Reprinted from the Journal of Nervous and Mental Disease, 1893. 
ACROMEGALY. 
• BY • 
JOSEPH COLLINS. M.D., 
New yofTI- ACROMEGALY, 
( 
By JOSEPH COLLINS, M.D., 
New York. 
The disease now known to the profession as acrome- 
galy is of comparatively recent date, it being scarcely six 
years since it was first accurately described as it showed 
itself in two of Charcot's patients, both females, at the 
Salpetriere. It is unnecessary to say that homage is due 
to P. Marie for first describing the disease with preci- 
sion; indeed, Verstraten has given to it the name of 
Marie's disease, and many writers following him have 
referred to it in the same way. However much we may 
deprecate the application of personal names to particular 
diseases, it would probably be advisable to continue des- 
ignating the symptom complex known as acromegaly, as 
Marie's disease, until we have learned something about 
its causation and pathology, and then give to it a name 
based on such acquired knowledge, particularly the lat- 
ter. The term acromegaly is especially unappropriate, 
its literal meaning being simply large extremities. In 
the disease to which the name is applied, however, the 
changes in the face are as of much importance and as 
frequent occurrence as in* the extremities. Therefore 
the clinical picture called up by the term acromegaly 
does not literally suggest the disease described by Marie. 
Mosier, in an extensive critical study of the disease, and 
particularly of the arguments put forth by Souza-Leite in 
his well-known monograph, argues that we should refer 
to the disease as pachyacria, a word which would in a 
way signify that the change was a thickening of all the 
structures of a part involved, and this not alone of the 
extremities. Recklinghausen was the first to put for- 
ward this term pachyacria, and Mosier concurs in its 
propriety. 
Like a great many other diseases that are seemingly 
of recent date, acromegaly has probably been noticed 
and described under other names for many decades past. 
A disease which was probably acromegaly was reported 
as seen in two cases by Fri'edreich, under the title of 
" hyperostosis of the entire skeletonanother by Fritsche 
and Klebs, under the title of " gigantismAnother by 2 
CRITICAL DIGEST. 
Lambroso as "general hypertrophy, macrosomia." Then 
no doubt some of the cases that have come to light under 
the heading of myxoedema have been of this nature, par- 
ticularly a case by Henrot reported under this title. Souza- 
Leite thinks that there can be no question but 'that a case 
by Saucerotte-Noel in 1772 was really a typical case of 
this disease. A critical search of the literature of the 
past century would be likely to yield other cases which 
were quite as characteristic as those reported by Marie. 
This does not in the least detract from the honor due 
Marie for calling the attention of the profession to this 
pathological entity in such a lucid and explicit way, that 
although a great number of cases have since been re- 
ported, no additional important symptoms have been 
produced. 
In Souza-Leit's brochure, which is a most complete 
exposition of the subject up to the date of its appear- 
ance, a complete record of all the published cases are to 
be found. More recently a translation of Souza-Leite's 
article under the auspices of the New Sydenham Society 
has appended to it the notes of nine cases, the reports of 
which had appeared in the journals between the time of 
the appearance of the brochure and its translation. This 
brought the sum total of cases up to forty-eight, which 
probably includes every case on record till near January, 
1891. The principal object of this present digest is to 
bring the bibliography of acromegaly up to date, and to 
note and discuss any advances that have been made in 
respect to the disease, either in its etiology or pathology. 
It is a deserved compliment to Marie to say, that so 
thorough and critical was his description of the disease 
as originally observed by him, that really nothing of 
importance has been added to the symptomatolgy of the 
disease since that time. Although the clinical picture 
presented by acromegaly • is very well known, it will 
probably be of no disadvantage if we take a glance at 
the history and development of the disease before we 
present the notes of the cases that have been recently 
published. 
As regards the etiology of the disease it may be said 
that it occurs somewhat more often in males than in 
females. Although we cannot speak definitely concern- 
ing its appearance in the different races, racial differ- 
ences probably offers no exemption. A case has recently 
been described in a negro (Berkley). Although it may 
appear at any age, the larger proportion of cases by far CRITICAL DIGEST. 
3 
first show themselves between puberty and early adoles- 
cence (19 to 26, Souza-Leite). It may show itself at a 
very early age (Rolletson's case), or it may first present 
itself long after middle age (Erb's, Waldo's, and Hare's 
cases). Congenital and hereditary influences are ex- 
cluded from etiological significance in this disease by 
Marie. He is particularly decided on the point that 
those cases that have been described under the heading 
of congenital acromegaly do not belong to the category 
of true acromegaly as he has described it. Recently, 
however, some cases have been reported that would 
tend to show that hereditary influences may have some 
place in its causation. 
Among the exciting causes mentioned are fright 
(Pel), mental depression (Pechardre), syphilis (Marie, 
Brigidi, et al}, exposure to cold (Marie, Verstraeten), 
traumatisms, either falls or direct injury (Minkowski), 
rheumatism or gout (Hadden, Ballance, Marie, Souza- 
Leite, Goodlee, et al}, alcoholism (Brigidi, Osborne), the 
exanthematous fevers, such as variola, scarlatina, malaria, 
and bronchitis, epistaxis, multiple abscess, severe and 
prolonged cardiac palpitation, abortion, have all been 
mentioned by one or more writers as having preceded 
the appearance of the symptoms of acromegaly, but 
their connection would not seem to be a very intimate 
one. In most of the cases published within the last two 
years there has been absolutely no apparent connection 
between an etiological influence and the appearance of 
the disease. In some few cases (Hare, Rolletson, Litt- 
hauer), the extremities had been large so long as the 
patient could remember. 
The theories that have been forwarded concerning 
the actual causation of the disease may be stated as 
follows: 
1. Marie's. That the disease is a systematic dys- 
trophy dependent in some obscure way upon the disease 
of an organ, the pituitary body, the functions of which 
are as yet unknown. It is only just to say that although 
a comparatively large number of autopsies have shown 
that there was a lesion in the hypophysis cerebri in 
many of the cases, Marie does not support this theory 
with any more vigor than formerly; that is, he is still 
inclined to believe that the pathogeny of the disease is 
yet to be demonstrated. A considerable number of cases 
yet under observation, of which may be mentioned 
Osborne's, Bignami's, Bard's, Hare's, present symptoms 4 
that are apparently dependent on and traceable to a 
lesion in the pituitary body. 
2. Klebs'. This pathologist, astonished by the exist- 
ence of the thymus in his case, and taking into considera- 
tion a symptom known as post-sternal dullness which had 
some importance attributed to it by Erb, formulated the 
theory that the thymus persisting was the seat of vas- 
cular budding and proliferation, angioblasts were pro- 
duced and these formed the foci of the change that went 
on in the affected parts of the body. 
There are serious objections to this theory, the prom- 
inent one being that in many cases it is found on post- 
mortem that the thymus has not persisted; indeed 
Klebs had a case sometime after formulating the above 
hypothesis in which there was no post-sternal dullness. 
Then again there are other conditions attended with 
persistence, or even hypertrophy of the thymus, and 
which are not associated with the development of acro- 
megaly. It must also be remembered that it was not 
possible to prove that the thymus was the middle point 
of the vascular budding. 
3. Virchow's. This pathologist thinks that in acro- 
megaly we have only half a disease described, i. e., the 
latter half, with its degenerative details, while at an 
earlier period it is often accompanied by an increase of 
muscular power, and is in some instances apparently 
hereditary. Freund's case lends considerable support to 
this view. 
4. The nervous theory. In spite of the fact that it is 
based on no positive knowledge, the theory that acro- 
megaly is a nervous disease has taken a very firm hold 
on the minds of those who have seen most of the disease. 
A favorite supposition of physiologists is that there 
is no organ in the body in post-uterine life but what has 
some physiological function to perform. This was the 
principal reason why Klebs' theory was not greeted with 
any enthusiasm; the thymus is a body which plays no 
part in post-uterine life. On the other hand, the pitu- 
itary body is always present, and the supposition is that 
it is a glandular body, particularly the pre-hypophysis. 
The histological structure of this part of the pituitary 
gland, being made up of convoluted tubules lined with 
epithelium and highly vascular as it is and its origin, 
favors this view. Ragowitsch reasoning from the results 
obtained by Marmesco by removing the hypophysis in 
some rabbits, is inclined to favor the view that these 
CRITICAL DIGEST. CRITICAL DIGEST. 
5 
glands secrete a substance the retention of which in 
the system, and particularly its action on the nervous 
system, facilitates the development of acromegaly. If 
this theory gain acceptance, as pure theory, it would be 
easy to follow out a process of reasoning such as is 
suggested by Marie and Marmesco in the " Archives de 
med. et d'anatom, path." for July, 1891, and say that the 
accumulation of this poison in the extremities and face 
from some special predilection brings about a condition 
which is the equivalent of the hyperaemia of inflamma- 
tion and which is followed by the hypertrophic changes 
so apparent in the disease. If this theory could be in 
any way proven, the disease would then take its place as 
one of the auto-toxaemic diseases. 
The symptoms of the disease present themselves 
very gradually and are preceded or not by perversions 
of the sexual functions (amenorrhcea in women, sexual 
weakness in man). The first thing noticed is a gradual 
enlargement of the fingers and hands, and simultane- 
ously, or a little later, the feet are involved. The 
enlargement affects the soft parts as well as the hard, 
and goes on to an enormous extent. The fingers 
become sausage shape; the hands, principally because of 
the great increase at the wrists, battledore shape. ' The 
arms are rarely affected. Except in some cases a widen- 
ing of the epiphysis at the elbows and atrophy of the 
muscles. The fingers appear short; the nails, though 
greatly increased in size, do not generally present 
any trophic trouble, and there is no deformity of the 
extremities. In the feet the large toe may become 
increased out of all proportion to the rest of the foot. 
The changes in the head are principally confined to the 
upper and lower jaw, particularly the latter, which gives 
the prognathous face. The thing that may first attract 
the patient's notice, however, is that each time that he 
purchases a new hat it must be a size larger (Osborne). 
The nose, lips, especially the lower, and the tongue are 
enormously enlarged. The alveolar processes are fre- 
quently widened and the teeth separated. The eyelids 
become elongated, the lashes coarse and unwieldly, and 
the color of the lids a mild brown. The shoulder girdle 
is enlarged principally from the participation of the 
clavicle in the hypertrophy. Occasionally there is an 
area of post-sternal dullness at the upper part (Erb). 
The trunk presents two curvatures, a more or less 
marked kyphosis in the cervico-dorsal region, and an 6 
CRITICAL DIGEST. 
anterior deformity due to involvement of the lower por- 
tion of the thoracic cage. The deformity has been aptly 
compared by Marie to the figure of Punch. There is 
frequently a slight degree of scoliosis, and always, if the 
course of the disease is sufficiently long, a compensating 
lordosis in the inferior dorsal and upper lumbar region. 
The pelvis is frequently involved, but only to a moderate 
extent. Ordinarily there is no disturbance of sensation. 
The hearing is frequently affected and the ears are 
greatly enlarged. There is often a considerable degree 
of exopthalmos, and occasionally unilateral hemianopsia 
and homonymous hemianopsia. The optic disc is occa- 
sionally very pale and the veins of the retina turgid. 
The larynx 'is frequently augmented in volume not alone 
in man, but in woman, and the voice becomes more grave, 
stronger, of longer duration, and especially disagreeable. 
The speech is slow, embarrassed, guttural, and seems to 
stick in the mouth. The face takes on the appearance 
of an elongated oval, and the sexual organs are fre- 
quently atrophied. The disease may be preceded in its 
appearance by any variety of hybrid symptoms, having 
more or less intimate relation to the disease. They are 
headache, malaise, mental apathy, varying pains, feel- 
ings of premonition, change in temperament, bodily 
weakness and loss of ambition, markedly increased appe- 
tite, great somnolence (Packard), perversion of morale, a 
dry skin, which has a tendency to crack, and polyuria. 
Many of these symptoms may attend during the course 
of the disease. 
The symptoms have been elaborately classified by 
Souza-Leite as follows: 
i. Objective. 
2. Subjective. 
3. General. 
Each of these two first groups may be subdivided 
into: 
(a) Constant, fundamental, or principal symptoms. 
(0 Inconstant, accessory, or secondary. 
This classification will be found very useful even 
though it be somewhat artificial; but it is not possible to 
here enter into a consideration of it. 
The following cases have appeared since the English 
translation of Souza-Leite's brochure, and will, with the 
list appended to the end of this paper, I hope, bring the 
bibliography of the disease up to date. It will be remem- 
bered that the number of cases in that translation was CRITICAL DIGEST. 
7 
brought up to forty-eight. The following cases will be 
numbered from that number onwards, without respect to 
priority of publication. 
Observation XLIX.-(Stembo.) Woman, aged forty, 
who first presented symptoms of the disease concomitantly 
with the appearance of the climatric at the age of thirty. 
She first noticed enlargement of the feet and hands so 
that her shoes and gloves would not fit. The enlargement 
was after noticed in the nose, the lower jaw, lower lip, 
and the tongue enormously; likewise the palate and a 
part of the larynx. The ears remained normal; voice 
deep and masculine; urine increased in quantity, no 
sugar or albumen, no disturbance of sensation. Right 
patellar reflex absent; left, weak; internal organs, nor- 
mal. No apparent causation for the development of the 
disease. 
Observation L.-(Litthauer.) Male ; good family and 
personal history; married; three children, two died in 
infancy. Disease first showed itself thirteen years before. 
The hands and feet began to enlarge, and went on increas- 
ing for two years and then stopped. In the beginning the 
hands did not give him any particular trouble, but now 
they often become " sleepy," and he cannot do his work. 
Formerly his sexual appetite was enormous and was 
gratified; now the sexual functions are normal. He 
denies syphilitic infection. Mucous membranes pale; 
no oedema; no eruption on the skin ; no sensory disturb- 
ances. Some kyphoses; ideation slow; speech altered; 
mental hebetude. Pupils normal. Perverted proportion 
between the size of face and head. Face has assumed an 
oval shape mainly from increase in size of the lower jaw. 
Nose, greatly enlarged ; the lower lip likewise and some- 
what cyanosed. Neck short and thick, circumference 
41 c.m. No post-sternal dullness. Heart and lungs 
normal. Urine and genital apparatus normal. Red and 
white blood corpuscles normal in proportion. Haemaglo- 
bin remarkably decreased, 40 per cent. Hands cold to 
the touch, battledore shape; fingers, sausage shape. 
Marked anaemia. Myopia of both eyes; field of vision 
limited ; retina normal. No disturbance in sensation or 
electrical reactions. . 
Observation LI.-(Pel.) A girl, previously healthy, 
of good family history, and with no acquired neuropathic 
predisposition, received just at the time of menstruation 
a severe psychical trauma. From this time she dates all 
the symptoms of the present trouble. First she had gen- 8 
CRITICAL DIGEST. 
eral nervous symptoms, such as head and body ache, 
paraethesia, psychical depression, apathy, etc. Soon after 
this the hands, feet, and face began to enlarge. In due 
time a complete picture of acromegaly was developed. 
She has had amenorrhoea since the time of the fright, 
although the genital apparatus seems normal. No post- 
sternal dullness or other evidence of persistent thymus. 
Thyroid apparently smaller. Author gives it as his 
opinion that the trouble is neurotic. 
Observation LIL (Bignani.) Female, forty-nine years 
old. Symptoms began when twenty-five years old, and 
came on after an abortion which was accompanied by a 
great loss of blood. Since that time she has not menstru- 
ated. There are no hereditary or etiological factors with 
the exception of the abortion. At the beginning of the 
disease there were vague pains, paraesthesia, pains in the 
bones and joints, headache, and then the remarkable 
increase in size, which was participated in by the lower 
jaw, the skull, scapulae, clavicles, larynx, and extremities. 
Muscular power began gradually to decrease ; moderate 
degree of exopthalmos on both sides; opthalmoscope 
showed simple atrophy of the papillae, right external 
strabismus, nystagmus, limitation of the movability of 
the eyeballs in all directions; appetite enormously in- 
creased ; general muscular weakness without apparent 
muscular atrophy ; skin thickened in places, and, with the 
exception of slight sensorial disturbances in the hands, 
sensibility was intact; weakness of the patellar reflexes ; 
cardia hypertrophy ; sensation of taste rather slow in its 
response. The disease made far greater progress in the 
first part of its course than the last. 
Observation LIII. (Graham.) Male, aged thirty-nine ; 
presented the following marked features: Enlargement of 
the face; thickness of the lips, especially the lower one; 
face elliptical in shape ; hypertrophy of superior and in- 
ferior maxillae; atrophy of the optic nerves; enlarge- 
ment and flatness of the hands, feet likewise enlarged ; 
arms and legs normal in size. The disease had lasted 
for upward of five years. 
Observation LIV.-(Graham.) Male, died aged fifty- 
one. The disease commenced when he was about twenty- 
five years of age. He presented the following conditions : 
Enlargement of the head and face ; prominent eyebrows ; 
nose enlarged ; hypertrophied superior and inferior maxil- 
lm ; lips thickened, especially the lower one ; face elliptical 
in shape and enlarged in every way, resting upon the upper CRITICAL DIGEST. 
9 
and anterior portion of the chest; neck short and thick ; 
marked kyphosis of the spine in the, upper dorsal and 
lower cervical vertebrae sternum very prominent; en- 
largement of the scapulae, scoliosis, lumbar lordosis. 
Hands were enormously enlarged, as were also the feet. 
No marked change in the arms or legs with the excep- 
tion of the knees which were increased in size. No post- 
mortem examination was made. 
In both these cases the soft parts and bones were en- 
larged ; the vitality diminished ; the mental faculties im- 
paired ; the voice was altered in both, and there was 
sexual weakness, but children were begat in both cases 
after the disease had shown itself. 
Observation LV.-(Paget.) Male, aged forty-two; dis- 
ease had been progressing for ten years. There was 
extreme lengthening of the face, with overgrowth of the 
facial bones, particularly of the inferior maxillary. The 
hands and feet were enormously and characteristically 
enlarged. The patient had lost six inches in height 
from the advancing deformity of the spine. Thyroid 
apparently enlarged, vision defective, molluscous growths 
on the trunk, and osteophytes in the knee-joint. Voice 
thick and guttural. Loss of muscular strength. 
Observation LVL- (Bury.) The author presented to 
the London Pathological Society the brain and thyroid of 
the patient who was the subject of the following sketch: 
Female, twenty-three years of age, who had been troubled 
with loss of strength and headache for upward of three 
years. Eighteen months before death her sight began 
to fail. She presented great prominence of the orbital 
arches, low retreating forehead, enlargement of the nose, 
lips, tongue and body of lower jaw. Voice low-pitched 
and monotonous, speech low-pitched and deliberate. 
Right lobe of thyroid gland unduly prominent. Hands, 
feet and digits enlarged, increased principally in their 
breath and thickness. Kyphosis and slight scoliosis of 
the upper dorsal and lower lumbar vertebra. Abdomen 
enlarged and its walls thickened; limb muscles soft and 
flabby, but no paralysis. Reflexes normal. Taste, smell 
and hearing unaffected. Left eye nearly blind ; temporal 
hemianopsia of the right eye. Sugar in the urine, and 
death from coma. 
On autopsy, there was found a pulpy tumor at the 
base of the brain, excavating the sella turcica and ex- 
tending from the optic chiasma, which, with the optic 
tracts, were compressed to the cerebellum. Microscopic- 10 
CRITICAL DIGEST. 
ally, the tumor was apparently a glioma. Each lobe of 
the thyroid was found enlarged and contained a cyst. 
Pendant masses were found attached to the pericardium, 
similar to a persistent thymus. Heart and liver normal. 
Uterus small, infantile. Small cysts in ovaries. With 
the exception of severe headache, starting in the left 
temple, there had been no sensory disturbances in this 
case. 
Observation LVII.-(Boltz.) Male, forty-one years 
of age, of good family history, has one boy seven years 
of age who has always been in good health. While the 
patient was at school he was troubled a great deal with 
attacks of cardiac palpitation, and latbr had an attack of 
pneumonia. In later years dyspepsia and hemorrhoids 
have been troublesome. He cannot exactly state when 
the present illness began. The first thing that he noticed 
was bodily weakness and then trouble in reading, and 
shortly after the defect of vision prevented him from 
working. He presented the ordinary typical face and 
countenance of acromegaly. Teeth good and held firmly 
in their sockets. Tongue enormous, the filliform papillae 
greatly enlarged, giving rise to the so-called hairy 
tongue. Hair strong and coarse, beard scanty. Clavicles 
elongated, principally from growth at the acromial ends; 
muscles of shoulder girdle atrophied. Moderate kyphosis 
of the cervical vertebra. Tonsils normal; epiglottis en- 
larged and thickened; thyroid somewhat smaller, prob- 
ably atrophic on the right side. Hands and finger present 
the characteristic enlargement. Patella and both epi- 
physes of the tibia enlarged. Feet enormously enlarged. 
Visceral organs normal, no post-sternal dullness; urine 
normal; muscular strength lessened; sensation and re- 
flexes normal; intelligence not disturbed, but answers 
very slowly. Voice deep, and sounds if it were hindered 
in the throat. Sexual desire and ability has been absent 
for seven yfears, although the genital organs appear to 
be normal. Taste, smell, and hearing normal. Denies ve- 
nereal infection. Bitemporal hemianopsia; rotatory nys- 
tagmus when he fixes sharply. To explain the bitemporal 
hemianopsia, we must have a lesion of the inner crossed 
fibres of the optic nerve in the chiasm, and an intact 
condition of the outer uncrossed. The writer, therefore, 
believes that this case is probably due to an increasing 
or proliferating tumor of the hypophysis cerebri which 
has caused an atrophy of the inner crossed fibres of 
chiasma, the outer uncrossed fibres remaining as yet CRITICAL DIGEST. 
11 
undisturbed. It might be stated in connection with this 
case that Schultze's case somewhat resembling this gave 
a left-sided hemianopsia. 
Observation LVIII.-(Bradford.) The patient was a 
woman forty-three years of age, who had noticed enlarge- 
ment of the hands and feet for the past ten years, and 
which came on without any apparent cause. Four years 
later she developed a kyphosis of the cervico-dorsal ver- 
tebra. The skin of the hands and feet was greatly 
thickened, both clavicles lengthed and enlarged at the 
acromial ends, and the thoracic cage enlarged mainly 
from increase in size of the ribs. The under lip was 
markedly enlarged, and face showed the type of acro- 
megaly. Reflexes normal, great muscular weakness, and 
mentally very dull. 
Observation LIX.-(Berkley.) A sixty-year-old negro 
woman, who presented herself for treatment on account 
of mental disturbance. No neuropathic inheritancy. The 
excessive growth first began to be noticeable in 1889 and 
from October, 1890, to March, 1891, the period in which 
she was under the care of the reporter, no particular 
change had taken place except some trophic disturbances 
in the arms and hands. The internal organs apparently 
normal and the sensory and special sense organs are not 
appreciably affected. Patient troubled greatly with ex- 
cessive perspiration which is exceedingly offensive. Patel- 
lar reflex good ; absence of Romberg's symptom. Patient 
has a very wicked temper and is very weak mentally. 
Head, nose, lips and tongue, but not the ears, appear 
enormously enlarged. Hands present the characteristic 
enlargement; arms and forearms unaffected. In the 
lower extremities the patellae and feet seem to be the 
only parts hypertrophied. Very little information could 
be obtained regarding sensation, as the patient was prac- 
tically devoid of sense. The trophic disturbance of the 
forearms were of the nature of ulcers. 
Observation LX.-(Hare.) Female, aged twenty-five, 
of good family history. Three years ago menstruation 
was irregular for a time and afterward absent for periods 
varying from three to six months. Then vision began 
to fail, first in the outer half of left eye and gradually 
proceeded across the eye till the vision was entirely lost; 
latterly the vision in right has markedly failed. She 
presented slight distention of the abdomen, general 
increase in size of all the members, posterior curvature 
of the vertebra, extending from the twelfth dorsal to the 12 
CRITICAL DIGEST. 
seventh cervical vertebra. On the anterior surface of 
the thorax at the third interspace, half way between the 
nipple and the sternum, there is a considerable bulging 
due to increase in the length of the third and fourth ribs; 
no exostosis. On the left side the floating ribs are pro- 
truding. Nose enlarged and face massive. Considerable 
increase of the bony and connective tissue of the entire 
body. She gives the appearance of a large woman un- 
equally developed. In three years she has gained sixty- 
five pounds. Distinct enlargement of the thyroid gland, 
but no associative circulatory disturbance. Suffers from 
a severe neuralgic pain in the right temporal and supra- 
orbital region, and occasionally sharp pains in the ex- 
tremities. Variable pre-tibial oedema. Appetite good, 
urine rather scanty; loss of hearing on the right side, 
and chronic otitis media purulenta of right side. While 
under observation the patient had a haemoptysis lasting 
for about a week, and this was followed by an epistaxis. 
Electrical examination shows a normal qualitative re- 
sponse in all parts tested, but somewhat altered quanti- 
tative reaction chiefly in the direction of a delay, espe- 
cially in the thighs. Examination of blood showed 
4,700,000 red corpuscles to the cubic millimetre and 11,000 
leucocytes. Haemaglobin percentage normal. Red cor- 
puscles crenated and irregular in shape, many of them 
seeming to be poorly developed. Vision, R. L. O. 
Total atrophy of optic nerve of left side. Optic nerve of 
right eye is pale with shallow cupping, but not including 
entire disc. R. pupil normal in reaction. Left does not 
act alone, but only in harmony with right. Slight central 
color scotoma, most marked for green. 
Observation LXI.-(Cohen.) Male, American, twenty- 
eight years of age, 6 feet 2^ inches in height, weighing 
238 pounds. At the age of sixteen he thinks he was as 
tall as he is now and weighed 180 pounds. He has 
never been troubled with spontaneous or intense head- 
ache, although headache may be brought on by study, 
occasionally he has confusion of ideas; until four years 
ago worked as a blacksmith and wielded a thirty-pound 
hammer. Appetite increased; great drowsiness; urine 
normal. Thickness and dumpiness of fingers character- 
istic ; hands spade-like ; skin thick and tough ; nails broad 
and short, but not striated. Has comparatively little 
strength. Feet flat, enlarged, broad and clumsy. In 
two years' time the size of his hat-band has increased 
from 6^ to 7^ ipches. Cervico-dorsal kyphosis with tqn- CRITICAL DIGEST. 
13 
ency to forward thrust of the head; paunching of the 
abdomen. Varicose veins of the legs very prominent. 
Superciliary ridges prominent, frontal sinuses much en- 
larged. Malar bones enlarged and projecting laterally. 
Face presents typical lengthened ellipse of acromegaly. 
Ears enlarged and stand out at right angles from the 
head. Lips greatly thickened, lower lip overhanging 
nearly to the chin ; tongue broad, thick, and furrowed. 
Chin much enlarged vertically, scapulae enormous; sternal 
ends of clavicles stand out prominently like knobs. Ster- 
num unusally long and xiphoid process apparently 
ossified. Thyroid cartilage enlarged. Thyroid gland not 
demonstrable. Some post-sternal dullness. Olecranon 
process apparently small and fossa of same name appar- 
ently much deepened, so that hyperextension of arm can 
be easily produced. Opthalmoscopic examination nega- 
tive. 
Observation LXH.- (Harris.) Female, fifty-three 
years of age, of good family history; her own children 
healthy and intelligent. Until twenty years of age she 
was in perfect health, when she suffered from an intoler- 
able neuralgia, which sometimes attacked the face and 
head and sometimes the extremities. As the time went 
on the interval between the attacks became less, until 
the pain was continuous. She suffered in this way for 
thirteen years. The pains then began to disappear, and 
simultaneously with the improvement she noticed changes 
in the face and extremities. This change was a slow in- 
crease in size of bones and cartilage of the bones of the 
face, neck, hands, and feet, and increase and thickening 
of the skin over these parts. Her mind gradually became 
enfeebled, and she was generally dull, apathetic, and 
easily fatigued, and passed the greater part of her time 
in bed. For six or eight years, it was said, she had a 
" goitre " on the right side of the neck, and for about the 
same length of time she had been unable to see objects 
on her left side. Chloroform-like odor from the patient; 
no post-sternal dullness ; voice coarse ; speech slow, thick, 
and often hesitating. Prominent frontal eminences ; nose 
drawn strongly to right and enormously increased ; mouth 
large; lips thickened; skin dirty yellowish color, and 
seemed slightly thickened; no obvious enlargement of 
malar or superior maxillary bones; great length and 
hypertrophy of inferior maxillary bone, and alveoli pro- 
ject far in front of inferior maxilla ; tongue filled entire 
cavity of mouth ; teeth lost; thyroid on right side en- 14 
CRITICAL DIGEST. 
larged, on left side could not be felt; hands and feet 
characteristic enlargement; menstruation normal; ante- 
rior curvature of spine in upper dorsal region. Measure- 
ments made after death given in detail. 
Observation LXIII.-(Holsti.) Male, who, although 
his parents were healthy, inherited a distinct psychical 
taint, and one of his brothers had some mental trouble. 
As a child he was sickly and weak, and, among other 
things, had an attack of chorea. When fifteen years old 
he began to grow very rapidly, and somewhat later had 
an attack of transient oedema of the fingers. When 
thirty-nine years of age he suffered an attack of typhoid 
fever, after which he never completely recovered his 
former health. Had acute pains in arms and legs very 
frequently. A year later he noticed that his hands and 
feet were growing larger, the lower jaw and chin more 
prominent, and his hat too small. Five years later, 
shortness of breath, great muscular weakness, atrophy of 
the muscles, especially the glutei, and could walk only 
with a stick; kyphosis of upper part of spine and chin 
brought forward toward sternum ; face the shape of elon- 
gated oval, eyelids oedematous, skin light yellow color, 
insomnia, mind clear, hearing normal, rumbling and 
swashing sounds in ears, hyperidrosis, absence of pain; 
thyroid not to be felt, acromial ends of clavicles enlarged, 
cardiac hypertrophy, mitral insufficiency and obstruction. 
Excepting the atrophy of the thenar and hypothenar 
muscles, the hands and fingers are characteristic of acro- 
megaly ; legs below knee large, and feet enormously 
enlarged. Died of erysipelas after frost-bite. 
Autopsy.- Cranium greatly thickened; brain large, 
1,870 grms., with pons, cerebellum, and medulla, which 
weighed 240 grms.; cranial nerves appear very broad; 
hypophysis cerebri greatly enlarged, measuring antero- 
posteriorly 25 mm., side to side 30 mm., pulpy consist- 
ency. In place formerly occupied by thymus, a large, 
united, gray red mass, looked like whitish fat with in- 
numerable small round bodies in it; thyroid enlarged, 
consistency hard ; heart, liver, and spleen diseased ; peri- 
osteum thickened, more adherent, especially at epiphysis ; 
around the joints especially, surface of bone showed ele- 
vations and depressions; marked difference between 
epiphyses and diaphyses, former broadened and thick- 
ened, the latter appear narrow; microscopically, con- 
densing osteitis at periphery and marked rarefying ostei- 
tis in cancelous structure ; Haversian canals and lacunae CRITICAL DIGEST. 
15 
very markedly enlarged; hyperplasia of the interstitial 
tissue of thyroid and general degeneration of the paren- 
chymatous portion; the body occupying location of 
thymus showed fat ground substance, uncommonly rich 
development of blood-vessels, and some normal thymus 
tissue. 
Observation LXIV.-(Dulles.) Male, Syrian, twenty- 
seven years old, of good family and personal history. 
Falsely charged with misdemeanor while visiting his 
native country and placed in prison. After liberation he 
was under great distrust and mental anxiety until he left 
the country. While in prison, hands and feet began to 
enlarge; had profuse sweats, great drowsiness after meals, 
increased appetite ; has broad leonine countenance, wide 
malar eminences, large mouth, broad lower jaw, large 
chin, thick lips, lateral projections of rami of jaws. 
Hands and feet have characteristic enlargement. The 
feet have a large fleshy pad along outside and under os 
calcis. Internal organs and urine normal. Eyes com- 
pound myopic astigmatism, absence of hemiopic pupillary 
reaction; typical left lateral hemianopsia with great con- 
traction of preserved field of vision. No improvement 
while under treatment. 
Observation LXV.-(Fratrich.) Male patient, thirty- 
nine years of age. His father had epilepsy at sixty, and 
an uncle was likewise psychopathic. The father was 
short in stature and had large hands, like the patient. 
One brother died of meningitis and one of intestinal 
trouble. Patient had attack of some sickness when he 
was six years old, in which he was unconscious for three 
weeks. Until eighteen years old he was quite healthy, 
when the symptoms that still persist first showed them- 
selves. He first had severe neuralgia in the forehead 
and pain and formication in hands and feet; great hunger, 
but no thirst; marked enlargement of fingers, toes, clav- 
icles, and lower jaw ; no enlargement of thyroid gland ; 
lately general weakness and pains, beginning at the hips 
and going down to the tibia; right side of face more 
developed than left; eye normal, teeth intact, hearing 
normal, ears enlarged ; speech slow and dragging ; larynx 
increased and vocal cords thickened; muscles of upper 
extremity atrophic ; condyles of radius and ulna greatly 
developed; hands and feet markedly enlarged; pelvis 
and genitals normal; sexual ability diminished; heart 
hypertrophied. Measurements given in detail. 
Observation LXVI.-(Redmond.) Female, aged nine- 16 
CRITICAL DIGEST. 
teen ; admitted complaining of great weakness and swell- 
ing of hands and feet, and in wrists, knees, and ankles 
when she moves, and pain at night in back, right shoulder 
and right side. Had pneumonia three years previously, 
and after this remained weak, languid, constipated, and 
had irregular scanty menstruation. Present illness began 
seven months before entrance to hospital, with swelling 
of hands and feet, somewhat sore to the touch. She went 
to bed, and swelling disappeared, but hands remained 
enlarged. Later the kiiees became swollen, stiff, and 
painful. The present enlargement of the hands reached 
its extent in a few weeks. She is anaemic; fingers greatly 
enlarged, ends bulbous, nails slightly convex; marked 
increase in carpal ends of radius and ulna; back of hands 
considerably swollen, does not pit on pressure; knees 
greatly enlarged; considerable effusion into the joints; 
some enlargement of the heads of the tibia and fibula; 
patella freely movable ; legs uniformly enlarged ; ankles 
widened ; effusion in ankle joints; feet wider than normal; 
toes thickened and bulbous, and some oedema on the back 
of foot; thyroid gland not to be felt; urine normal; 
nausea; headache ; elevation of temperature ; diarrhoea ; 
melaena; inanition, etc. 
[I can see no reason for calling this case one of acro- 
megaly from the description given by the author in the 
original article, and it is put under this title under pro- 
test.-J. C.] 
Observation LXVII. (Packard.) Male, aged forty-five ; 
of good family and personal history. Has always had large 
hands and feet, and at fifteen had reached his mature 
growth. When thirty-seven years old he had pains all 
through his body, supposed to be rheumatic attack, which 
was followed by a very exhaustive diarrhoea. On account 
of the weakness and occasional vague pains, he has been 
unable to work since that time. He has had three attacks 
of somnolence, the first lasting for three weeks, the other 
two lasting for a long time. His brain power had failed 
for several years, and he is apathetic and irritable ; speech 
slow and deliberate, and slowness of mental response. 
Later on unconsciousness would appear, and remain for 
days at a time ; before and after these attacks the somno- 
lence would be very intense. Examination of the eyes 
at this time showed partial optic atrophy on both sides, 
with hemianopsia, both temporal fields being lost. When 
seen, seven years afterward, he gave a history of having 
suffered from severe generalized headache, with appar- CRITICAL DIGEST. 
17 
ently causeless exacerbations. The spells of somnolence 
have disappeared; sweats a great deal, especially in warm 
weather ; hearing, taste, and smell are all normal; sexual 
desire and power absent, as it has been for fifteen years; 
face large and heavy, and gives evidence that it has in- 
creased in size since seven years before, when he was first 
under observation ; the thyroid cannot be felt; no post- 
sternal dullness ; scapulae prominent; forward curvature 
of upper portion of spinal column ; some lumbar lardosis 
and prominence of abdomen and lower portion of thorax ; 
hands and feet markedly enlarged, but no deformity, and 
temperature; pain and tactile sense preserved; skin of 
hands soft and pliable and entirely hairless; the great 
toes are especially enlarged ; urine albuminous. In past 
few years his visual field has enlarged considerably, 
though he still has bitemporal hemianopsia. 
Observation LXVIII.-(Osborne.) Male, forty-two 
years old, German; has lived here for eleven years. 
Mother died of ascending paralysis; otherwise family 
history is good. Although the patient's wife is healthy, 
their offspring have all died of tuberculosis or croup. 
Patient suffered from severe attacks of epistaxis for sev- 
eral years when a young man ; then for a period of four- 
teen years, although his health was not seriously impaired, 
he noticed continuous gradual enlargement of hands, feet, 
face, and body, occasional headache (often severe), ver- 
tigo, pains in bones and joints, ravenous appetite and 
dyspepsia, tinnitus aurium, which, with the headache, 
has increased to almost unbearable severity. He has had 
suicidal and homicidal tendencies, and always at night. 
He has attacks of sharp pain and a peculiar pressure 
feeling in the top of the head just over the region of the 
anterior fontanelle, which is painful on pressure, and a 
feeling of " rolling shot " starting from the top of his 
head and coursing down through his body to the feet. 
The headache for the past four years has ceased to be 
continuous, but the tinnitus aurium has continued to 
grow worse, as has the vertigo. With the exception of 
fullness of the retinal vessels, the eyes are normal. The 
right ear is larger than the left; the canals are increased 
in size; the drum is very concave, and the hammer is 
markedly drawn up. The right side of the whole body 
is more enlarged than the left. The abnormal bone and 
tissue growth began when the patient was about twenty 
years old. The hands and feet are now characteristic as 
described by Marie. The cranium does not seem much 18 
CRITICAL DIGEST. 
altered, but the face is elongated, brow low, supra-orbital 
ridges very prominent, and some exophthalmos; nose 
very much enlarged and flattened ; lower jaw projecting; 
lower lip and tongue markedly hypertrophied ; scoliosis 
and kyphosis of upper dorsal region ; thyroid apparently 
normal; larynx enlarged ; voice deep, heavy, and loud ; 
slow mentation and forgetfulness ; sensation of heat and 
cold normal; right patella reflex absent, left very much 
diminished; knee-joints enlarged, and the seat of great 
joint pain, the finger-joints suffering also frequently; no 
post-sternal dullness. Since this case was reported, the 
upper part of the left external ear has become as hard as 
bone, and the right ear shows a beginning change in 
the same direction. The prognathism has markedly 
increased, and there has been considerable development 
of molluscum growths. 
Observation LXIX.-(Denti.) Male, aged thirty-two; 
free from hereditary or acquired taint. The disease first 
made its appearance at the age of twenty-three, during 
convalescence from a grave attack of typhoid fever. He 
first noticed progressive enlargement of the hands and 
feet, and of the cephalic extremity, especially the face, 
with an increase in the height of the patient. No func- 
tional disturbance. This condition persisted for seven 
years, during which time the patient, a cavalry officer, 
was distinguished for his extraordinary robustness, 
uncommon muscular strength, voracious appetite, and 
excesses in smoking and drinking. At the end of this 
period the lower jaw began to increase enormously in 
size, likewise the hands and feet enlarged greatly, and 
shortly afterward the clinical picture changed. There 
was a breaking down of health, emaciation, loss of color, 
paleness of the mucous membranes, earthy pallor, great 
anorexia, grave and continuous lethargy, somnolency, 
profuse perspiration, dimness of vision first in the right 
eye and then in the left, then temporal hemianopsia first 
of the right and then of the left, and after a short period 
complete bitemporal hemianopsia. 
The opthalmoscope showed a congestion as of neuro- 
retinitis, which was followed by a bleaching of the papil- 
lary disc on the right side and then on the left. The 
atrophy had a neuritic character. 
At this period a sort of remission in the course of the 
disease appeared, though the disease was not arrested. 
The appetite improved as did the nutrition and muscular 
strength, and the lethargy and profuse perspiration were CRITICAL DIGEST. 
19 
not so troublesome. Treatment: arseniate of iron, hypo- 
dermatic injections of strychinia, and the application of 
the galvanic current to the eye by means of the electric 
water bath. 
Observation LXX.-(Sarbo.) Fireman, aged forty- 
three. On account of mental condition of patient no 
history could be obtained. Evidences of syphilis were 
present. Hands and feet were enormously enlarged, as 
were also the ears. Malar bones thickened, face ap- 
peared broad. The fingers were characteristic in their 
shape and some oedema was found in the calf of the left 
leg. Patient died after having been for a short time in 
the hospital. Autopsy showed marked thickening of 
the skull, especially in the frontal region ; evidences in 
the brain of peri-encephalitis chronica, hypophysis cerebri 
normal, heart enlarged as was likewise the spleen, scar 
on glans penis, evidences of phthisical processes in the 
lungs. The result of the examination of the bones 
showed that the clavicle, the occipital bone, and the 
bones of the hands and feet were greatly hypertrophied 
and that the enlargement was not alone in the bones, but 
in the soft parts as well. 
It is to be remarked that the kyphosis so commonly 
attending this disease was absent in this case. Thyroid 
gland apparently normal. Ends of the bones showed a 
condensing osteitis. (A table of measurement appended 
to the original.) 
Observation LXXI.-(Gonzalez Cepeda.) Male, aged 
forty-eight; office-clerk ; sanguine temperament; robust 
constitution. Had suffered for a long time from intense 
cephalalgia, which was increased in intensity by the re- 
cumbent posture. This, with weakness, had for a long 
time incapacitated him for work. On examination the 
cranium did not seem to be noticeably enlarged, the 
sutures were somewhat prominent. The lengthening of 
the face and the enormous orbital eminences were quite 
characteristic. The cheek bones were projecting, the 
superciliary ridges enlarged, and the pre-orbital circle 
was very prominent. The eyelids were stretched and 
drawn, puffed and of a dark color, the nares enlarged, 
the alae swollen, and the walls of the nose greatly in- 
creased in thickness. Lips thick and fleshy, especially 
the lower. Lower jaw very prominent, conspicuous 
prognathism, jaws separated, tongue massively enlarged, 
so that it could be hardly contained in the cavity of the 
mouth. Head constantly inclined forward. Hands a CRITICAL DIGEST. 
third broader and thicker than normal. Feet greatly 
enlarged. Judging from the history of the patient 
there was in the beginning some polyuria, and a great 
dimunition of the venereal appetite, which last still per- 
sisted. Urine contained a slight and somewhat vari- 
able amount of sugar. Patient died in syncope. The 
autopsy showed a hypertrophic condition of the pituitary 
gland without any evidences of inflammation or degener- 
ation. The increase in the size of bones was most charac- 
teristic in those of the hands and the feet; that is to say, 
osseous hypertrophy presented itself in the bones of the 
extremities and in the extremities of the bones. 
Observation LXXII.- (Massalonggo.) Male, aged 
fifty-one; nothing hereditary in his history, and he likewise 
denied specific. Had always been healthy and robust, and 
supported without fatigue the hardships of a military life 
during the time of war. Without any apparent cause the 
symptoms of the disease began to manifest themselves 
in his twenty-seventh year. The symptoms then were 
severe pains in the left side and later in the right half of 
the head; he had also less frequent but more severe pain 
in the lumbar region and along the side of the left leg. 
After each attack of cephalalgia the patient would be worn 
out and incapable of enduring any fatigue. Two years 
later the patient noticed his neck becoming increased in 
size, and the size of his hats had to be constantly increased. 
At this period virile, power became completely lost. It 
is important to mention that when the patient was about 
twenty-two years of age he had an attack of sickness 
attended with loss of consciousness and delirium which 
lasted for forty days, and which was called by the physi- 
cians cerebral fever. With the progress of the disease 
there was no cessation in the cephalalgia, lumbar pains, 
etc., the general debility became more marked, and the 
hands, feet, and head progressively enlarged. The face 
assumed a new outline, that of an elongated oval. Pres- 
ently there appeared an extraordinary weakness of the 
legs, which necessitated his occupying continually a 
recumbent posture. Patient complained of a sense of 
oppression, constriction in the throat, and tachycardia. 
Great prominence of the superciliary ridges, frontal 
sinuses, the zygoma, nose, mouth, tongue, and lips. 
Lower jaw remarkably enlarged, and teeth of the lower 
jaw separated from each other for about a half centi- 
metre. Examination of the head shows coarse gray hair, 
spiky osseous protuberances along the sutures, especially CRITICAL DIGEST. 
21 
the lambdoid. Thyroid is hypertrophied more in the left 
lobe than in the right. Cervico-dorsal kyphosis. Clavi- 
ele enlarged, sternum lengthened, thorax protuberant, 
sides depressed, heart hypertrophied, abdomen bulky 
and pendant, skin pigmented in portions, and various 
localities are found mollusci penduli. Sensibility normal, 
reflexes weak, slight paleness in fundus of the right eye, 
field of vision normal, timbre of voice normal. 
Observation LXXIH.-(Barclay and Simmers.) Male, 
aged forty; Scotch, and by occupation a farmer; family 
history excellent. The disease began when he was 
twenty-five years of age. He ascribes it to a fall from a 
horse, and shows a depression in the skull, at the upper 
border of the occipital bone, about two inches in diameter, 
the result of this injury. At first there was violent and 
frequent attacks of epistaxis, and for a period of four or 
five years he suffered greatly from headache, which be- 
came after that period gradually less and infrequent. 
Joint pains were occasionally troublesome. Patient stands 
six feet two inches in height, and weighs twenty stones. 
Has great strength for a single effort, but becomes easily 
fatigued and is readily prostrated. Hands enormously 
enlarged, both the bones and the soft parts participating 
equally, the increase in size is chiefly lateral. Nails longi- 
tudinally striated with incurved edges; they are twice as 
broad as they are long. Great hypothenar masses of flesh. 
Wrists enlarged and bones of arm and forearm some- 
what hypertrophied. Feet and legs exactly analogous to 
that of hands and forearm, only the hypertrophy is not so 
great. The tendo-Achillis is enlarged and rope-like and 
attached to an enormous os calcis. Nose, supra-orbital 
ridges, lips, and tongue greatly enlarged. Face mark- 
edly prognathus. Zygoma and malar bones prominent; 
antrum of Highmore apparently enlarged. Cranial bones 
not greatly affected. Scalp thickened and easily mov- 
able. Beard scant, hair thick, coarse and abundant. 
Cervico-dorsal kyphosis and compensatory dorso-lumbar 
lordosis ; no scoliosis. Sternum greatly hypertrophied ; 
circumference of chest at nipple 49 inches. All the 
joints are somewhat enlarged and give a kind of crack- 
ling noise. Thyroid cannot be felt; no retro-sternal 
dullness; sexual appetite in abeyance; skin pigmented 
in parts ; knee-jerks lessened; appetite enormous; great 
thirst, and urine is excessive, but otherwise apparently 
normal. There is continuous tinnitus aurium, but no 
headache. He has had two or three epileptiform syn- 
copal attacks. Hearing and sight fairly good. 22 
CRITICAL DIGEST. 
Observation LXXIV.-(Brown.) Male, aged forty- 
two ; clergyman. Father died of anaemia at an advanced 
age ; an uncle died of phthisis; mother epileptic. Pa- 
tient had an attack of rheumatism at nine years of age, 
which left a mitral diastolic murmur. Has had right 
frontal headache for the past ten years, made worse by 
mental exercise, and for the past six months has suffered 
from palpitation; profuse acid sweats, thirst and weak- 
ness. Hands and feet were noticed to be very large 
while he was still young, but they have greatly increased 
•in size during the past few years, until now they are 
quite characteristic in shape. Pulse no to 130. The 
face shows the typical shape of Marie. Left side is some- 
what larger than the right. Thorax enlarged and a con- 
siderable number of molluscum fibrosum over neck, chest 
and arms. Appetite increased, urine normal. Pharyn- 
geal linings lie in folds; voice altered. Patient seemed 
to improve under antipyrine and arsenic. 
Observation LXXV. - (Orsi.) Female, forty-five; 
married, no children. Mother died of pulmonary trouble ; 
family history otherwise good. Had intermittent fever 
when thirteen years old and later an attack of epidemic 
parotitis. Menstruated at seventeen years of age, scanty 
and irregular for three years, and then it stopped and 
came on only at intervals of from five to six months. 
Married when twenty-two years of age. When thirty- 
three years old began to suffer from pain in the chest 
unaccompanied with cough or respiratory disturbance; 
the pain afterward extended to shoulder, to half of the 
neck and head, and the left eye. This continued for 
about three years, when it completely ceased for a few 
days and was replaced by a most intolerable vertigo. 
As this disappeared the pains returned, now associated 
with feeling of burning in face, swashing sounds in the 
ear (right), and weakness of memory. Three years later 
she was troubled with pains in the legs, and now for the 
first time noticed an enlargement of the face and feet. 
Two years later she suffered from pains in the hands 
and forearms, and at one time there was an eruption of 
pimples on the right forearm. A short time before pre- 
senting herself for treatment, after a period of violent 
pain in the head, she awakened one morning with marked 
exopthalmos of the left eye and swelling and inflamma- 
tion of the conjunctiva; this abated, after lasting for 
fifteen days. With the exception of the absence of prog- 
nathism the face is very characteristic; chest is enlarged,. CRITICAL DIGEST. 
23 
curvature of the spine, no post-sternal dullness, external 
and internal genitals atrophied, menstruation scanty or 
absent, continual desire for sexual intercourse, which in- 
dulgence is not followed by gratification. The enlarge- 
ment of the hands and feet is rather typical, except that 
the hypertrophy seems to be more in the hard than soft 
parts. The subjective symptoms are still persistent. 
Observation LXXVI.-(Long.) Male, German, aged 
forty-eight, good family history ; denies syphilis; had 
always been well, except at the age of twenty-five, when, 
in the German army, he had an abscess on left hip which 
lasted for five weeks. Came to this country in 1870 ; mar- 
ried shortly afterward, and from this union were three 
children, two of whom died in infancy; the third is now 
a young man and perfectly healthy. Twelve years ago 
he had an abscess on right hip which was very severe, 
but he made a good recovery. The symptoms of acro- 
megaly first made their appearance in the hands in 1874; 
he was then thirty-one years old. Since that time 
the growth has been constant Although he is but 5 feet 
9| inches in height, he weighs 262 pounds. The skin is 
of dirty yellow color. Hands, feet, and face enlarged ; 
cranium normal in size ; forehead retreating ; hair thick 
and wiry; nose and lower lip very much enlarged ; eye- 
lids and upper lid normal. Marked prognathism ; lower 
jaw greatly hypertrophied ; tongue much enlarged ; slight 
cervico-dorsal kyphosis; thyroid gland apparently normal. 
Hands and arms are typical, the right hand and foot 
slightly larger than the left. No post-sternal dull- 
ness. Genital organs apparently normal; sexual appetite 
diminished. The thorax, clavicles, and ribs partake of 
the hypertrophy. Knees and legs enlarged; feet en 
larged, flat-footed. 
Special senses normal with the exception of sight, 
which has been lost for ten years, and so completely that 
he has no perception of light. Eyeballs not greatly pro- 
nounced, but marked nystagmus and complete optic 
atrophy. Patient is of average intelligence, and there is 
no polyuria, polydipsia or bulimia ; measurements given. 
Observation LXXVH.-(Cenas.) A boy, aged fif- 
teen. Mother, who was an alcoholic, died at forty-nine 
years of age ; the patient the youngest of six children and 
the last child. The mother was drunk at least once a 
week while carrying this child, and had a tedious labor, 
lasting five days. Asymmetry of face was noticed at 
birth. Enlargement of hands and feet, and to some 24 
CRITICAL DIGEST. 
extent the arms, was remarked when the child was a few 
months old. The hands and feet continued to enlarge, 
as the child grew older, out of proportion to the other 
parts of his body. For past two years he has had fre- 
quent fainting-spells of a few minutes' duration. Intelli- 
gence less than is common to his age, and frequent 
headache. The face is round and asymmetrical; hands 
covered with large violet spots; head large and asym- 
metrical ; feet enormous; forearms small; wrists small; 
fingers sausage-shape; nails thick and crooked; hands 
and arms not quite symmetrical ; of the right hand all 
the fingers are affected ; of the left, only the thumb and 
index finger. The legs, thighs, and knees are normal; 
all the toes of left foot are enlarged, but only the first, 
second, and fifth of the right are affected Similar spots 
on feet as on hands. Head large ; marked prognathism 
of lower jaw ; the teeth partake of the enlargement; right 
side of face larger; and like condition exists in right side 
of palate, cheeks, lips, and tongue. Thyroid body en- 
larged on right side. Slight cervico-dorsal kyphosis; no 
retro-sternal dullness. In lumbar region the skin shows 
signs of scleroderma. Penis markedly enlarged. Head- 
ache, vertigo, and fainting are troublesome. Special 
senses normal. Voice thick, harsh, and muffled ; appetite 
and thirst increased. 
This case has been given somewhat in detail, as it is 
reported as the only congenital case on record. 
Observation LXX VI IL -(Gerhardt.) Male, aged 
sixty-two ; no family history pertaining to the disease ; he 
has been exposed greatly to inclemency of the weather, 
and a hard drinker. Has had gonorrhoea and syphilis, 
intermittent fever, and has suffered severely from bron- 
chial catarrh. Symptoms began in 1888, with pain and 
swelling in left ankle ; then it went to the other ankle, and 
later to the hands, the right hand being the most severely 
affected. The pains are intermittent; there is excessive 
sweating and thirst; the nails are striated and crack easily, 
and the terminal phalanges are greatly enlarged of the 
feet and hands. 
[It is scarcely posssible from the description of this 
case to see just why it should be classified under acro- 
megaly.] 
Observation LXXIX.-(O'Connor.) Female, born in 
Ireland, aged fifty, no family history, and with the excep- 
tion of attacks of headache was healthy during childhood ; 
married at eighteen years of age, and afterward had an CRITICAL DIGEST. 
25 
attack of yellow fever. First noticed that she was getting 
stout in 1883. The hands and feet felt as if bursting, the 
right hand being first affected, then the left foot. This 
sensation of fullness was also complained of in the throat. 
Then the nose began to get red and enlarged, and the 
voice harsh. The face became enlarged, both trans- 
versely and longitudinally lower lip thickened and 
curled, tongue immense. Hands and feet characteristic. 
The left foot shows a greater increase than the right, 
and it has a marked thickened pad beneath metatarso- 
phalangeal region. No enlargement of the bones of the 
arms or legs. There are distinct circumscribed tumors 
on some of the bones, such as the seventh rib and the 
clavicle. The thyroid gland can be made out; she 
sweats profusely and has great thirst. The menopause 
occurred at forty-seven years of age. 
Observation LXXX.-(Sommers.) Male, Italian, 
fifty-one years old; has had large hands and feet since 
he was twenty years old. They have greatly increased 
in size in recent years. In 1886 he had a chancre, but 
no secondary symptoms appeared. In 1870 he had an 
attack of small-pox. The voice is croaking; he is surly 
in disposition and very reticent. Forehead narrow, low, 
and retreating; frontal sinuses large; nose very large; 
ears immense; lips thick; tongue hypertrophied and 
deeply fissured; marked prognathism of lower jaw; 
hands typical in shape, the width and thickness of fin- 
gers out of all proportion to the length; palms covered 
with great pads of tissue, more marked on ulnar side. 
The enlargement of the feet is of the same character as 
seen in hands. The great toe is enormous; patellae are 
immense; knee-joints crepitate; very slight kyphosis. 
He weighs 275 pounds, though but 5 feet 11 inches in 
height. Thyroid small, special senses normal. At the 
autopsy, the brain and spinal cord was not examined. 
There was found fatty and cirrhotic liver, enlarged 
spleen, and absence of thymus. 
Observation LXXXL-(Bruzzi.) Male, age fifty- 
one, unmarried, of good family and previous history. 
No illness of importance in childhood; had spermator- 
rhoea when a young man. He was of good constitution 
and development, and performed military service. When 
twenty-six years of age he had attacks of severe pain in 
back of head and neck and the dorsal region. At twenty- 
nine years of age he was impotent, and the pains were 
troublesome, and he had an attack of nervous prostra- 26 
CRITICAL DIGEST. 
tion. In 1870 he had an attack of prostration, with deli- 
rium and a tendency to coma, in which he remained in 
an unconscious condition for forty days. His physician ✓ 
diagnosed this as cerebral congestion. After a long con- 
valescence he regained strength, but was troubled with 
aggravated attacks of dyspepsia. The signs of acrome- 
galy were quite typical, but not of a marked order. Prog- 
nathism and kyphosis were not well marked. A full 
table of measurements appended to original paper. 
Observation LXXXII.-(Gajkiewiczi.) 
Observation LXXXIII.-(Gause.) 
These reports are inaccessible in the time necessary 
to complete this article. Dercum reported two cases to 
the American Neurological Association in June, 1892, 
which have not as yet been published. 
Foy has reported a peculiar case, which I have in- 
cluded under this heading for the purpose of drawing 
attention to local manifestations resembling acromegaly, 
and to which he has given the name cheiromegaly. The 
case is in brief as follows : The patient, a refined lady, had 
had small ecchondromata removed from her hand twelve 
months before, and presented herself for the removal of 
a second such tumor, about the size of a large hen's egg. 
Shortly after the removal of the second tumor, a strange 
alteration occurred in the hand; it became broad and 
large, and very much resembled the hand of acromegaly, 
but unattended with any other changes or concomitants 
of acromegaly. The patient died afterward, but from 
what cause the reporter does not mention. 
As yet the most obscure factors concerning acrome- 
galy are the causation and pathology of the disease. As 
we have already stated in the beginning of this article, 
its occurrence has been attributed to various factors with- 
out its being in any particular instance shown to be 
dependent upon the attributable causes. Although the 
majority of the cases have been observed in persons 
occupying the most lowly walks of life, we cannot say 
that it is a respecter of persons, for it has been observed 
in clergymen, officers, and the refined and educated. 
Regarding the theories of its pathology, the one 
looked to with most unanimity is that promulgated by 
Marie, who is particular to confess that the nature of the 
disease is wrapped in obscurity, but that the cases which 
have come to autopsies have shown, with considerable 
concordance, changes in the pituitary body. Many of 
the cases still under observation present symptoms, as CRITICAL DIGEST. 
27 
can be seen in our abstracts of them, which point with a 
considerable degree of accuracy to an involvement of 
this body. In more than one-half the cases reported, 
eye or ear symptoms, pointing to the pituitary body, 
have been present and headache in almost every case. 
What this change in the hypophysis cerebri is, only 
time and detailed examinations will show. At the 
same time it is interesting to note instances where the 
pituitary body has presented changes in conjunction 
with other diseases without any symptoms of acrome- 
galy developing. Such a case has recently been reported 
by Wills ("Brain," autumn and winter number, 1892). 
This . patient had pains in the head for fifteen years, 
which were greatly increased in severity during the last 
six months. With the exception of progressive dementia, 
the symptoms were not well marked. There was some 
paresis of the left internal rectus muscle of the right 
eye with external strabismus; the other muscles of this 
eye were normal. Right pupil reacted to light and 
accommodation, the left to neither; consecutive optic 
atrophy in both discs. After death a tumor, about the 
size of a Tangerene orange, divided into two portions, 
was found wedged in the sella turcica. It lay in the 
interpeduncular space, extending anteriorly as far as the 
posterior termination of the orbital surface of the frontal 
lobes, and laterally it was overhung by the tempero- 
sphenoidal lobes. Posteriorly it separated the crura 
cerebri. Anteriorly the olfactory nerves were thin and 
flattened, the left more than the right, and likewise the 
optic tracts were more involved on the left side. Micro- 
scopical examination showed it to be an adenomata. 
Boyce and Beadles have likewise reported three cases 
in which there was enlargement of the thyroid without 
symptoms of acromegaly (Journal of Pathology, 1892). 
Two of these cases were of myxoedema and one of 
sporadic cretinism, and associated with the enlargement 
of the hypophysis was an atrophied condition of the 
thyroid glands. Suckling has also seen the same condi- 
tion in a case of myxoedema. 
It has been suggested that in acromegaly the changes 
in the pituitary and thyroid glands stand in relationship 
one to the other; that is, when the latter is absent or 
diminished in size the former is hypertrophied. If has 
been shown experimentally by Hofmeister (Fortschritte 
der Medicin, No. 4, 1892) and others that after thyroidec- 
tomy in rabbits the hypophysis increases in weight; but 28 
CRITICAL DIGEST. 
these experiments have not been corroborated in every 
instance by other workers in the same line. In acro- 
megaly many of the cases, such as Hudden's, Ballance's, 
Virchow's, Kanthack's, and others, there was atrophy of 
the thyroid gland, while in others the gland remained 
normal or was hypertrophied. 
The functions of these two bodies, the thyroid and 
hypophysis, have yet to be learned; there is no doubt, 
as has been shown by Rogowitsch, that an intimate con- 
nection exists between them and that they stand in a 
close relationship with the nervous system, particularly 
the sympathetic. That one should take up the function 
of the other when diseased is comprehensible even when 
experiments fail to show that change goes on in the 
pituitary body after extirpation of the thyroid. The fact 
that acromegaly does not develop in every case of tumor 
of the hypophysis cerebri cannot be logically advanced 
as an argument that its normal existence does not pre- 
vent acromegaly ; for we know that disease of the spleen 
is attended with the development of leucocythaemia, yet 
leucocythasmia does not necessarily follow extirpation of 
that organ. Nor does myxoedema necessarily accom- 
pany disease of the thyroid gland, although in bodies of 
persons dead from myxoedema, the thyroid is invariably 
degenerated and generally atrophied. 
If acromegaly is dependent on disease of the pituitary 
body, it does not necessarily follow, as I have before 
stated (American Neurological Association meeting, 
June, 1892), that there must be enlargement or tumor 
of that body. There may be atrophy or parenchymatous 
degeneration; for if we accept that disease of the pituit- 
ary gland has a causative relation to acromegaly, it must 
be in either one of two ways : Either the pituitary gland 
-the prehypophysis, so called-secretes and pours out 
into the circulation certain substances necessary for the 
preservance of proper nutrition, and the absence of which 
is manifested by changes in the general system through 
the nervous system, particularly the sympathetic; or the 
normal pituitary gland filters out of the blood certain 
substances the retention of which would give rise to a 
sort of toxaemia,-the consequences of which would be a 
deleterious action on the nervous system and the result- 
ing changes of the disease. Why there should be a 
special predilection for the extremities would have to be 
explained by some conditions of peculiarity of the circula- 
tion influenced through the vaso-motors. CRITICAL DIGEST. 
29 
It will be seen, from a glance at the literature for the 
past two years, that the disease known as acromegaly 
has come to stay, and that a diffusion of knowledge con- 
cerning its occurrence is followed by the report of many 
cases formerly classified under some other heading, but 
clearly belonging to acromegaly. 
Acromegaly is most easily confounded with the disease 
known as osteo-arthropathy hypertrophica pneumique: 
a disease characterized by enlargement and deformity of 
the extremities, particularly at the joints, and dependent 
on some pulmonary disease, most often of a septic nature. 
It may also be confounded with myxoedema, leontiasis, 
oteitisdeformans of Paget, elephantiasis, erythromelalgia, 
and rarely, if ever, with arthritis deformans. 
In acromegaly the hands are large and thick in 
appearance, the fingers are uniformly enlarged, and the 
proportion between the segments of the fingers is well 
preserved. The nails are flat, small, longitudinally 
striated, and the flesh has a tendency to grow beyond 
and around, seemingly imbedding them. In osteo- 
arthropathy of pulmonary origin, the fingers, and not 
the hand as a whole, are affected. The fingers assume 
the shape of drum-sticks, and the ends of the bones 
of the forearm are markedly thickened, projecting 
voluminously on the dorsal surface of the hand, and the 
hand, as a whole, shows very evident deformity. The. 
nails become changed, so that they resemble a parrot's 
beak. This last is a very important factor, and will 
suggest the diagnosis very quickly; for while, in acro- 
megaly, there is great enlargement, there is no actual 
deformity, as the relationship between the different parts 
of the hand is well preserved, and the hypertrophy of 
the wrist is proportionate to that of the hand in acro- 
megaly. In acromegaly the carpo-metacarpal region is 
very greatly enlarged, giving rise to the so-called " battle- 
dore " hand, while in osteo-arthropathy this articulation 
is nearly normal. The same remarks apply to the feet, 
excepting that there the changes are a little less marked. 
Another very important difference is that, in acromegaly, 
the changes are equally in the bones and soft tissues, 
while in osteo-arthropathy the alterations are only in the 
bones. There are certain parts of the bone-namely, the 
epiphysis-where a marked predilection exists for these 
changes. 
In acromegaly the face undergoes an important change. 
There is enormous hypertrophy of the inferior maxilla, 30 
CRITICAL DIGEST 
and this gives a characteristic prognathous appearance. 
In osteo-arthropathy the lower jaw is never affected, with 
the exception of occasional thickening of the alveolar 
border in both inferior and superior maxillae. Acro- 
megaly is attended with a more or less well-marked 
cervico-dorsal kyphosis, which develops early; while 
such a change, if it occurs at all in osteo-arthropathy, is 
a late manifestation. 
In acromegaly there are frequently symptoms refer- 
able to the eyes and ears, indicative of change in the 
pituitary body or adjacent to it; while such symptoms 
do not exist in osteo-arthropathy. Two very constant 
accompaniments of acromegaly are the development of 
little nodules of molluscum fibrosum and a large welt 
of thickened tissue on the inner side of the plantar sur- 
face of each foot. These have not been noted in osteo- 
arthropathy. 
Finally, osteo-arthropathy is always secondary to pul- 
monary disease, and particularly, as has before been said, 
pulmonary diseases attended with the production of pus, 
such as phthisis tuberculosis, empyaemia, pulmonary 
abscess, and the like. 
The decomposition of pus would seem to be the 
necessary antecedent for the development of the osteo- 
arthropathy, the morbid changes being brought about 
by the absorption of the products of such decomposition. 
The locus of such purulent change being in the lungs, 
would seem to facilitate, in some unknown way, the 
development of the osteo-arthropathy. In this disease, 
likewise, there has been found quite a hereditary ele- 
ment ; while in acromegaly, on the other hand, the origin 
of the disease is in entire obscurity, and, with one pos- 
sible exception, the disease has shown no hereditary 
factors in its etiology. 
The differential diagnosis from myxoedema is gener- 
ally not difficult. In myxoedema the face is of a charac- 
teristic " full-moon " appearance; the skin is of a peculiar 
waxy color, with a pinkish tint in cheeks; mentality is 
sluggish; the chin drops forward on the sternum from 
sheer inability on the part of the extensors of the head; 
the skeleton remains free from enlargement. In acro- 
megaly, on the other hand, the outline of the face is 
elongated; there is marked prognathism; the skin is 
thickened and muddy-looking; the patient is frequent!v 
very alert mentally (Cohen's case); and remarkable 
changes go on in the skeleton. In myxoedema there is CRITICAL DIGEST. 
31 
absence of secretion of sweat and early alopecia; while 
in acromegaly there is hyperidrosis and thick, tough, 
wiry hair. 
In Paget's disease (osteitis deformans) the bony 
changes in the upper part of the skeleton are most 
marked in the cranium. The outer table of the cranial 
bones becomes porous and spongy, as a result of inflam- 
mation, and the normal distinction between the outer 
table and the inner table and diploe is lost, the entire 
thickness of the bone consisting of a uniformly compact 
tissue, in some parts looking like chalk. The bones of 
the face are but slightly affected, and then only late in 
the disease; while in the long bones the changes in size 
and curvature are principally in the shafts, the extremi- 
ties being scarcely affected. It will be readily seen that 
these are in marked contrast to the conditions present 
in acromegaly. 
Arthritis deformans, leontiasis, and elephantiasis will 
scarcely be confounded with acromegaly, if the latter is 
carefully studied. In leontiasis ossium there is a growth 
of true bony structures in the shape of tumors of the 
cranium and face, and generally an absence of hyper- 
trophy of the extremities. In arthritis deformans the 
changes are confined to the joints of the extremities, the 
face being rarely affected, and never does it present the 
elongated face of acromegaly. Elephantiasis consists of 
cystic and tubular enlargements of the lymphatics-first, 
of the cutaneous structures, then of the more deeply 
seated, attended with thickening and induration of the 
skin and connective-tissue and dilatation and multiplica- 
tion of the blood-vessels, with wasting of the muscles, 
and attended with no change in the bony structure. A 
disease presenting these conditions will scarcely be con- 
founded with acromegaly. Souza-Leite informs us that 
it is possible to confound acromegaly with the disease 
to which Weir Mitchell gave the name of erythromelalgia 
-a word signifying literally pain and redness in a limb. 
The disease in question is, however, only occasionally at- 
tended with an increase in the size of the fingers and 
hands and a slight fullness of the arms and forearms, 
and rarely a small degree of kyphosis. 
There is, moreover, to assist us in the differential 
diagnosis, an absence of elongated face and prognathism 
of the lower jaw, of the enlargement of the lips and 
tongue, and, in fact, of all the signs referable to the 
cephalic extremity so apparent and characteristic of 32 
CRITICAL DIGEST. 
acromegaly. Although enlargement of the extremities 
may occur in erythromelalgia, it is due to congestion and 
oedema, and the changes in the fingers, nails, and ex- 
tremities, so typical in acromegaly, are absent. 
. Though much new material has b£en given for obser- 
vation during the past two or three years, scarcely any- 
thing has been added to our knowledge of the causation 
and nature of the disease and its treatment. Undoubtedly 
the prognosis in this disease is extremely bad as regards 
complete recovery, but so few cases have as yet been de- 
scribed from the pathologist's point of view, the disease 
has not yet been recognized sufficiently long for us to 
give definite ideas as to its natural duration. It is prob- 
ably, however, not less than a decade and longer in the 
greater number of cases. In one case (Bury) the dura- 
tion of the disease was but three years, while in another 
(Graham) thirty-four years passed before death occurred. 
On account of our ignorance of the genesis of the dis- 
ease, the treatment must be empiric and symptom- 
atic. There has but little been suggested in a thera- 
peutical way since the appearance of Souza-Leite's 
brochure, in which it is stated that Verstraeten has 
prescribed in this affection: phosphorus, perchloride of 
iron, arsenic, rhubarb, etc., and has placed patients on a 
modified Oertel's regimen, and other plans, but with little 
promise of success. In a few cases there is an ameliora- 
tion of some of the symptoms, while other symptoms re- 
main the same or are exaggerated. 
Brown has recently stated that his patient was im- 
proving under the use of antipyrine and arsenic. Massa- 
longa states that the activity of the disease was held in 
check by the administration of the salicylates and iodides. 
For the intense cephalalgia preceding marked manifes- 
tations of the disease, and likewise present in the earlier 
part of the disease, valerianate of caffeine and phenace- 
tine have been found of great service. In cases present- 
ing symptoms of intra-cranial pressure, particularly ocular 
symptoms, iodide of potash has been given very largely, 
but without apparent benefit. 
The symptomatic treatment consists in combating 
the headache, overcoming the glycosuria when it exists, 
and attention to the bulimia, polydipsia, and hyperidrosis, 
which are frequently troublesome. The glycosuria is 
generally combated readily by paying attention to the diet 
and the administration of arsenic and the alkaline waters. 
All writers have been impressed with the necessity of paying attention to the nutrition of the patient from 
the beginning. The cause of death, in all cases reported 
as terminating fatally, has been asthenia, from intra- 
cranial pressure or from intercurrent acute diseases. 
The establishment of a high grade of nutrition will 
prevent these from occurring to some extent, especially 
the first and the last. Further than this, treatment seems 
to be of no avail. 
Before closing, it might be well to remark that among 
English writers there might be a little more unanimity 
in the spelling of the word which Marie gave to the dis- 
ease known by his name. There can scarcely be any 
excuse for writing it, as has been done by a recent writer 
(Wills), " acromegale ; " and the substitution of a k for a c, 
in the first syllable, is merely a subserviency to the Ger- 
man, which is unnecessary. The appended bibliography 
brings the literature of the disease up to the date. 
CRITICAL DIGEST. 
33 
LITERATURE OF ACROMEGALY. 
1772. Saucerotte : Observation communicated to Acad, de Chirurgie in 
1772. 
1801. Mdlange de Chirurgie, 1801. Parti., p. 407. 
1822. Alibert: Precis theorique et pratique des .Maladies de la Peau. 
Paris, 1822. T. iii., p. 317. 
1857. Chalk: Trans. Path. Soc. of London, 1857. Vol. viii., p. 305. 
1864. Verga : Caso singolare de Prosopectasia in Rendiconti del Reale 
Institute di Scienze e Lettere. Adunanza del 28 Aprile, 1864. 
1868. Friedreich's: Virchow's Archiv. Vol. xlvii., p. 83. 
1869. Lombroso : Le Giornale Itai, delle Maliattie Veneree, etc. Also, 
Virchow's Archiv. Vol. xlvi., 1869, p. 253. 1868. 
1872. Ewald : Virchow's Archiv. Vol. Ivi., 1872. 
1877. Brigidi: Societa medico-fisica Fiorentina. Aug. 26, 1877. 
1879. Faruffi : Annali Universal! di Medicina, 1879. Vols. ccxlvii. and 
ccxlix. 
1882. Henrot: Notes de Clinique medicale, Rheims, 1877 ; et Notes de 
Clinique medicale, Rheims, 1882. 
1884. Fritsche and Klebs: Klinische und pathologisch-anatomische 
Untersuch ungen. Leipzig, 1884. 
1885. Hadden and Ballance : Transac. Clinical Society. London, 1885, 
vol. xviii.; also, loc. tit., vol. xxi. 
1885. Wadsworth : Boston Med. and Surg. Journal. Jan. 1, 1885. 
1886. Marie: Rev. de Med. Paris, 1886. vi., 297. 
1887. Minkowski: Berlin, klin. Wochenschr. 1887, No. 21. 
1888. Bier : Mittheilungen aus der chirurg. Klinik zu Kiel. Bd. iv., 1888, 
1888. Golee : Brit. Med. Journal. 1888. 
1888. O'Connor, J. T. : N. Am. Journal Homoeop. New York, 1888, 3, 
s. iii., 345. 
1888. Fraentzel: Deutsche med. Wochenschr. Aug. 9, 1888. 
1888. Adler: Boston Med. and Surg. Journal. 1888, vol. cxix., p. 507. 
1888. Wilks: Clinical Society of London. April 13, 1888. 
1888. Marie: Nouvelle Iconograph. de la Salpetriere. Paris, 1888, 
Nos. 5 and 6, part i. 
1888. Lancereaux: Trailed' Anatomiepathologique. Vol. iii.,parti.,p.29. 
1888. Broca : Archiv. gen. de Med. Paris, 1888, p. 656. 
1888. Elliott: Lancet. 1888. 
1888. Erb: Deutsches Archiv f. klin. Med. 1888, Ixii., f. iw, 296. 34 
CRITICAL DIGEST. 
1888. Tresilian : Brit. Med. Journal. 1888, p. 642. 
1889. Virchow: Berlin, klin. Wochenschr. Feb. 4, 1889. Translated 
in Illustrated Medical News, London, 1889, vol. ii. p. 241. 
1889. Freund: Sammi, klin. Vortrage. Leipzig, 1889, Nos. 329 and 330. 
1889. Saunsby : Illustrated Med. News. London, March 2, 1889 
1889. Sollier: France medicale. 1889. 
1889. Guinon : Gaz. des Hopitaux. Nov. 9, 1889. 
1889. Brb : Versamml. deutschen Naturforscher, med. Aerzte zu Hei- 
delberg. September, 1889. 
1889. Marie: Prog, medicale. No. 11, March 16, 1889. Translation in 
"Brain," 1889, vol. xii., p. 59. 
1889. Farge : Prog, medicale. July 6, 1889. 
1189. Adler: N. Y. med. Moriatsschr. 1889, i., 225. 
1889. Striimpell: Munch, med. Wochenschr., Aug. 15, 1889. 
1889. Bwald : Berlin, klin. Wochenschr., March 18, 1889. 
1889. Verstraeten : Rev. de Med. May, 1889. 
1889. Schultze : Deutsche med. Wochenschr. 1889, xv., 981. 
1889. Gouraud : Paris, 1889. 
1889. Hutchinson : Archivesof Surgery. London, 1889 90, vol. i., p. 14. 
1889. Schapovnikow: Med. Rundschau. 1889. (Russian.) 
1889. Klebs : Die krankhaften Storungen, etc. 1889. 
1889. Schaposchinkoff: Moskau, 1889. 
1889. Sacchi: Venezia. 
1^90. Pechadre : Rev. de Med. Paris, 1890. 
1890. Holschewinkoff: Virchow's Archiv. Bd. 119, 1890. 
1890. Von Recklinghausen : Virchow's Archiv. Bd. 119, 1890. 
1890. Waldo : Brit. Med. Journal. 1890. 
1890. Thomson, J. : Anat, and Physiol. 1889-90, vol. xxiv., p. 475. 
1890. Souza-Leite: De 1'Acromegalie. Paris, 1890. 
1890. Gauthier : Le Progres medicale. 1890, No. 4. 
1890. Reuner : Vereine der pfalzischen Aerzte. Frankenthal, 1890. 
1890. Grham: Trans. Assoc. American Physicians. 1890, vol. Ivii. ,p. 390. 
1890. Grham : Medical News. Philadelphia, Oct. 18, 1890. 
1890. Surmont: Nouvelle Iconograph de la Salpetriere. Paris, 1890, 
iii.. p. 147. 
1890. Pick: Prag. med. Wochenschr. 1890, xv., p. 521. 
1890. Campbell: Trans. Clinical Society London. 1890, xxiii., p. 257. 
1890. Flemming : Trans. Clinical Society London. 1890, xxiii., p. 253. 
1890. Silcock : Trans. Clinical Society London. 1890, xxiii., p. 256. 
1890. Cenas : Loire Med. 1890, ix., p. 313. 
1890. Claus : Ann. Soc. de Med. de Garad. 1890, Ixix., p. 281. 
1890. Gerhardt: Berlin, klin. Wochenschr. 1890, xxvii , p. 1183. 
1890. Bettencourt: Jour.. Soc. de Sc. med, de Lsb. 1890, liv , 366. 
1890. Holsti: P'estski f. path.-anat. Inst. Helsingfor, 1890, 103. 
1890. Souza-Leite: Rev. scient. Paris, 1890, xlvi., 801. 
1890. Hutchinson : Archives Surgery. London, 1890, iv., 296. 
1891. Paget: London Lancet. January 31, 1891. 
1891. Cheron : Union m£d. Paris, 1891, 3, s. 25. 
1891. Leizet: Archive gen. de Med. Paris. 1891, i., 194. 
1891. Pel. : Berlin, klin. Wochenschr. 1891, xxviii., 53. 
1891. Long : 'Lehigh Valley Medical Magazine. April, 1891, 144. 
1891. Du Cazal: La Semaine medicale. October 21, 1891. 
1891. Arnold : Beitr. f. path. Anatomie und zur allgemeiner Pathologie. 
Jena, 1891, x., p. 1. 
1891. Pinel-Maisonneuve : Bui. et Mem. Soc. med. de Hop. de Paris' 
1891, 3, s. viii., 137. Also, Archive d'Ophth., Paris, 1891, xi., 309. 
1891. Groccu : Riv. gen. Itai. d. Clin. med. Pisa, 1891, iii., p. 17. 
1891. Mosier: Festschr. R. Virchow. Bd. ii.. 103. 
1891. Ruttie: Brit. Medical Journal. London, 1891, i., 697. Also, 
Medical Press and Circular, 1891, n. s., Ii., 397. CRITICAL DIGEST. 
35 
1891. Debierre : Rev. gen. d'Ophth. Paris, 1891, x., 12. 
1891. Bury: Lancet. 1891, i.. 1383. 
1891. Kanthack : Brit. Medical Journal. 1891, ii., 188. Also, Trans. 
Path. Society London. 1890-91, xliii., 251. 
1891. Mar e et Marinesco : Archive de Med. exper. et d' Anat. path. 
1891, iii., 539. 
1891. Berkley: Bui. Johns Hopkins Hospital. 1891, ii., 134. 
1891. Somers: Occidental Medical Times. 1891, v., 537. 
1891. Foy: Medical Press and Circular. London, 1891, n. s. liii., 
P- 491-. 
1891. Gorjatcheff: Chir. Laitof. Mosk., 1891,!., 155. 
1891. Spellman et Haushalter : Rev. de Med. 1891, xi., 775. 
1891. Litthauer: Deutsche med. Wochenschr. Nov. 19, 1891. 
1891. Bignani: Bui. d. Soc. Lancisiana d'Osp. d. Roma. 1891, x., 258. 
1891. Gajkiewiczi: Gaz. Lekarska. Warszowa, 1891, 2, s. xi., p. 846. 
1891. Stembo : St. Petersb. med. Wochenschr. 1891, Nos. 45 and 46. 
1891. Bradford: Brit. Medical Journal. Dec. 26, 1891, 1354. 
1891. Redmond: Trans. Royal Academy Ireland. 1890 91, ix., 64. 
1892. Packard : Am. Journal Medical Sciences. June, 1892. 
1892. Osborne: Am. Journal Medical Sciences. June, 1892. 
1892. Duchesnau: Contribution a I'Btudje anatomique et chir. de 
l'Acromegalie, etc. 40, Lyon, 1892. 
1892. Mobius: Munch, med Wochenschr. June 9, 1892. 
1892. Tanzi: Archivio Itai. d. Clin, med., v., p. 533 ; Gaz. degli Ospit., 
No. 9, 1891. 
1892. Appleyard: Lancet. 1892, i., 316. 
1892. : Lancet. 1892, i., 746. 
1892. Balzer : Bui. et Mem. Soc. med. d'Hop. de Paris. 1892, 3, s. ix., 
237- 
1892. Bard. : Lyon m€d. 1892, Ixix., 547. 
1892. Phillips: Brit. Medical Journal. Feb. 27, 1892. 
1892. Barrs: Lancet. 1892, i.. 683. 
1892. Gonzalez-Cepeda: Rev. Balear de Cien. med. Palma de Mal- 
lorca, 1892, viii., 7. 
1892. Hare: Medical News. Philadelphia, 1892, lx., 257. 
1892. Hutchinson: Archives Surgery. 1891 92, iii., 343. 
1892. Solis-Cohen : Medical News. Philadelphia, Nov. 5, 1892. 
1892. Harris : Medical News. Philadelphia, Nov. 5, 1892. 
1892. Dulles : Medical News. Philadelphia, Nov. 5, 1892. 
1892. Brown: Brit. Medical Journal. April 23, 1892. 
1892. Barclay and Symmers : Brit. Medical Journal. Dec. 3, 1892. 
1892. Denti: Atti d Asso. Lombardi. Milano, 1891-92, 41. 
1892. Sarbo : Orbosi hetit. Budapest, 1892, xxxvi., 136. 
1892. Orsi: Gaz. med. Lombard. 1892, li., 201. 
1892. Boltz: Deutsche med. Wochenschr. 1892, xviii., 635. 
1892. Fratrich: Allgemeine Wiener Zeitung. 1892, xxxvii., 405. 
1892. Holsti: Zeitschrift f. klin. Med. 1892, xx., 298. 
1892. Massalongo : Rif. med. Napoli. 1892, viii., part 3, 74. 
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