deepened, the skin thick and resilient, the hairs coarse, the nails broadened, thick, and strongly striated longitudinally.

The feet show similar changes, and usually there is a heavy welt of fibro-elastic increase around the heel and along the outer border of the foot.

The thorax usually presents an anteroposterior curvature in the cervicodorsal region, which may be compensated by lumbar lordosis and attended by scoliotic twists. The clavicles are almost invariably increased in thickness and sometimes in length, and the sternum may also share in the hypertrophy. The ribs and cartilages are often enlarged. These bony changes give the chest an unusual breadth and anteroposterior depth. The respiration is ordinarily abdominal in character, and the abdomen is often protuberant or even pendulous. The pelvic girdle may be enlarged.

The external genitalia in women are ordinarily hypertrophied, the uterus atrophic. In men there may be hypertrophy or atrophy of the external genitals. Amenorrhea and sterility are the rule with women, sexual inappetence and impotence with men.

Cephalalgia of an intense, persistent, deep-seated character is present in the great majority of cases.

Speech is frequently thickened from the clumsiness and voluminous size of the tongue, and the voice is ordinarily very deep, strong, and rough, owing to the enlargement of the larynx, which to palpation may appear of increased dimensions and unusual prominence.

The organs of special sense may all be affected. Smell, taste, or hearing may be reduced or abolished, but this is uncommon. Vision, however, is usually more or less affected eventually. This may arise from optic neuritis or from atrophy, and in either case points to encephalic tumor. Amblyopia, blindness, intra-ocular pains, exophthalmos, contraction of the visual field, temporal hemianopsia, and miosis have been noted. The

bilateral loss of the temporal fields or their manifest reduction indicates injury to the chiasm by the pituitary tumor.

The muscular system may be normal or some atrophy may be found, but general muscular weakness is the rule. The reflexes are normal or diminished. The electrical responses are frequently quantitatively reduced. Cardiac hypertrophy, arteriosclerosis, varicose veins, and slight lymphatic adenopathy may be encountered. The thyroid may be absent, normal, or hypertrophic. Polyuria, glycosuria, polydipsia, excessive appetite for food, and dyspepsia are common.

General physical feebleness is usual, and mental sluggishness, irritability, and inaptitude are common.

Course and Forms.-The disease is of insidious onset and slow progression, presenting a duration of twenty to thirty years and terminating by a cachectic state marked by great muscular weakness, during which death often occurs suddenly through cardiac failure. Intercurrent affections find acromegalics very vulnerable.

We may distinguish two varieties of acromegalia, depending mainly upon the age at which the disease commences and the condition of epiphyseal ossification with the diaphyses: (1) Before complete ossification takes place the enlargement is not only in lateral dimensions, but also in length, and the limbs become disproportionate to the body, producing gigantism. Autopsical findings by Hutchinson, Dana, Bramwell, Taruffi, and skiagraphical investigations by Marinesco conclusively show this relation. (2) After the diaphyses and the epiphyses are united by bone, only circumferential increase is produced, and the stature, from scoliosis, may actually be reduced. The commoner massive type originally described is then developed.

Fig. 200. Cervicodorsal curvature of spine; chest and abdominal distortion in acromegalia (Marie).

Diagnosis. The diagnosis can rarely present difficulty if the disease has attained any considerable degree of development. Myxedema shows no osseous deformities, and the thickening of the soft parts is waxy and boggy. Pulmonary osteo-arthropathy presents joint-changes and a chronic pulmonary process. The clubbed enlargement of the fingers is largely confined to the terminal phalanges, over which the hypertrophic nails hang like parrot-beaks. In hyperostosis cranii the hands, feet, and mandible are not affected. Paget's disease, or osteitis deformans, spares the face, but affects the skull, and causes bowing of the long bones, especially the femora and tibiæ. The x-ray may show excavation of the sella.

Prognosis. The progress, as above indicated, is toward physical helplessness and mental depression, which in more than one instance have led to suicide. According to Thompson, the disease may run an 1 "Br. Med. Jour.," April 9, 1899.

1

acute, intermittent, or chronic course, lasting from two to thirty years. Sudden death from cardiac failure is rather frequent. As yet the disease is not therapeutically manageable.

Treatment is confined to relieving the cephalalgia and correcting the symptomatic disturbances as far as possible. For the first, phenacetin and similar synthetical anodynes seem to be most efficacious. Treatment by thyroid, thymus, and pituitary preparations, singly or combined, seems to be of little avail, except in some instances to reduce weight, and then often at the expense of the general health and strength. Animal extracts may, however, yet control the malady, but a recession of osteal hypertrophy is too much to reasonably anticipate when once it has developed.

HYPERTROPHIC OSTEO-ARTHROPATHY.

For

In 1890 Marie and, independently, Bamberger described cases of chronic intrathoracic disease attended by skeletal deformities. such, Marie proposed the term osteo-arthropathie hypertrophiante pmeumique. Massalongo, Thayer, and others insist that the pulmonary factor is by no means essential, and Thayer 1 found it absent in 12 out of 55 typical cases. Other chronic conditions to which it is secondary are syphilis, heart disease, diarrhea, and spinal caries. It has been associated with phthisis, empyema, bronchiectasis, pulmonary syphilis and neoplasms, pleurisy, bronchitis, and gastric dilatation. The disease presents a multiple osteitis, affecting mainly the terminal phalanges of the hands and feet, the extremities of the long bones of the limbs, and the neighboring joints. The affected bones are enlarged, rarefied, and show the evidence of inflammation. The cartilages are eroded, the synovial membranes thickened. The fingers, owing to the globular enlargement of the distal phalanges, have been likened to drumsticks. The nails are greatly enlarged and overhang the thickened finger-ends like a parrot's beak. Usually they are thin and smooth. The joints creak and grate on motion, and the ankles and wrists are ordinarily broadened and thickened. Elbows and knees may be similarly affected, and the toes show deformities and disproportions similar to those of the fingers. The invariable presence of chronic toxemic states indicates a toxic basis for the trophoneurosis; for instance, Preble 2 noted it in a case of gastrectasis. The disease usually is of insidious onset and is frequently attended by rheumatoid pains. It may occur at any age.

The diagnosis is commonly easily made, though at first this dystrophic disease was confused with acromegalia. It does not affect the head, face, or soft parts, and does involve the joints. In acromegalia the fingers and toes are uniformly enlarged, and the wrists and ankles are not disproportionately increased in size. The facies of acromegalia is never seen in pulmonary osteo-arthropathy.

The disease runs a protracted course, but may come to a standstill, or it may recede slightly if the thoracic condition is greatly improved. Desmons and Beraud report some improvement following subcutaneous injections of extracts made from sheep's lungs.

166

1 Phila. Med. Jour.," Nov. 5, 1898.

3" Archives gen. de Méd.," 1894.

2 66

Medicine," Jan., 1898.

HYPEROSTOSIS CRANII.

Virchow used the term leontiasis ossea, Starr, megalocephalie, and Putnam, hyperostosis cranii to designate certain rare cases in which the bones of the cranium, and less markedly those of the face, undergo enormous enlargement. The process is apparently inflammatory in character, but its symmetrical distribution, association with developmental periods of life, and progressive nature point to a lack of trophic control. Putnam, accepting seven from Baumgarten's list, has been able to tabulate fifteen cases, including that of Edes. In the majority

the disease appears under thirty years of age, and often in childhood or at puberty. The cranial enlargement is sometimes preceded by inflammations about the head, such as erysipelas, and by traumatism. Early symptoms have been headache, drowsiness, epileptic attacks, deafness, and blindness. Mental irritability or enfeeblement is common. Exophthalmos, loss of hearing, facial palsy, optic neuritis, and blindness are due to local or intracranial pressure. The anterior portion of the head is usually most enlarged, and the upper facial bones are more affected than the inferior maxilla. Prognathism is not commonly ob

1 "Amer. Jour. Med. Sciences," July, 1896.

served. There is usually a large increase in the bitemporal diameter. In some instances the bones are rather evenly enlarged; in others there are numerous exostotic thickenings, both on the outer and inner surface of the cranium, or on either aspect alone. The cervical vertebræ are sometimes also enlarged. The disease is progressive and not amenable to treatment. Putnam, Starr, and others have tried thyroids in vain. Encephalic pressure may in suitable cases be relieved by trephining.

MYXEDEMA.

Under the generic term of myxedema it is proposed to bring together those clinical variations of nutritive disorder dependent upon partial or complete cessation of thyroid activity. In 1873 Gull described a cretinoid state occurring in adult women. Four years later Ord reported additional cases and proposed the word myxedema (mucous swelling). Charcot, about this time, struck by the cutaneous thickening and the cachectic state, used the term pachydermatous cachexia. In 1880 Bourneville and d'Olier described a case of myxedematous idiocy and subsequently many more. In 1882 Reverdin, and shortly afterward Kocher, reported myxedema following complete extirpation of the thyroid, for which they severally proposed the terms of operative myxedema and cachexia strumipriva. The analogies between acquired myxedema, myxedematous idiocy, and cretinism have been noted by many, and Brissaud, in his lectures of 1893-'94, brings certain cases infantilism, or physical retardation, into the same category. We will commence by a description of acquired myxedema in adults. Due allowance being made for the age and growth of the individual, and the suddenness and completeness with which the thyroid is affected, will practically enable this description to be applied to all the abovementioned varieties.

of

Acquired myxedema of adults is of insidious onset, as a rule, and more common in women than in men. It usually appears between the ages of thirty and fifty. Occasionally it has abruptly followed an attack of acute rheumatism, some infectious fever, or a severe hemorrhage. It is marked by: (1) Tumefaction of the dermal and mucous structures; (2) by intellectual and physical enfeeblement, and (3) by atrophy of the thyroid body.

The dermal changes are the most striking. The skin is infiltrated with a mucoid substance and the fatty panniculus is frequently greatly thickened. The swelling offers an elastic resistance to the touch and does not pit on pressure. The color is usually pale, yellowish, and waxy or cheesy. The face is enlarged, rounded, and apathetic. The heavy, thickened lids droop over the eyes, the nose and lips are thickened, the brow is furrowed, the ears enlarged, and the cheeks rounded and showing jelly-like trembling on slight jarring. The whole appearance is one of hebetude and stupidity. The skin of the trunk and extremities is likewise infiltrated. In the axillæ and subclavicular depressions lipomatous-like masses are often encountered. The hands