240 ACROMEGALIA 



The question cannot now be determined with absolute certainty because 

 we must admit that it is not yet fully recognized that the hypophysis is dis- 

 eased in all cases of acromegalia. No less an authority than E. Virchow has 

 maintained from the beginning that the changes in the hypophysis are a sec- 

 ondary finding and were absent in some of his characteristic cases. A case 

 from Virehow's Institute has lately been published by 0. Israel, which appar- 

 ently proves this. These extraordinary differences in opinion can only be 

 reconciled by the fact that the differential diagnosis of the disease is by no 

 means so exact as might appear from the publications of P. Marie and Stem- 

 berg. It must be' borne in mind that any of the individual symptoms of the 

 disease, the peculiar osseous growth, the changes in the soft parts, the macro- 

 glossia, and even the tumor of the hypophysis may occur independently. 

 Hence in many cases a difference of opinion may arise as to what symptom- 

 complex justifies the diagnosis of acromegalia. Virchow lays great stress 

 upon the changes in the bones of the extremities, and undoubtedly has fur- 

 nished incontestable proof, which is confirmed by the case of 0. Israel, that 

 they also occur without a tumor of the hypophysis. This was also recognized 

 by Pierre Marie who diagnosticated a similar disease of the extremities as 

 hypertrophic osteoarthropathy. 



I believe, however, that if we adhere to the name acromegalia for the 

 classical, clinical and anatomical symptom-complex of P. Marie alone, we 

 must admit that the changes in the soft parts and in the bones of the face have 

 at least as much importance as those of the bones of the extremities. In the 

 case of Israel clinical observation together with the autopsy findings in the 

 bone reveal, as the celebrated author himself emphasized, that other impor- 

 tant symptoms of acromegalia besides the tumor of the hypophysis were absent. 

 It appears to me most important that there was no record of the acromegalic 

 maeroglossia and the corresponding deformity of the lower Jaw. We may, 

 therefore, safely deny that this case is acromegalia, and must agree with the 

 author that it is inadvisable to deduce from it any far-reaching conclusions 

 as to the nature of acromegalia. 



The fact is much more important that in literature quite a number of cases 

 are mentioned in which true adenomata of the hypophysis were found with- 

 out acromegalia. I still entertain the hope that by careful investigation with 

 the most approved methods we may find these tumors to deviate from the type 

 of those occurring in acromegalia. In a case recently examined by me, the 

 question arises whether the age of the patient, sixty years, might not explain 

 the absence of corresponding general symptoms. Opposed to the view that 

 the tumor of the hypophysis is a symptom and not the cause of acromegalia 

 is the fact that the common type of hypophysial tumors differs from the normal 

 structure of the gland (as was especially apparent in all of my four cases which 

 were minutely investigated) as well as from the other acromegalic hyper- 

 plasias, which in the main are composed of connective tissue. 



The opinion that disease of the hypophysis produces the symptoms of 

 acromegalia only by co-operation with the other blood-vessel glands is not in 

 accordance with the fact that no other blood-vessel gland is so constantly 

 involved in the disease as the pituitary body. Indeed this is not even approxi- 



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