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dular swelling of the scrotum； until finally the scrotum was two feet long and six feet in circumference。 It is mentioned that mortification of the part caused this patient's ultimate death。
Figure 281 is taken from a photograph loaned to the authors by Dr。 James Thorington。 The patient was a native of Fiji； and was successfully operated on； with preservation of the testes。 The tumor； on removal； weighed 120 pounds。
W。 R。 Browne； Surgeon…General； reports from the Madras General Hospital an operation on a patient of thirty…five with elephantoid scrotum of six years' duration。 The proportions of the scrotum were as follows： Horizontally the circumference was six feet 6 1/2 inches； and vertically the circumference was six feet ten inches。 The penis was wholly hidden； and the urine passed from an opening two feet 5 1/2 inches from the pubis。 The man had complete control of his bladder； but was unable to walk。 The operation for removal occupied one hour and twenty minutes； and the tumor removed weighed 124 3/4 pounds。 Little blood was lost on account of an elastic cord tied about the neck of the tumor。 and secured by successful removal of a scrotal tumor weighing 56 pounds。
Fenger describes a case of the foregoing nature in a German of twenty…three； a resident of Chicago。 The growth had commenced eight years previously； and had progressively increased。 There was no pain or active inflammation； and although the patient had to have especially constructed trousers he never ceased his occupation as a driver。 The scrotum was represented by a hairless tumor weighing 22 pounds； and hanging one inch below the knees。 No testicles or penis could be made out。 Fenger removed the tumor； and the man was greatly improved in health。 There was still swelling of the inguinal glands on both sides； but otherwise the operation was very successful。 The man's mental condition also greatly improved。 Fenger also calls especial attention to the importance of preserving the penis and testes in the operation； as although these parts may apparently be obliterated their functions are undisturbed。
The statistics of this major operation show a surprisingly small mortality。 Fayrer operated on 28 patients with 22 recoveries and six deaths； one from shock and five from pyemia The same surgeon collected 193 cases； and found the general mortality to be 18 per cent。 According to Ashhurst； Turner； who practiced as a medical missionary in the Samoan Islands； claims to have operated 136 times with only two deaths。 McLeod； Fayrer's successor in India； reported 129 cases with 23 deaths。
Early in this century Rayer described a case of elephantiasis in a boy of seventeen who； after several attacks of erysipelas； showed marked diminution of the elephantoid change； the fact shows the antagonism of the streptococcus erysipelatis to hypertrophic and malignant processes。
Acromegaly is a term introduced by Marie； and signifies large extremities。 It is characterized by an abnormally large development of the extremities and of the features of the face；the bony as well as the soft parts。 In a well…marked case the hands and feet are greatly enlarged； but not otherwise deformed； and the normal functions are not disturbed。 The hypertrophy involves all the tissues； giving a curious spade…like appearance to the hands。 The feet are similarly enlarged； although the big toe may be relatively much larger。 The nails also become broad and large。 The face increases in volume and becomes elongated； in consequence of the hypertrophy of the superior and inferior maxillary bones。 The latter often projects beyond the upper teeth。 The teeth become separated； and the soft parts increase in size。 The nose is large and broad； and the skin of the eyelids and ears is enormously hypertrophied。 The tongue is greatly hypertrophied。 The disease is of long duration； and late in the history the bones of the spine and thorax may acquire great deformity。 As we know little of the influences and sources governing nutrition； the pathology and etiology of acromegaly are obscure。 Marie regards the disease as a systemic dystrophy analogous to myxedema； due to a morbid condition of the pituitary body； just as myxedema is due to disease of the thyroid。 In several of the cases reported the squint and optic atrophy and the amblyopia have pointed to the pituitary body as the seat of a new growth of hypertrophy。 Pershing shows a case of this nature。 The enlargement of the face and extremities was characteristic； and the cerebral and ocular symptoms pointed to the pituitary body as the seat of the lesion。 Unverricht； Thomas； and Ransom report cases in which the ocular lesions； indicative of pituitary trouble； were quite prominent。 Of 22 cases collected by Tamburini 19 showed some change in the pituitary body； and in the remaining three cases either the diagnosis was uncertain or the disease was of very short duration。 Linsmayer reported a case in which there was a softened adenoma in the pituitary body； and the thymus was absent。
Hersman reports an interesting case of progressive enlargement of the hands in a clergyman of fifty。 Since youth he had suffered with pains in the joints。 About three years before the time of report he noticed enlargement of the phalangeal joint of the third finger of the right hand。 A short time later the whole hand became gradually involved and the skin assumed a darker hue。 Sensation and temperature remained normal in both hands； acromegaly was excluded on account of the absence of similar changes elsewhere。 Hersman remarks that the change was probably due to increase in growth of the fibrous elements of the subcutaneous lesions about the tendons； caused by rheumatic poison。 Figure 283 shows the palmer and dorsal surfaces of both hands。
Chiromegaly is a term that has been applied by Charcot and Brissaud to the pseudoacromegaly that sometimes occurs in syringomyelia。 Most of the cases that have been reported as a combination of these two diseases are now thought to be only a syringomyelia。 A recent case is reported by Marie。 In this connection it is interesting to notice a case of what might be called acute symptomatic transitory pseudoacromegaly； reported by Potovski： In an insane woman； and without ascertainable cause； there appeared an enlargement of the ankles； wrists； and shoulders； and later of the muscles； with superficial trophic disturbances that gradually disappeared。 The author excludes syphilis； tuberculosis； rheumatism； gout； hemophilia； etc。； and considers it to have been a trophic affection of cerebral origin。 Cases of pneumonia osteoarthropathy simulating acromegaly have been reported by Korn and Murray。
Megalocephaly； or as it was called by Virchow； leontiasis ossea； is due to a hypertrophic process in the bones of the cranium。 The cases studied by Virchow were diffuse hyperostoses of the cranium。 Starr describes what he supposes to be a case of this disease； and proposes the title megalocephaly as preferable to Virchow's term； because the soft parts are also included in the hypertrophic process。 A woman of fifty…two； married but having no children； and of negative family history； six years before the time of report showed the first symptoms of the affection；