234 ACROMEGALIA 



fifty, years. It appears to me more rational to regard as malignant or acute 

 all cases which pursue an uncomplicated and progressive course leading to 

 death. In this type of disease the cases on record show that a duration of 

 about six years is the rule. It is best to regard as benign or chronic all cases 

 in which death is probably caused not by the acromegalia but by complications 

 which are not connected, or but slightly coimected with the main disease. 



PATHOLOGY 



A somewhat wider, but by no means complete knowledge of the nature of 

 this remarkable disease has been obtained by autopsies and microscopic investi- 

 gations, of which quite a number are already at hand. Beginning with the 

 skeleton, we shall first direct our attention to the bones of the hands and feet, 

 which form the nucleus of the astonishing anomalies of growth that appear 

 during life. It is unquestionable that the bones in many of the cases that 

 have been described showed great enlargement. A case lately reported by 

 0. Israel is a prominent example of this kind. I believe, however, that in 

 most cases a sensation of slight disappointment cannot be suppressed when 

 the skeleton of the hand or foot is compared with our recollection, or, better, 

 with a plaster cast of the fleshy member. Above all we are then convinced 

 that the most prominent disturbance of proportions in many cases has almost 

 disappeared, and only minute comparison with normal skeletons will enable 

 us to note the abnormalities. The flattening and irregularities of the end 

 phalanges, which at the ©nset attract attention, as Sternberg correctly states, 

 are but slightly different from the normal skeleton, but it appears to me that 

 in acromegalia, they are found somewhat more constantly than in normal 

 skeletons. In a foot in our collection the second phalanx of all the toes from 

 the second to the fifth is somewhat elongated. Otherwise, however, only the 

 insertions of the muscles and tendons are roughened, thickened and covered 

 with osseous proliferations. It is these which at first sight give the impres- 

 sion of gross deformity. Upon minute investigation we discover smaller exos- 

 toses, irregular porosities of the cortical layer, bony outgrowths upon the ends 

 of the joints and the like, but we must admit that even all of these collectively 

 cannot produce the picture of the "bear's paw," as we see it in life. The 

 same impression is conveyed on examining the long tubular bones of the ex- 

 tremities, as well as those of the trunk. Everywhere the important point is 

 the decided roughness of the insertion of muscles which have proliferated; 

 otherwise the bones show only moderate change in form. As an exception I 

 must mention the clavicle, which in most cases of acromegalia shows a decided 

 increase in bulk. But we must not permit ourselves to be led astray by occa- 

 sional investigations of individual bones. One femur in our collection shows 

 enormous thickness, but it belongs to Stadelmann's case, and must be correctly 

 looked upon as a combination of acromegalia with gigantism, and may be 

 entirely independent of the former disease. 



The vertebral column occasionally shows ankylosis of the vertebral bodies 

 by bony bridges, but the commonest lesions are the hyperostoses and exostoses 

 of the vertebral processes, which perhaps form the main substratum of the 



