458 PLURIGLAXDULAR DISEASES 



The fronto-occipital circumference reaches 67 cm. The occipitomental circumference 73 

 cm. The superciliary arches project markedly, as do also the malar ones. There exists 

 distinct prognathia. The anterior upper incisors are 1.5 cm. from each other. The set of 

 teeth is normal; only one tooth is absent. The tongue is disproportionately large. The 

 palate is in proportion. The least circumference of the neck is 42 cm. The pomum Adami 

 projects markedly. The thyroid gland is palpable and is in proportion. The voice is 

 very deep and low. The hairiness is very abundant. The mustache is well developed, 

 the man must shave every two days. The chest and the linea alba are extensively pro- 

 vided with hair. Also the hairiness on the genitals ,and the perineum, and in the axillse is 

 abundant. The genitalia are proportioned to the other relations. Heart dulness; upper 

 border of the fifth rib, left sternal border, 7^ cm. to the left of the border of the sternum. 

 Heart sounds clear. Slight tachycardia (105). 



The orthodiagram shows a greatest heart breadth of 13 cm., breadth of the aortic 

 shadow 7 cm. These measurements are relatively very small. Tuberculous affection of 

 both apices. The stomach is enormously large, sac-like, reaches 20 cm. below the navel. 

 The ordinary bismuth meal is just enough to fill the fundus of the stomach. 



Blood examination: Hemoglobin (according to Sahli), 80 per cent. 

 Erythrocytes, 5,720,000 

 Leucocytes, 5600, of which: 

 Neutrophilic polymorphonuclear, 65 per cent. 

 Lymphocytes, 20 per cent. 

 Large mononuclears, 9 per cent. 

 Eosinophiles, 6 per cent. 



The examination of the urine shows sugar o, albumin o, urobilin o, indican + . 



Eye examination (Dr. Ulbrich). The pupillary distance is 72 mm. (normaLaroout 65 

 mm.). The length of the palpebral fissures 33 mm. (normal 28 mm.). 



On the contrary we find that globes lie abnormally free on all sides and thatjiiie, width 

 of the cornea is not greater than the normal average (n mm.). Eye-ground^ normal. 

 Visual field and color field normal. 



The X-ray plate of the hand shows entirely normal ossification. The enlargement 

 affects bones and soft parts rather to a like degree. 



The X-ray plate of the head shows enormous relations. We see the frontal and the 

 maxillary sinuses considerably broadened and, further, the distinct prognathia of the lower 

 jaw. The bones of the cranial vault are enormously thickened, the sutures markedly 

 projecting, especially striking is the enormous external occipital protuberance. 



The sella is markedly enlarged and deepened; the posterior clinoid processes are dis- 

 tinct, and the anterior less evident. The introitus of the sella is relatively not very 

 wide (Fig. 80). 



We are hence dealing in this case with a typical acromegalic giant. 

 The acromegalic tendency became evident at a rather early age and seems 

 to have progressed very gradually. At least this man can give no sure 

 statement as to when the coarsening of the features and the prognathia be- 

 gan to develop. He states that, his hands and feet have not become essen- 

 tially larger in the last ten years. We have better data so far as the kyphosis 

 is concerned. During the military service, hence fourteen years ago, this 

 did not exist. Another point is furnished by the diminution of muscular 

 strength, which at about the twentieth year must have been enormous. 

 The pulmonary tuberculosis that has developed in the last year can surely be 



