the unciformbone are alone visible 

 in the carpus, while at this time the nuclei of the entire skeleton of the carpus should 

 have been laid down. The epiphysis of the radius is present. The skeleton corresponds 

 to that of a one and one-half to two-year child. 



Summary. The patient is from a goiter-free neighborhood. There exist no other 

 grounds for the assumption of an endemic cretinism. We are indeed dealing with sporadic 

 cretinism, probably dependent on aplasia or high-grade hypoplasia of the thyroid gland; 

 and perhaps later there was added some other factor that we are not able to define that 

 made the insufficiency still greater. 



Thyroid medication here succeeded less than in the preceding case. It was also 

 introduced much later. Apparently the thyroid insufficiency is here very much greater. 



The investigation with adrenalin and pilocarpine several weeks after the discon- 

 tinuation of thyroid-gland therapy shows slight or negative action. The test as to ali- 

 mentary glycosuria results negative. It is very interesting also that in this case adrenalin 

 plus dextrose leads to an entirely usual degree of glycosuria. 



Worthy of note in this case is the enormous tolerance for thyroidin and also the 

 action of thyroidin on the disturbance of hearing and on the enlargement of the liver. 



Observation XVI. H. A., entrance into the psychiatric clinic (of Wagner) Jan. 21, 

 1009. Fifteen years old, female dwarf (95 cm.); face puffy, skin of the entire body myxe- 

 dematous, dry and scaly. Supraclavicular fossae filled with pad-like masses. Con- 

 junctivitis eczematosa. Fundus normal. Circumference of skull 50^ cm. Root of 

 nose sunken, tongue thick, also the lips; the teeth with transverse ridges, in great part 

 carious, have remained very much behind in their development. Abdomen markedly 

 distended, umbilical hernia. 



Measurements. Height, 95 cm. 

 Circumference of skull, 50% cm. 

 Upper arm (acromion to olecranon), 19 cm. 

 Arm proper, 13 cm. 

 Lower extremity (spine [anterior superior] to heel), 46 cm. 



Intelligence that of a four-year child. Can speak, can understand questions and state- 

 ments addressed to her; can, however, not write nor read, and can say, of a prayer, only 

 the words at the beginning. Weight 20 gm. 



From April 27 on, 0.5 gm. sodium iodide, after which she became livelier; from June 

 8 on, one thyroid-gland tablet a day. Body weight at the beginning of July had gained 

 16.9 kg. The bowel movements, which formerly frequently occurred only every two or 

 three days, have gradually become entirely normal. Rapid mental development. Is 

 much more active, plays much, wants a looking glass, a net for her hair, begins to sing. 



Jan. 18, 1910. 101 cm. Myxedematous texture of the skin much lessened, slight 

 sweating of the palms of the hands. Dermographism. 



