SYMPTOMS 231 



appears that acromegalia most frequently attacks individuals- characterized 

 already by great bodily size. According to Sternberg 20 per cent, of the 

 " giants " are attacked by acromegalia. Among my four cases two were above 

 medium size. But, as is noticeable from the figures, the relation is not a 

 necessary one. At this point I should like to call attention to the fact that 

 in the skeleton of a dwarf which is in the Berlin Pathological Museum, and 

 which I had an opportunilty of- examining through the kindness of Professor 

 Waldeyer, I found suspicious acromegalic stigmata, so that, with all due regard 

 to what has been expressed above, I may presume that even dwarfs are not 

 exempt from the disease. 



The cause of the disease is enveloped in obscurity. Of course trauma and 

 psychical emotion, as in all diseases which involve the nervous system, are 

 mentioned as starting points by the patients and their relatives, and are sug- 

 gested as causes of the afEection. 



SYMPTOMS 



The onset of the disease is accompanied by very various neuropathic phe- 

 nomena. There are reports of extreme lassitude, of drawing pains and pares- 

 thesia in the head and in the extremities; in short, mild symptoms such as 

 almost every patient, whatever his disease, will admit if they are suggested to 

 him, such also as almost any healthy person will also acknowledge. Of impor- 

 tance in women is the invariable cessation of menstruation, and in some males 

 the appearance of impotence. 



The peculiar changes, as a rule, are first noticeable in the face. A distor- 

 tion of the features occurs which renders the patient unrecognizable to his 

 nearest relatives, and this in a few cases can also be objectively shown by 

 photographs taken prior to the disease if the pictures and the patient are 

 brought together for comparison. I must further take this opportunity to 

 warn physicians against photographs of acromegalic patients. I regret that 

 I must sow the seeds of doubt in what the laity believe to be the absolute art 

 of photography, but I am a photographer myself, and I know how the products 

 of this art are attained. Besides pathologic acromegalia, there is also (as I 

 must reveal) an artificial one, which in portraits by novices in photography 

 is almost epidemic. This always occurs when a picture is taken of the entire 

 sitting figure, full face, with arms and legs extended. This depends upon a 

 simple perspective effect due to the use of photographic objectives of short 

 focus, and to our habit of placing the object at a very short distance from 

 the camera as is necessary to obtain large pictures. The first cause of this 

 faulty perspective is the misplacement of the object, which is seen in almost all 

 pictures of acromegalics that are known .to me. In such pictures full face 

 reproduction, similar to that of the statues of Egyptian kings, has almost 

 become typical. How far the other effects of this faulty perspective extend 

 can only be determined by pictures in which the distortion, even of a single 

 extremity, is recognizable at once, as in a picture in my possession, in which 

 the extended great toes are almost as broad as all the rest of the foot. The 

 photographer has unconsciously intensified the impression of the abnormal- 



