ACROMEGALY 239 



lordosis. Thorax is barrel shaped, compressed, reaching deep downward in front. Cir- 

 cumference of the thorax at the level of the nipple is on deep inspiration 104 cm., on 

 strong expiration 101 cm. The clavicles are markedly thickened. The ribs and the 

 intercostal spaces are strikingly broad. The upper and lower extremities have taken on 

 in circumference in their distal parts. Abnormal breadth of the middle of the hand. 

 Circumference of the middle finger 8% cm. Right hand displaces 625 cc. of water, 

 left hand 640 cc. of water. X-ray examination shows chiefly hypertrophy of the soft 

 parts. The metacarpi are biscuit-shaped on account of the pressure of the increased 

 soft parts and decrease in size at their diaphysial portions. Also the middle portion of 

 the foot is enormously broadened, showing a similar picture to the X-ray. Enormous 

 thickening of the toes. 



Transverse diameter of the heart to the X-ray 13 cm. Otherwise cardiac findings normal. 

 A slight decrease of tachycardia. Liver and spleen not palpable. On X-ray examina- 

 tion the stomach is not enlarged. 



Examination of the eye. (Docent Ulbrich) O. D. ^, O. S. jjf . External halves of 

 the papillae pale, with however a large physiological excavation so that the diagnosis 

 paling is not possible. Visual fields for white and colors are normal. 



X-ray Examination of the Skull. Enormous enlargement of the entire skull, especially 

 the facial bones. Sella turcica enlarged to the size of a gulden. Clivus sharpened. 



Erythrocytes, about 4,500,000. 



Hemoglobin, 75 per cent. 



Leucocytes, 6,240 of which: 



Polymorphonuclear neutrophiles, 57.6 per cent. 



Lymphocytes, 25.4 per cent. 



Large mononuclears, 15.7 per cent. 



Eosinophiles, 1.3 per cent. 



Examination as to alimentary glycosuria was unsuccessful, as the patient vomited 

 No sugar in the urine on the administration of a diet rich in carbohydrates. 



Pulse between 90 and 100. 



Examination of the exchange of gases (Dr. Bernstein). 



CO 2 . Respiratory CO 2 O 2 



quotient 



235.7 288.8 0.816 



240.7 296.3 0.793 3-!5 6 3- 8 57 



243.2 298.4 0.781 



The examination of the elimination of uric acid on a purin-free diet shows a marked 

 increase of the endogenous factor. This lies higher than double the normal average 

 of the (Novaczinsky and Falta). 1 



Examination of ammonia, amino-acids, and polypeptid elimination shows normal 

 relations as may be seen by few figures here adduced. 



N N(NH 3 ) N. (amino acid) N. polyp. 



16.64 gm. 0.7202 0.2718 0.0683 



18.65 gm. 0.6902 0.2842 0.1561 



On Feb. 28, a portion of the hypophysis of the patient was removed by the endonasal 

 route by Dr. Hirsch. 



Mar. 5, the patient was retransferred to the clinic. 



Mar. 15, patient has fallen off in weight and the acromegalic symptoms have not as 



1 On the administration of sodium nucleinate there was -a-^ prompt and rather high increase 

 of the uric-acid elimination. 



