ACROMEGALY 251 



six years on his face became broader. He died of pneumonia in his seventieth year. 

 No ductless glandular diseases in the family. The patient has seven brothers and 

 sisters, all well. She has five children, the first child born when she was in her twenty- 

 eighth year, the last when she was in her fortieth year. All the births were normal, 

 and all the children were well developed. Menstruated first at the age of twenty-two 

 years, the menses were always rather profuse, lasting two to three days, and occurring 

 regularly every four weeks, menopause at the forty-sixth year. For two years headaches, 

 especially at the roof of the skull of the right side, which headaches have increased in 

 intensity. The pains now exist day and night and for the most part are so intense 

 that the patient cannot sleep. During the last four to five months she has always 

 remained in bed on account of these headaches, and on account of the fact that when 

 she attempted to get up she would suffer with attacks of vertigo. The patient had 

 also had headaches for some time before this but she did not give them much attention. 

 She states definitely that the enlargement of the hands and feet developed gradually 

 between the twentieth and thirtieth year of life. At the time of the birth of her first 

 child in her twenty-eighth year the hands and feet were much larger and thicker than 

 at present, and have gradually decreased in circumference. Also the prognathism 

 of the lower jaw has existed since that time. She never suffered from sweats or from 

 pains in the extremities. 



The patient looks at least fifteen to twenty years older than she is. Height 145.5 

 cm., span width 150.5 cm. Layer of fat well developed. Skin pale, smooth and dry, 

 musculature weak, build of bones medium, considerable kyphosis; the extremities are 

 extraordinarily heavy, head farge, fronto-occipital circumference 56 cm., nose large with 

 broad insertion; distance from between the eyebrows to the tip of the nose 5.8 cm.; 

 breadth of the nose 4.5 cm., distinct prognathism. From temporomaxillary joint to 

 tempo romaxillary joint, over chin, 26 cm. Lower lips thick, cushiony, and prominent. 

 The teeth are in greater part absent, the two lower incisor teeth are present and are 

 spread apart from each other. The clavicles are rather broad; the extremities extraor- 

 dinarily awkward. The fingers are markedly thickened and the X-ray shows that the 

 thickening affects the weak spots exclusively. The metacarpal bones are pushed apart 

 from each other, only very slight bone formation at the seat of the muscular insertions. 

 Also the feet are awkward. Axillary hair and pubic hair well developed. Isolated 

 hairs on the upper lips. Slight arteriosclerosis. 



Alimentary glycosuria (100 gm. dextrose), 0.8 gm. 

 Blood findings: Leucocytes, 9800, of which: 

 Polymorpho nuclear neutrophiles, 66 per cent. 

 Lymphocytes, 30 per cent. 

 Large mononuclears, 3 per cent. 

 Eosinophiles, i per cent. 



One week later repetition of the test for alimentary glycosuria after two injections 

 4 cm. pituitrinum glandulare intramuscularly (100 gm. dextrose) 0.9 gm. 



X-ray examination of the skull (Dr. Schwarz) : Widening of the sella turcica to the size 

 of a 2-crown piece. Deepening of the floor of the sellae, processus clinoidei sharpened. 

 Entrance to the sellae widened. 



Eye examination (Docent Ulbricli) papillae normal, the inner borders slightly effaced 

 and slightly prominent. Nothing certainly pathological; on the contrary, vision O. D. 

 3/36, O. S. 1/36, but there is an old trachoma with corneal scars; visual field on each side, 

 so far as can be tested, normal; also normal for colors. 



The examination of the uric-acid elimination on purin-free diet shows values between 

 0.4-0.5 gm., therefore no increase. 



