ACROMEGALY 237 



ening and the weight of the tongue articulation may be affected. The larynx 

 is often considerably enlarged, the voice is deep and, on account of the reson- 

 ance in the enlarged pneumatic spaces, abnormally loud. This is true for 

 both male and female individuals. The clavicles, especially, are enlarged. 

 Often there develops rather quickly a pronounced kyphosis of the lower cer- 

 vical and upper thoracic spine and a lordosis of the lumbar spine. 



Then, too, there may occur ankylosis of the vertebral bodies. The ribs are 

 thickened and broadened. Very characteristic is the tremendous thickening 

 of the places for the insertion of the muscles, the widening of the vascular for- 

 amina and the deepening of . the vascular furrows (Slernberg); the entire 

 osseous system can be enlarged in all dimensions as in the cases of Schultze 

 and Fischer. 



On the hands only the soft parts are considerably thickened, the thicken- 

 ing occasioning a spreading apart of the metacarpal bones. The hands 

 become paw-like. The X-ray picture does not show anything especially 

 beyond a slight thickening of the places of muscular insertion (type en large, 

 Pierre Marie), (see St, Observation XXX, reported later). In other cases 

 there is in addition to this an increased growth in length, leading to a true 

 giant hand (type en long see Ti, Observation XXV). Here are found both 

 lengthening and broadening of the hands and feet. Launois and Roy find the 

 type en long in acromegalic gigantism. The feet may behave similarly. 



X-ray examination of the skeleton shows a thickening of the walls of the 

 skull, enlargement of the pneumatic cavities, increase in size of the lower jaw 

 and broadening of the epiphyses of the long bones, formation of osteophytes 

 on these, thickening of the phalanges of the fingers and toes (Schuller) ; in the 

 later stages of acromegaly there is found considerable atrophy of the osseous 

 structure; on section Deitnch found especially the spongiosa atrophic. He 

 regards this as neuropathic atrophy. Frankel, Stadelmann, and Benda in 

 each of four cases found pronounced atrophy, in one case distinct porosis and 

 always formation of osteophytes. 



As in the later stages the muscles of the arms and legs are for the most 

 part markedly atrophic, the amorphic condition of the extremities becomes 

 that much the more conspicuous. 



As example of the skeletal alterations in acromegaly I cite the following 

 case: 



Observation XXIV. V. U., thirty-two years old, entered the clinic Jan. 10, 1912, car- 

 penter. No hereditary predisposition to disease, no similar sickness in the family. 

 Married seven years. One year after the marriage a child was born that died soon 

 after birth. One illegitimate- child is ten years old. 



The present disease began seven years ago with a feeling of furriness in both hands, 

 formications, and a characteristic sensation of stiffness especially in the morning. For 

 some months severe pains in the hands and forearms so that the patient had to get up often 

 at nights and walk about the room. Soon afterward the patient noticed gradual enlarge- 

 ment of the hands, and a short time after this the chin became larger so that chewing was 



