236 THE DISEASES OF THE HYPOPHYSIS 



1891 described in detail a case of acromegaly that began in the eighteenth 

 year of life. One of the patient's brothers was affected with the same 

 disease earlier in life. Also Franlzel describes a case in which the affec- 

 tion began in boyhood; in the eleven-year-old daughter of which patient 

 the disease was also recognizable. In this family were many individuals 

 who were very tall. We find a statement of Schwoner's that the mother 

 of the female patient who was seventy-three years old apparently be- 

 came sick with acromegaly at the age of fifty; the father of the patient 

 was also very large. Frankel, Stadelmann and Benda state that the father 

 of two blood relations of the case described by them was said to have shown 

 the same anomaly. In the case reported by H. Salomon, we find the state- 

 ment that the mother of the patient seems to have suffered with acromegaly 

 and diabetes. 



Symptomatology. I begin with a description of the alterations in the 

 bones and soft parts. The alteration of the face in fully developed cases can 

 be so marked that the individuals actually become unrecognizable. The nose 

 is monstrously thickened, the superciliary arches and malar bones protrude 

 markedly; this is chiefly dependent on an increase in volume of the pneu- 

 matic cavities. I refer to the X-ray illustration of Observation XXV in 

 which the large frontal cavity is to be seen as a light space. Such an enlarge- 

 ment may bring about narrowing of the auditory passages and of the orbits. 

 In the case of youthful acromegaly described by Schultze and Fischer there 

 occurred almost complete deafness probably due to the thickening of the 

 internal ear. Also the cranial skull may increase essentially in circumference, 

 so that the hats no longer fit. The sutures often close prematurely. The 

 external occipital protuberance is in most cases enormously developed. The 

 narrowing of the orbits may bring about exophthalmus although this may be 

 also brought about by other causes such as enlargements of the eye-balls and 

 stagnation in the cavernous sinuses (Benda) . In many of the cases associated 

 with symptoms of Basedow's disease the cause of an existing exophthalmus 

 may be due also to a heightened tonus of Muller-Landstrom's muscle. The 

 great variation that the exophthalmus shows in such cases may be as well 

 explained in this manner as by the cause assigned by Benda. 



Very characteristic is the spreading apart of the teeth on account of the 

 enlargement of the upper jaw, especially of the lower jaw. On account of the 

 marked prognathia of the lower jaw, and on account of the oblique position 

 of the alveolar process due to this, chewing becomes almost impossible. The 

 mucous membrane of the oral cavity is for the most part thickened, the 

 tongue can so increase in size that in spite of the enlargement of the jaws it 

 projects over the teeth. The mucous membrane of the tongue becomes thick- 

 ened, the papillae are enlarged, the microscopic examination showed enormous 

 proliferation of the interstitial tissue, while the muscle fibers show, at least in 

 the later stages, signs of atrophy and degeneration. On account of the thick- 



