PATHOLOGICAL ANATOMY 237 



tremities, as well as in the face, which have also been noted by previous inves- 

 tigators, and shall regard them as a feature more prominent than disease of 

 the bones. I have already mentioned how slightly in some eases the bones 

 take part in the enlargement. The principal mass of the so-called " bear's 

 paw " is formed by the soft parts, so that here the conviction is almost forced 

 upon us that the enlargement of the bones, the thickening as well as the 

 elongation, arises only secondarily as a support for the increased mass of 

 the soft parts, and that in the exostoses at the insertions of the ligaments and 

 muscles we may also recognize the reaction of the enormous increase in weight 

 which is to move the extremities. The hypertrophy of the soft parts, as we 

 may convince ourselves both macroscopically and microscopically, is due to 

 extremely tense connective tissue strands richly permeated with elastic fibers. 

 These first thicken from the cutis itself downward. Afterward, enlarge- 

 ment of the papillae and thickening of the epidermis become visible. The 

 connective tissue proliferation is most massive in the subcutis, next in the 

 deep fatty layers of the hands and feet. Each fat globule appears to be sur- 

 rounded by its own thick connective tissue capsule, and connective tissue 

 forces its way also between the fat-cells in thick layers, although we cannot 

 recognize any decided atrophy of the fat-cells. In one of my cases I found 

 the fat globules permeated in many places by a loose fibrous connective tissue 

 rich in mucin. Nevertheless, by their outlines and by isolated, well preserved 

 fat-cells, the distribution of the lobules is still easily recognizable, also their 

 sharp line of demarcation from the tense connective tissue of the surroundings. 

 This remarkable condition of the fatty tissue accounts for the fact that, in 

 fresh sections, it exudes like a compressed filling, and gives the impression, 

 described by several authors, that the skin is too scant for its contents. The 

 sweat-glands and nerve trunks of the cutis and of the subcutis have their own 

 special thickened layers of connective tissue, and we may note in the cutaneous 

 nerves, what Arnold first described, viz. : that connective tissue forms between 

 the individual fibers. The degeneration particularly described by P. Marie 

 and Marinescu, I could find in only one of the cases investigated by me, but 

 I do not doubt that it is frequently a natural consequence of the previously 

 described alterations. The same may also be said of the muscles, in which 

 also the hypertrophy of connective tissue is probably the primary factor and 

 degeneration the occasional consequence. Besides these diffuse changes, fibro- 

 mata moUusca, papillomata, and abnormal pigmentation are also observed. 

 The sebaceous glands and the hair remain quite normal, nor was I able to find 

 any decided abnormalities in the vessels. 



PATHOLOGICAL ANATOMY 



Of the pathological findings in internal organs I shall first briefly men- 

 tion a number of the less constant ones. The internal organs may be impli- 

 cated in the hypertrophy so that splanchnomegalia has been spoken of. We 

 cannot, however, determine in these findings in how far the observers were 

 dealing with simple gigantism, and how far it was a progressive enlargement 

 caused by acromegalia. This doubt applies to the large kidneys and livers 



