ACROMEGALY 813 



number of eosinophile cells was large. The proximal epiphyses of the first 

 phalanges of the second and third toes showed the presence of centers of 

 ossification and the same was true of the epiphyses of the terminal pha- 

 lanx of the big toe. According to Wilms and Sick these centers normally 

 develop between the third and fourth years. 



In discussing the diagnosis Salle excludes pure gigantism on account 

 of the disproportionate hands and feet, and the complete symmetry of the 

 enlargements excludes localized gigantism. The osteo-arthropathie hyper- 

 trophiante pneumique of Marie (secondary hyperplastic ostitis) is ex- 

 cluded as the characteristic changes of the periosteum and articular ends 

 of the bones were lacking. As the most probable diagnosis he considers a 

 combination of gigantism and acromegaly or a modified form of acro- 

 megaly. Against acromegaly speaks the absence of thickening of the soft 

 parts of the extremities but in addition to the usual type en large Marie 

 has described a type en longue to which this corresponds. The hypophysis 

 which measured 11x10x4 mm. was of a size corresponding to that of an 

 adult rather than that of an infant. Although no typical hypophyseal 

 adenoma was present the prominence of the eosinophile cells was sugges- 

 tive of hyperpituitarism. 



Warda's mention of apparent congenital acromegaly in the four-year- 

 old child of an acromegalic and possibly syphilitic father is merely sug- 

 gested by a photograph and not based on personal examination of the 

 child. 



A more plausible case is that of Cenas of a boy of fifteen years who 

 was born with asymmetry of the face and developed deformities of the 

 hands when a few months old. At four years he had pigmented spots on 

 the hands and feet, which continued to enlarge so that at fifteen they 

 were described as "enormous." The lower jaw was enlarged and kyphosis 

 was present. 



Moncorvo described a microcephalic, idiotic child of fourteen months 

 with enlarged hands, feet, nose, and lips. Hinsdale mentions it as "a case 

 of what seems to be congenital acromegaly," which, however, cannot be 

 considered proven. 



Onset in Childhood. The occasional appearance of true acromegaly in 

 childhood is of great theoretical interest, as, according to views now quite 

 current, hypophyseal hyperfunction setting in before the closure of the 

 epiphyseal lines leads to general giant growth rather than to acromegaly. 

 This phase will be discussed in the chapter on Gigantism. It is inter- 

 esting to pass in review the reported cases in connection with which more 

 or less definite claims for the onset of acromegaly in childhood have been 

 made. In several the data are insufficient. In others we are impressed 

 by the many signs of a pluriglandular affection, the hypophyseal disorder 

 and resulting acromegalic features constituting only a part, though gener- 

 ally the most conspicuous part, of the clinical picture. Field describes a 



