A CASE OF ACROM- 
EGALY. 
i BY 
CHAS. EONG, A' M'' D-' 
ww^esTjarre, penna. 
REPRINTED FROM 
The Lehigh Valley Medical Magazine. 
. Vol. ii. No. 3, DR. LONG'S CASE OF ACROMEGALY. A Case of Acromegaly. 
CHAS. LONG, A. M., M. D., Wilkes-Barre, Penna. 
Symptoms which resemble those of this disease have been 
grouped together as early as the year 1772, by Sancerotti, and 
since then various observers have published what were prob- 
ably cases of this affection under the names, myxoedema, 
gigantism, exophthalmic goitre, etc. Indeed this group of 
symptoms was not classed together as a distinct morbid entity 
until the year 1885, when two cases came under the observa- 
tion of Marie, then chief assistant to Prof. Charcot, who made 
a special study of the affection and described its typical symp- 
toms. In naming it, he selected its most prominent symptom, 
"a striking non-congenital hypertrophy of the extremities 
(hands, feet^md cephalic extremity)" and called it Acrome- 
galy (akroi extremity, megas, large). Broca describes it as a 
disease in which "the bones of the extremities and the ex- 
tremity of the bones are enlarged." 
In Brain, July, '89, Marie gives a biographical index of 
cases which have come under his notice. This includes eigh- 
teen (18) cases of undoubted acromegaly, (one of which is 
Wadsworth's Boston case) ; four (4) cases, in which details are 
wanting, but which he classes as acromegaly, and six (6) cases 
which do not come under the head of acromegaly at all. 
Since then one European case has been reported by Drs. 
Holschewinkoff and von Recklinghausen (Virchow's Archiv, 
January, 1890), and a case is also now under observation in 
Dublin, but has, as yet, not been reported. In this country 
the first case reported was by Dr. Wadsworth (Boston Med. 
and Surg. Journal, January 1, 1885, as a case of myxoedema, 
but Marie classes it among his eighteen cases of undoubted 
acromegaly. Adler, of New York (Medicinische Monatschrift, 
May, 1889), reported a case in a German woman, 34 years of 
age. The third case was reported by Dr. O'Connor (American 
Journal of Homeopathy, 1888). The fourth and fifth cases 
were reported before the Association of American Physicians 
at the meeting in May, 1890, by Dr. J. E. Graham, of Tor- 
onto, and published in the Medical News, October 18th, 1890. 2 
As near as can be determined, therefore, from the researches 
that I have made, the case which I have the honor of pre- 
senting to the society this evening is the sixth reported case 
of Acromegaly in America. 
Case.-Matthias M., German, age 48, laborer (until 10 years 
ago). His father was a strong, healthy man, who never 
showed signs of any special enlargements and died at the age 
of 65, after a two days' illness. Patient can give no informa- 
tion about his mother, who died when he was an infant. He 
has two brothers and three sisters living, and he thinks they 
are all healthy ; at least, they have never presented any ab- 
normality of growth. The patient's growth was normal, nor 
did he ever suffer from any sickness during his boyhood or 
youthful days. At the age of 22 years he entered the German 
army as a cavalryman, and served three years, until he was 
25 years old. At the time he must have been healthy or he 
would not have been accepted as a soldier. During his ser- 
vice he suffered for five weeks with an abscess on the left hip, 
but fully recovered. In 1870 he emigrated to America, and 
was then still a well-proportioned man. Soon after his arrival 
he was married and lived with his wife for fourteen years. 
The result of this marriage was three children, two of whom 
died in infancy, the third is a healthy boy, seventeen years 
old. About twelve years ago he had a serious abscess, on the 
right hip this time, from which he also fully recovered. He 
is sure that he has never had any other sickness, and is free 
from specific taint. During last summer he suffered for sev- 
eral weeks with headache, but never before or since. He has 
always been more or less constipated. Symptoms of enlarge- 
ment were first observed, by the patient's wife, in his hands 
in 1874, when he was 31 years old, and since that period the 
hypertrophy has been gradually but constantly increasing. 
The patient is 5 feet 9*4 inches in height and weighs 262^ 
pounds, an increase in weight of seventeen pounds in twelve 
years. 
Present condition.-The skin has a dirty yellow color, is 
free from eruption and is very loose, so that it can easily be 
drawn up in folds. The hands, feet and face are very large, 
out of proportion to the rest of the body. The face has a dis- 
tinct elliptical shape so characteristic of patients suffering with 
Acromegaly. 3 
The cranium is normal in size and shape, and covered with 
a thick, well preserved crop of gray hair. The forehead 
recedes from very prominent eye-brows. Neither the eye-lids 
nor the ears are enlarged. The nose is large and broad. The 
upper lip is not at all enlarged, but the lower lip is very prom- 
inent and everted. The cheek bones are prominent, caused 
probably by the dilations of the maxillary sinus. The lower 
jaw is enormously hypertrophied and massive, the chin pro- 
jecting forward, causing a decided prognathism. 
The tongue is very large, thick and wide, and always cov- 
ered with a grayish-yellow coating. Notwithstanding the 
enlargement of the tongue, articulation is distinct. The neck 
is short, thick and bulky, and the head is inclined distinctly 
forward, due to a slight cervco dorsal kyphosis. The larynx 
is not all enlarged. The thyroid gland is smaller than nor- 
mal, but both lobes can be felt. The voice is strong, deep 
and not at all discordant. Indeed the patient can sing quite 
well. 
The hands are very much hypertrophied, especially in their 
width and thickness. There is hypertrophy of the soft parts 
as well as of the bones, and this is especially true of the ulnar 
side of the hand, where there is an excessive amount of soft 
tissue. The lines in the palm of the hand are very marked. 
The fingers are characteristically stumpy and sausage shape, 
thick and rather flat. The joints are large and flat, showing 
that hypertrophy is more marked at the ends of the bones. 
Flexion is complete and the patient is able to make a tolerably 
good fist. The finger nails are broad and short. The wrist 
is thick and enlarged in proportion to the hand. The fore- 
arm shows some hypertrophy, but the arm is small in propor- 
tion to the hand and fore-arm. The muscles of the upper 
extremity, and indeed, in all parts of the body are flabby and 
soft. The hand, wrist, foot and ankle of the right side are 
slightly larger than those of the left side. 
The thorax is very large and bulky, especially deep in its 
antero posterior diarpeter. There is distinct flattening on the 
sides. The clavicle and ribs show marked hypertrophy, espe- 
cially at their extremities. The ribs are inclined very ob- 
liquely downward and forward. The scapula is also enlarged. 
There is a peculiar depression at the upper end of the ster- 
num and no especial prominence of the xiphoid appendage, 4 
which is so marked in the majority of the reported cases. 
There is also no retrosternal dulness ; the thymus gland is 
therefore absent. Breathing is natural. Enlargement of the 
heart cannot be detected. The pulse is small, soft and com- 
pressible. The abdomen is decidedly prominent. There is 
no enlargement of the genital organs. The sexual appetite, 
never very strong, is now almost entirely absent. 
The thighs are not abnormally large, except the hypertro- 
phy at the ends of the femur. The knee joints are very prom- 
inent. 
In the legs both the soft tissue and the long bones show 
hypertrophy, but that of the muscles is not very marked. 
The feet are very large, the increase in size being especially 
marked in the thickness and breadth. The patient is also 
flat-footed. The toe nails, like the finger nails, are broad and 
short. The cutaneous sensibility is good, the knee reflex is 
normal and the nervous system shows no abnormal symptoms. 
Excepting vision the special senses are all normal. The 
patient is completely blind and has been in this condition for 
more than ten years. This is, I believe, the first recorded 
case of acromegaly where blindness is complete. The fol- 
lowing is the ophthalmascopic examination, kindly made for 
me by Dr. L. H. Taylor : 
"Matthias M., aet. 48. Acromegaly, 3, 13, '91. Is now 
totally blind. Does not distinguish difference between day- 
light and dark. Cannot distinguish bright lamp held in front 
of him. Pupils moderately dilated Eye-balls full but not 
unusually prominent. Left eye, slight divergent strabismus. 
He has nystagmus of high grade, so that an ophthalmoscopic 
examination is difficult. 
" 3, 15, '91. Atropia dropped in diluted pupils and seemed 
to steady the eye-ball so that an ophthalmoscopic examination 
could readily be made. Each eye shows chronic optic atrophy, 
evidently about the same degree in each. Vessels are small 
and the nerve greenish. Retina not markedly changed. The 
patient states that he was examined by Qr. Keyser ten years 
ago for his eye trouble, and pronounced incurable, having, as 
he states, trouble with the nerve. It is quite possible that the 
condition of the eye may have been developed independently 
of the acromegaly, as he has been blind for ten years. He 
has used tobacco and also alcohol, but he says not to excess. 5 
SchHltz (Neurologisches Centralblatt, July, 1889), reports two 
cases, in one of which the first symptoms of trouble were dis- 
turbances of vision ten years before, which in five years de- 
veloped into complete temporal hemianopsia. At the time 
the case was reported the patient was completely blind in one 
eye and nearly so in the other, so that it was probable that a 
tumor of the pituitary body was present. In Mr. M.'s case 
there is nothing to indicate a tumor except total blindness, 
which of course might be due to tumor of the brain, but in 
such event other symptoms would probably have been mani- 
fest." 
The patient has the average intelligence for one in his station 
of life. His appetite for food and drink is not excessive, and 
patient says this has always been the case. 
Urinary analysis was made by Dr. Lathrop, senior resident 
physician at the city hospital, Urine Sp. Gr. 1028. No al- 
bumen. No sugar. Mucus and slight excess of urates were 
present. The average daily quantity of urine is 52 1-6 oz., 
but the daily quantity varies from 29 oz. to 84 oz. 
In measuring the patient I have followed the plan adopted 
by Marie, and I have also made use of the metric system, as 
well as the inch measure, so that comparison of this patient 
with others could be made. The measurement of the ex- 
tremities have all been taken on the left side. 
MEASUREMENTS : 
Length of hand from lower fold of wrist to end of middle finger . . 
210 mm.-8X in- 
Length of middle finger starting from palmar fold to base . 98 mm.-3% in. 
Length of middle finger on dorsal aspect, starting from the base of its 
first phalanx 130 mm.-4 7-16 in. 
Length of little finger, palmar aspect 78 mm.-3 1-16 in. 
Circumference of hand without thumb at metarcapal-phalangeal joints. 
■ • - 265 mm. 10 7-16 in. 
Width-ditto 120 mm. 4 11-16 in. 
Greatest thickness of hand at level of thenar eminence . . 55 mm. 2 3-16 in. 
Circumference of middle finger 93 mm. 3 11-16 in. 
" thumb 96 mm. 3 12-16 in. 
" " little finger 80 mm. 3 3-16 in. 
" " wrist immediately below extremity of ulna and ra- 
dius 220 mm.-7 11-16 in. 
Circumference of wrist immediately below styloid proces of ulna . . 6 
218 mm.-7 9-16 in. 
Circumference of forearm at middle 305 mm.-12 in. 
" " arm at middle 331 mm.-13 in- 
Length from iliac crest to summit of the head of fibula . 552 mm.-21^ in. 
Length from summit of head of fibula to tip of external maleolus . . 
430 mm.-17 in. 
Vertical diameter of patella 7° mm.-2^ in. 
Transverse 80 mm.-3 3-16 in. 
Circumference of thigh at middle 570 mm.-22 7-16 in. 
Greatest circumference of calf . 453 mm.-17 9-16 in. 
Circumference immediately above tip of internal maleolus . 330 mm.-13 in. 
Greatest length of foot 295 mm.-11 10-16 in. 
Circumference over heel and instep 423 mm.-16 10-16 in. 
Greatest circumference of foot 319 mm.-12% in. 
Greatest width of foot 119 mm.-4 11 16 in. 
Circumference of big toe 136 mm.-5 5-16 in- 
" " little toe 75 mm -3 in' 
Length from top of forehead to tip of chin 257 mm.-10% in. 
Length from top of forehead to upper part of nasal bones, 85 mm.-3 5-16 in. 
Length from upper part of nasal bones to tip of nose . . 85 mm.-3 5-16 in. 
Greatest width of alae nasi 46 mm.-1 13-16 in. 
Distance from tip of nose to point of junction of latter writh upper lip. 
35 mm.-1 6-16 in. 
Length from septum of nose to point of chin 103 mm.-4 1-16 in. 
Greatest distance between the outer surfaces of the cheek bones . . . 
135 mm-5 5 16 in. 
Width of mouth 66 mm.-2 10-16 in. 
Vertical measurement of lower lip 16 mm. -10-16 in. 
Transverse measurement at middle of tongue 70 mm.-2^ in. 
Length of one of borders of tongue pulled out as far as possible to the 
upper lip 70 mm.-2^ in. 
Lower jaw, vertical measurement from free borders of gum to lower 
part of symphisis 48 mm.-114-16 in. 
Distance from tempero malar articulation to lower part of symphisis 
of chin 178 mm.-7 1-16 in. 
Distance between the angles of lower jaw 131 mm.-5 3-16 in. 
Distance between angles of lower jaw with tape measure, along body 
of bone passing in front of symphisis 275 mm.-10 13-16 in. 
Circumference of thorax over nipple 1230 mm.-48^ in. 
Antero posterior diameter of thorax 359 mm.-14% in. 
Circumference of neck between hyoid bone and upper part of thyroid 
cartilage 440 mm.-17 5-16 in. 
(Where there was a projecting body between two points of measurement 
callipers were employed so as to be accurate.) 7 
There have been so few cases of acromegaly reported that it 
would be difficult to describe all the typical symptoms, no two 
cases being exactly alike. The elliptical shaped face and the 
hypertrophy of the hands and feet, however, have been pres- 
ent in every case. 
There is a notable absence of subjective symptoms in Mr. 
M.'s case. He has suffered slightly with headache, has had 
two abscesses, and has lost the sexual appetite. He is also 
completely blind ; but Dr. Taylor's report would lead us to 
infer that the blindness is due to causes distinct from the 
acromegaly, while he recognizes the possibility of its being 
caused by hypertrophy of the pituitary body. 
There is no constant headache, no polydipsia, polyphagia, 
or polyuria. The thymus gland is not present, and there are 
no varicose veins ; all of which symptoms have been present 
in the majority of patients. 
The etiology of the disease is unknown. Several of the 
patients have been syphilitics, but whether this has any effect 
upon the causation of acromegaly is doubtful. There has 
never been any proof of heredity. 
Acromegaly occurs with about the same frequency in both 
sexes. It first appears between the ages of 20 years and 30 
years ; is very slow in its progress, lasting 20 or 30 years or 
more. 
Little is known regarding its morbid anatomy. Marie 
(Brain, July, '89,) in concluding his description of acromegaly 
says, "That hypertrophy of the pituitary body with enor- 
mous dilatation of the sella turcica, persistence of the thymus, 
and finally hypertrophy of the cord and ganglia of the sym- 
pathetic system not only occur with a remarkable degree of 
frequency, but may even be looked upon as constant." 
That these conditions are not always present is proven in 
the case reported by Frantzel (Deutsche Medicinische Woch- 
enschrift, '88,) and on which an autopsy was performed a year 
later by Virchow (Berliner Klinische Wochenschrift, Feb- 
ruary 4, '89). Virchow noted absence of the thymus gland, 
and a normal condition of the thyroid and pituitary glands. 
Broca (Archives Generales de Medicine, December, '88,) de- 
scribes the skeleton of one of the original cases of acromegaly 
by Marie. "The principal change found was an hypertro- 
phied and increased porosity of the bones of the extremities 8 
and enlargement of the channels containing blood vessels. 
There were also exostoses at the articular extremities of the 
bones. The inferior maxillary bone was greatly hypertro- 
phied, and all the sinuses in the bones of the skull were 
dilated." 
Diagnosis.-The case presented cannot well be confounded 
with any of the diseases which resemble Acromegaly. 
In myxoedema the soft parts alone are affected. The skin 
is thickened and scaly, and both it and the subcutaneous 
cellular tissue present a waxy like condition. The face is 
round and the mental condition is bad. The skeleton, on the 
other hand, is unaffected. The symptoms are all absent in 
the patient presented. 
The Leontiasis ossea of Virchow gives rise to bony tumors 
on the face and cranium, causing a hideous appearance and 
great deformity. 
Osteitis deformans of Paget generally manifests itself after 
forty years, whereas Acromegaly appears from ten to twenty 
years earlier. The deformity does not occur symmetrically, 
as it does in this patient, and hypertrophy affects the long 
bones in preference to the bones of the extremity and the 
extremity of the bones. The long bones also present marked 
deformities. The bones of the cranium also undergo hyper- 
ostosis instead of the bones of the face, giving the latter a 
triangular and not an elliptical shape. 
In gigantism all parts are proportionately enlarged, there 
being no special hypertrophy of the lower jaw, hands and feet. 
Marie will not admit that Friedrich's disease, in which hy- 
pertrophies occur somewhat similarly to those of Acromegaly, 
has any connection with this disease, and also will not allow 
it to be confused with unilateral hypertrophies, which some- 
times occur in different parts of the body. 
Treatment has had no effect upon the progress of this dis- 
ease. In the present case there has been no attempt at treat- 
ment. 
My thanks are due to Dr. G. W. Guthrie for allowing me 
to observe the patient in the City Hospital ; Dr. L. H. Tay- 
lor for the ophthalmascopic examination, and Dr. Lathrop, 
(Resident of the Hospital), for the urinary analysis.