ACROMEGALY 265 



torn of hyperthyrosis; however, it seems to me certain that the outbreaks 

 depend on another cause lying in the nature of acromegaly itself, for we see 

 them also in the cases in which other symptoms of Basedow's disease above 

 all, the cardinal symptom of the hyperthyrosis, the tachycardia are absent. 

 This was the case, for instance, in case Ti (Observation XXV). 



The polyuria may also be looked upon as dependent on an abnormal 

 condition of excitability of the vegetative nerves. This also usually occurs 

 only temporarily, in crises. The specific gravity of the urine may sink in 

 these attacks to very low values, reminding us of a true diabetes insipidus. 

 As I have mentioned before, there may exist in many cases an especial 

 sensitivity of the nerves of the kidney for adrenalin or for pituitrinum in- 

 fundibulare. It is not clear how far such changes in the condition of ex- 

 citability of certain vegetative nerves may be brought into relationship with 

 functional alteration of the hypophysis. At most we may conjecture that 

 the critic polyuria may be associated with temporary irritation of the posterior 

 lobe and with the increased production of hypophysial "diuretin." 



The fact that complication with hyperthyrosis or hypothyrosis influences 

 the condition of excitability of the vegetative nerves in many ways needs no 

 further consideration in detail. 



Very often the pathologico-anatomical examination in advanced cases, 

 shows proliferation of the connective-tissue elements in the vegetative nerves 

 and ganglia (Marie and Marinescu}. 



The symptoms on the part of the somatic nervous system are very manifold. 

 To the early symptoms often belong the very burdensome rheumatoid pains 

 and eventually acroparesthesias (Sternberg). In many cases the pains 

 occur during night, so that the patient must get up and walk around the 

 room (Observation XXIV) . Also sensation of heat in the fingers may occur. 

 In one case there occurred transitory swelling of the finger-joints simul- 

 taneously with the pains. Whether combinations with continued articular 

 swellings and chronic deforming processes in the joints, as was present in 

 Str, Observation XXXI, are common, I have not been able to glean from the 

 literature. The behavior of the reflexes varies. Sometimes they are in- 

 creased, sometimes reduced. 



Also alterations of the mind and intelligence occur in acromegaly. In 

 many cases there exists a characteristic apathy, a want of initiative, and a 

 slowing of the speech. In rare cases, conditions of exaltation are observed. 

 The pathologico-anatomical examination of the nervous system shows no 

 constant findings; except that in the later stages there occurs regularly an 

 increase of the connective-tissue elements in the nerves. 



Among the symptoms of acromegaly there is still a group that has 

 nothing to do with the disease process in itself but is produced mechanically 

 by the enlargement of the hypophysis. To these belong first of all the changes 

 in the sella turcica; Oppenheim was the first to recognize enlargement of 



