SPORADIC CRETINISM 133 



In the incomplete forms of sporadic cretinism the disturbances of growth 

 are characterized by their slighter intensity. Here closure of the epiphysial 

 junctures may occur, even in advanced years. I mention as example a 

 case of Magnus-Levy, in which the treatment, instituted in the forty-fifth 

 year the patient was 132 cm. tall failed to exercise any influence on 

 growth, as the epiphysial junctures were already fully ossified. 



Disturbances in dentition go hand-in-hand with those of growth of the 

 bones. When the thyroid gland is entirely absent the children during the 

 first year remain completely toothless. In the later years the milk-teeth 

 develop very slowly and finally remain partially retained. (Often in addition 

 to the retained milk-teeth are found the rudiments of the permanent teeth.) 

 Here thyroid therapy, as we shall see later, may elicit excellent results. 



Umbilical hernia is a constant finding in the higher grades of sporadic 

 cretinism. Kassowitz observed it sixteen times in twenty- two cases of 

 infantile myxedema. The eldest of these children was twelve years old. 

 The hernia may attain the size of an apple. Therewith the abdomen is 

 distended, the navel is markedly deep (Argutnisky), there is high-grade 

 obstipation, which in the case of Maresch led to prolapse of the rectum. The 

 myxedematous texture of the skin is for the most part distinctly evident; in 

 the older cases, however, the skin is on the other hand rather atrophic, only the 

 pad-like swellings of the supraclavicular grooves and the slight puffiness of 

 the face, especially the eyelids, remain. For the most part the limit of the 

 hair zone is far back on the forehead, to which are added protuberance of the 

 malar bones, retraction of the root of the nose, cushiony lips, protrusion of 

 enlarged tongue; all this lends the impression of something of an animal 

 appearance to the face. 



Inspection of the mouth shows that the palatine arches are for the most 

 part high, deepened with furrows, the tonsils enlarged; and often in the 

 pharyngeal space there are adenoids. The hypertrophic rhinitis which is 

 present disturbs breathing; the children snuffle and snore; in most cases 

 there is a discharge from the nose. In two of the above cases I found a 

 distinct enlargement of the liver. In the case of Argutinsky there is the state- 

 ment that the border of the liver was palpable two and one-half finger- 

 breadths below the margin of the ribs. 



It should also be mentioned that in the fully developed cases, the breath- 

 ing is extraordinarily slowed. A twenty-eight-year-old case of Magnus- 

 Levy's, who at the age of fourteen years had sustained a total strumectomy, 

 breathed only six times in the minute. 



The sweat-inducing action of pilocarpine, in the three cases cited, was very 

 slight; salivation failed entirely; the mydriatic action of homatropine lasted 

 very long. 



The developmental disturbances of the genitalia are always very marked. 

 In females the labia majora are stunted and do not cover the labia minora; 



