280 THE DISEASES OF THE HYPOPHYSIS 



through the projection of an exostosis into the sella turcica; it was as large 

 as that of an adult, the enlargement affected especially the glandular part. 

 Microscopically was found a very considerable richness in eosinophilic cells, 

 such as is found in adults but not in children. 1 



Finally Hutinel describes a case with enlargement of the acra in a thirteen- 

 and-one-half-year-old boy. 



The cases set forth suffice to indicate the great multiplicity of the forms 

 of early acromegaly. In one is found a large tumor of the hypophysis, in 

 the others the sella turcica is not at all abnormally large; but despite this 

 latter fact I would not doubt that in these cases (Arnold, Pel, Demmer, etc.} 

 the diagnosis acromegaly is certain or at least hardly doubtful. Further, 

 the deformation of the bones is also very varied. A manifestation that ap- 

 parently may occur in early acromegaly in an especially well-marked manner, 

 is the entirely irrelative increase in size of the bones of the extremities in a 

 distal direction. Very diverse, too, is the proportioning, in that in many cases 

 the eunuchoid proportion is very prominently in the foreground; then 

 again the condition of the genitalia is very different too; in some cases there 

 is hyperplasia, in others hypoplasia and faulty development of the secondary 

 sexual characters, even association with eunuchoid obesity; then, as in the 

 case of Schultze and Fischer, hypoplasia of the genitalia and obesity, but 

 marked hairiness (hyperplasia of the suprarenals) . 



The cause of this great multiplicity of type can perhaps be seen in the 

 fact that the child organism or the ductless glandular apparatus of children 

 reacts to a hyperfunction of the hypophysis in a very much more diverse 

 manner than that of adults. Especially the developing genital glands that 

 are involved can behave differently, in that here the interstitial glands may 

 be damaged and thus may bring to the total picture admixture with features 

 of eunuchoidism. Then again, dependent to a large extent on the behavior 

 of the genital glands is the premature, normal, or delayed closure of the 

 epiphysial junctures. Also the dimensioning of the body may be influenced 

 on account of this. I would, however, treat of one point with emphasis. In 

 some cases the diagnosis may very well be doubted, in fact in some cases it is 

 even made by the respective authors with reserve. In other cases, however, 

 there is no room for doubt; and we must reckon with the fact that acromegalic 

 alterations in the extremities may occur also in youth, and that therefore 

 the hyperfunction of the hypophysis in early youth does not necessarily lead to 

 gigantism. 



Differential Diagnosis. The point of difficulty in the diagnosis of 

 acromegaly lies in the disproportionate growth of the peripheral parts, not 

 in the enlargement itself, as this may be congenital. There is found for in- 



1 Also Benda (Med. Klin., 1912, 284) regards the histological alterations as typical, but does 

 not regard the fact ruled out that the alterations of the jaws, tongue, and hands, may simply 

 have been inherited. 



