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This is to certify that the

thesis entitled

The Application of Differential Diagnosis to the
Paleopathology of Acromegaly and Giantism

presented by

Michelle Harushia

has been accepted towards fulfillment
of the requirements for

Masters degree in Anthropology

 

 

 

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Date December 13, 2000

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The Application of Differential Diagnosis to the Paleopathology
of Acromegaly and Giantism

By

Michelle Marushia

A THESIS

Submitted to
Michigan State University
In partial fulfillment of the requirements
For the degree of

Masters of Arts
Department of Anthropology

2000

ABSTRACT

The Application of Differential Diagnosis to the Paleopathology
of Acromegaly and Giantism

By

Michelle Marushia

The diagnosis of giantism and acromegaly were examined in case studies from
paleopathology literature. Major diagnostic characteristics were noted as used by the
authors and analyzed to examine how the diagnoses of giantism and acromegaly were
actually being applied to skeletal material. Autopsied soft tissue case studies were also
used. The results of this study showed that diagnoses of giantism and acromegaly have
been inconsistently applied, and that a clear understanding of the disease process in the
living is necessary to understand the skeletal changes that can occur. Also, researchers
did not offer enough information to allow for independent assessment of diagnosis by
others. Statistical analysis showed that a majority or researchers made the diagnosis of
giantism based upon “greater than average height” and the diagnosis of acromegaly
based upon the “elongation of the mandible”. Finally, an overall system of differential

diagnosis for giantism and acromegally was generated.

Copyright by
Michelle Marushia
2000

Table of Contents

List of Tables v
Introduction 1
Chapter 1 Discussion of Giantism and Acromegaly 3
Chapter 2 Methods 13
Chapter 3 Diseases Commonly Confused with Acromegaly and Giantism 23
Chapter 4 Acromegaly and Giantism: Skeletal and Soft Tissue Cases 34
Chapter 5 Analysis and Discussion 85
Chapter 6 Summary and Conclusions 106
Appendix 1 Characteristics of Specific Diseases 111
Appendix 2 Characteristics of Skeletal Case Studies 114

Appendix 3 Data and Percentages for the Analysis of the Skeletal Case Studies 124
Appendix 4 Time Lines and Data for the Soft-Tissue Case Studies 141

References 148

List of Tables

Table 1:
Table 2:
Table 3:
Table 4:
Table 5:
Table 6:
Table 7:
Table 8:
Table 9:

Table 10:
Table 11:
Table 12:

Table 13:
Table 14:
Table 15:
Table 16:
Table 17:
Table 18:
Table 19:
Table 20:
Table 21:

Table 22
Table 23
Table 24

Table 25:

Hormones Secreted by the Pituitary and Their Actions.
Compiled List of Lesions Associated with Acromegaly.
Compiled List of Lesions Associated with Giantism.

The Polish Giant Authors’ Described Characteristics.
The Tergensee Giant Authors’ Described Characteristics.
The Mutter Giant Authors’ Described Characteristics.
The Persian Giant Authors’ Described Characteristics.

Smithsonian Individual #2 Authors’ Described Characteristics.
Smithsonian Individual #3 Authors’ Described Characteristics.

Gardarene Skull Author’s Described Characteristics.
Charles O’Brien Authors’ Described Characteristics.
Rhine’s New Mexico Acromegalic Author’s
Described Characteristics.

Egyptian Skull Author’s Described Characteristics.

Marushia/Sauer Individual Authors’ Described Characteristics.

San Cristobal Individual Authors’ Described Characteristics.
Dick’s Mound Skull Author’s Described Characteristics.
Hososvski Individual Author’s Described Characteristics.
The Norfolk Giant Authors’ Described Characteristics.

The Archaeology of Nubia #1 Authors’ Described Characteristics.
The Archaeology of Nubia #2 Authors’ Described Characteristics.

Frequency of Other Selected Characteristics.

Heights (in centimeters) Used for T-test Analysis
Basic Statistics for Skeletal Case Studies with Heights
US. Population Statistics 1977-1980,

All Races, Male, Age 18-74

Summary of Giantism and Acromegaly Duration in
Soft—Tissue Case Studies.

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INTRODUCTION

The accurate assessment of disease processes in human skeletal materials is
important in the generation of a biological profile. This in turn is essential to the study
of other areas, such as paleodemography, prehistoric community health, and forensic
anthropology. This study will systematically examine the disease processes of giantism
and acromegaly, both of which have been identified in a number of historic and
prehistoric case studies. Giantism and acromegaly, the juvenile and adult forms of the
same disease process, are associated with the overproduction of growth hormone (GH),
which is often associated with a pituitary adenoma.

Both acromegaly and giantism have been identified in human skeletal remains.
Giantism and acromegaly result from an imbalance in the endocrine system, which is
specifically linked to the presence of a specific pituitary tumor, an acidophilic adenoma.
What separates the hyperpituitary giant from the acromegalic is the age of onset of the
disease process. Children or those individuals who have not reached puberty could
show the clinical signs and symptoms of giantism. Adults or those individuals who
have gone through puberty could be considered acromegalic (Aegerter and Kirkpatrick
197 5:379).

Overproduction of growth hormone, usually associated with these pituitary
adenomas or tumors, often leads to many of the characteristic clinical features of
acromegaly and giantism. Giantism is characterized by excessive height with normal
body proportions, whereas acromegaly is characterized by excessive growth of the

extremities and the skull (particularly in the mandibular condyle). Uncomplicated

giantism is characterized by bones that are long but are not massive. Many clinical
symptoms such as cardiac disease, depression and diabetes are also associated with
pituitary adenomas (Robbins and Cotran 1979:1338-1339, Jaffe 1972, and Hayles
1980).

“In acromegaly, bone deposition occurs and leads to... extreme height” (Roberts
and Manchester 1997: 1 81). While the most commonly cited feature is excessive height,
Aufderheide and Rodriguez-Martin (1998: 327) point out that acromegaly occurs in
“normal adults whose tumors develop after grth has ceased.” These authors also
note that those suffering from giantism can become acromegalic in adulthood if their
pituitary tumors remain active. Since other diseases produce skeletal characteristics that
overlap with acromegaly and giantism, it is necessary to distinguish among these
similarly appearing conditions. In order to address this issue, differential diagnosis can
be used. Differential diagnosis, usually used to assess the disease state in a living
individual, is implemented in skeletal biology and paleopathology to distinguish among
disease processes with similar lesions (Buikstra 1976).

This thesis will examine the diagnosis of acromegaly and giantism in human
skeletal remains through a systematic review of the literature. Using present medical
knowledge of the clinical presentations of these diseases, as well as information from
paleopathology, a systematic method of differential diagnosis will be generated.

Within this framework, variations of the presentation and distribution of skeletal
pathologies of giantism and acromegaly will be discussed using a number of case
studies. Cultural concepts will also be addressed as they relate to the observer’s ability

to accurately identify giantism and acromegaly in the human skeleton.

CHAPTER 1

DISCUSSION OF GLANTISM AND ACROMEGALY

Anatomy of the Pituitary

Tumors of the pituitary can affect the individual in two ways. First: the physical
presence of the tumor as it affects adjacent structures. Second: changes can result in the
production and secretion of pituitary hormones or “hypothalamic principles” (Anderson
and Kissane 1977:1616). Knowledge of the anatomic relationships of the pituitary to its
environs, therefore, is essential in understanding the symptoms caused by pituitary
tumors (Anderson and Kissane197721603, Robbins and Cotran 1979:1338). Growth of
this tumor can cause erosion and remodeling of the sella turcica as well as surrounding
bony structures (Aufderheide and Rodriguez-Martin 1998: 327-328, Ortner and
Putshcar 19992298).

In the adult, the pituitary gland is situated in the hypophyseal fossa of the sella
turcica in the sphenoid bone of the skull. The optic chiasm, hypothalamus, and the third
ventricle lie directly above the gland. Lateral to the pituitary on each side are the
cavernous sinuses, each containing the internal carotid artery and cranial nerves III, IV,
IV, and VI. If the tumor expands, these structures can be impacted (Weinreb 1984:277-
283, Moore 1992:637-782).

As the pituitary tumor expands, its physical presence can exert pressure on the
sella turcica and its surrounding tissues. Space-occupying lesions in general cause

nausea, vomiting, headaches and increased intercranial pressure (Robbins and Cotran

 

1979, Jaffe 19721333, and Cushing and Davidoff 1927). Headaches are one of the first
signs that press people to seek medical help (Cushing and Davidoff 1927 ). As the optic
chiasm and nearby nerves are compressed by the expanding tumor, visual disturbances
can result. If the pituitary tumor expands such that the blood flow is cut off to the
tumor, this disease can burn itself out (Jaffe 19722333, and Robbins and Cotran
1979:1340).

If the tumor continues to grow and expand, the posterior lobe of the pituitary
and the hypothalamus can be affected (Weinreb 1984:277-2 83). The pituitary gland
itself can be compromised, which can lead to an insufficiency of pituitary hormones or
diabetes. Production and transport of releasing substance and inhibitory factors can be
affected when a pituitary tumor physically crowds the hypothalamus. The hormones
secreted by the pituitary and their actions are listed in Table 1 (modeled after Weinreb

1984:282-283).

Table 1: Hormones Secreted by the Pituitary and Their Actions

0 Growth hormone: promotes bone grth
0 Thyrotropin: involved in metabolism regulation
0 Adrenocorticotropin: stimulates secretion of glucocorticoids

Gonadotropins

o F ollicIe-stimulating hormone: involved in functioning of ovary and testis
Luteinizing hormone: ovary function: secretion of estrogen and progesterone
Interstitial cell-stimulating hormone: testis function, secretion of testosterone
Prolactin: lactation and mammary glands

Melanocyte—stimulating hormone: Stimulates melanin/pigment production on skin

Hypothalmus

o Oxytocin: affects mammary glands and uterus

o Vasopressin/antidiuretic hormone: affects kidneys water reabsorption,
vasoconstriction, too little causes diabetes

As functions of the pituitary and hypothalamus are affected, imbalance of the
endocrine system can occur (Robbins and Cotran 1979:1338). The pituitary gland,
along with many other glands found throughout the body, is part of the endocrine
system. These glands secrete specific hormones that are involved in the regulation of
body activities. The endocrine system’s operations involve all tissues in the body,
which is why its influence “is widespread, of longer duration, and results in more
diversified, slower effects suitable to responses that require time, such as metabolism,
growth and reproduction”(Weinreb 1984:272) With this information, it is easy to see
why involvement of the pituitary would lead to a slow progression of the disease with
whole body involvement.

Tumors in the anterior pituitary are responsible for two distinctive, but
interrelated, syndromes. Giantism or acromegaly occur with the overproduction of
growth hormone. Amenorrhea-galacctorrhea results from the overproduction of
prolactin. “Structurally GH is similar to prolactin and many patients with acromegaly
have hyperprolactinaemia” (Bouchier and Morris 19821577). Cessation of menstruation
and infertility can result (Robbins and Cotran 1979:1339).

In order to understand the distribution of lesions in a systematic manner,
acromegaly and giantism will be examined as one disease-state that is differentiated by
developmental age of onset. Hyperpituitarism is the general term used to designate
increased levels of growth hormone regardless of age at disease onset (Robbins and
Cotran 1979:1339). “The term hyperpituitarism should, in reality, apply to any
syndrome resulting from hypersecretion of any one of the trophic hormones. Clinically,

this usually refers to acromegaly and giantism” (Robbins and Cotran 1979:1339).

 

Description ofGiantism and Acromegaly

Giantism and acromegaly occur in approximately three people out of one
million (Robbins and Cotran 1979). In contrast, Bouchier and Morris (1982:575)
suggest one in 10,000 for acromegaly. At autopsy, pituitary tumors were evident in
25% of the population examined (Harrison 1981:1899). Males and females show an
equal rate of occurrence. Diagnosis is usually not made until the disease has progressed
for 10-15 years. The average age at diagnosis is in the early 40’s. Researchers suggest
that acromegaly might have a genetic component in some cases. Inheritance is thought
to be autosomal dominant (McKusick (c) 1986, Nabarro 1987 and “National Institutes
of Health” 1995).

A pituitary adenoma is a cause of giantism and acromegaly. Overproduction of
growth hormone before puberty can lead to excessive height due to the unrestricted
grth at the epiphyseal plates. Because hypogonadism commonly accompanies
giantism, the lack of sufficient gonadal hormones delays puberty and epiphyseal
closure. Connective tissue of the skin and other subcutaneous tissues, such as ligaments
and synovial membranes are also affected by the overgrowth (J affe 1972, and Robbins
and Cotran 1979).

When height is increased, growth is increased proportionality through out the
entire skeletal system. If height is extreme, other lesions often result from the increased
weight of the individual, such as spinal curvature, vertebral arthritis, and general
arthritis. Fractures of weight-bearing bones can occur due to simple mechanical stress
from the increased weight load. This is complicated by the osteoporosis that can occur

with acromegaly and giantism (Anderson and Kissane 1977:1928, Aufderheide and

Rodriguez-Martin 1997:327). The sella turcica can be enlarged due to the pituitary
tumor (Ortner and Putschar 1981).

Acromegaly, characterized by continued overgrth of soft tissues and
connective tissue, develops in adulthood after epiphyseal closure takes place. This
overgrth results in many of the identifying facial and skeletal characteristics of
acromegaly. “Acral” refers to the hands and feet. “Mega” refers to large. Together,
these two concepts refer to the large hands and feet found in advanced acromegaly
(Robbins and Cotran 1979:1340). Because of the characteristic growth in the bone and
soft tissue of the face and skull, acromegalics are often said to look more like each other
than like members of their own family (Harrison 1981:1899).

Initially, there are few observable physical signs of acromegaly. Often the first
indication of the process is frequent, debilitating headaches often accompanied by
nausea and vomiting. Hat, shoe, and glove sizes increase, but often the people do not
take much notice until commented upon by others. Gradually, changes in skin
coloration and texture occur. The skin becomes thickened and darkened with an
increased production of sebaceous substances (Cushing and Davidoff 1927).

Women experience ammenorrhea, the cessation of menstruation without
pregnancy or menopause (J affe 1972:334). Men often experience decreased libido and
degeneration of the testicular tissue (Hamwi 19602695). Increasing duration of the
disease tends to increase the reproductive system changes (Nabarro 1987).

In general, the facial features of an individual with acromegaly become broader
and coarser. Supraorbital ridges, or brow ridges, and the malar prominences, or cheeks,

become more pronounced, and the exterior occipital protuberance becomes exaggerated

(Ortner and Putschar 1981). The jaw lengthens due to the increased growth at the
mandibular cartilage. Mandibular deformation occurs with increasing severity as
judged by increasing length of the lower jaw in relation to the maxilla. The chin juts
forward due to bone growth at the mental eminence. As this disease progresses, an
increasing prognathism can occur due to the bone growth expanding the maxillary and
mandibular radii. Teeth become widely spaced. Radiographs often reveal huge frontal
sinuses and a noticeably thickened skull (Ortner and Putschar 1981, and J affe 1972).

The appendicular skeleton also exhibits distinctive changes as result of the bone
and connective overgrowth. Fractures can occur due to simple mechanical stress, which
is complicated by osteoporosis (Robbins and Cotran 1979: 13 1339). Tufting of the
distal phalanges may occur, giving the fingers a clubbed appearance upon physical
examination. Increased growth at the costo-chondral junction results in elongation of
the ribs, which leads to an increased diameter of the thorax (Bouchier and Morris
19822575, and Ortner and Putschar 1981). Overall, all prominent points of the skeleton
demonstrate increased rugosity (Ortner and Putschar 1981).

Clinically, the individual presents with a series of symptoms that can be life
threatening. Cardiovascular disease including hypertension is common, due to the
overgrowth of connective tissue. Upper airway obstruction occurs due to soft and hard
tissue overgrowth. Endocrine system imbalances such as hyperprolactinernia, diabetes,
hypogonadism, hypothyroidism, hypoadrenalism and decreased reproductive and sexual
functions can occur due to the physical presence of the tumor or the abnormal

production of secretions (Weinreb 1984, and Nabarro 1987).

The skin becomes coarse and leathery. Skin coloration can become either very
pale or dusky. Pores are apparent and sebaceous gland activity produces oily skin with
increased sweating. Acne is a common complaint. There is thickening of heel pads and
other soft tissue particularly in the hands, face, and feet. The tongue and lips become
thicker and larger, interfering with speech and eating. Enlargement of the internal
organs such as the heart, liver, spleen, stomach etc. can cause other serious health
problems such as cardiovascular-disease- and strokes (Cushing and Davidoff 1927).

Most often noted are the neurological changes that alter the person’s intellect
and consciousness. As the disease progresses, lethargy and exhaustion increase. It is
difficult for the person to orient and focus to tasks, and visual fields become limited.
Metabolic disturbances often add to the clinical symptoms. Diabetes, the inability to
adequately metabolize sugars such that physical wasting occurs, is common (Robbins
and Cotran 1979:1339). Frequent urination, thirst, and incessant hunger are other
developments. Scoliosis occurs in a way characteristic to acromegaly (Cushing and
Davidoff 1927) Thoracic kyphosis is often present (Aegerter and Kirkpatrick
1975:380).

Constipation is a common complaint of those affected by acromegaly/giantism.
Appetites are often curtailed by the physical changes in the teeth, tongue and jaws.
Chewing, swallowing and talking are also compromised. A grossly enlarged tongue is
very common in acromegaly. Often, the tongue is so large it does not fit in the mouth.
Drooling results from the lack of space and in the inability to swallow. As the jaw
grows, malocclusion of the teeth occurs. Since the teeth do not fit together well,

chewing can be difficult. This growth in the jaw also causes the teeth to become spaced

farther and farther apart, which also can create difficulties in speech and eating
(Cushing and Davidoff 1927, and Ortner and Putschar 1981).

As the person’s weight increases, their lower extremities are stressed by the
increased weight bearing demands (Aufderheide and Rodriguez—Martin 1998, and
Aegerter and Kirkpatrick 1975:377). Muscles weaken, which can cause kyphosis and
gracile lower extremities (Ortner and Putschar 1981). Not only do the feet grow in
width and length due to an increase in bone dimensions, but extreme soft tissue
overgrowth occurs as well (Aufderheide and Rodriguez-Martin 19982327, and Ortner

and Putschar 1981).

Giantism and Acromegaly Literature Researched

Giantism and acromegaly have been discussed in the literature for over a
hundred years. In order to collect as large a sample as possible of reported acromegaly
and giantism in skeletal populations, the first stage of this research is a thorough review
of the literature. A literature search was conducted first using the Magic system at
Michigan State University. Acromegaly, giantism, giants, giant skeletons etc, were
used to search this database. The MSU system has an agreement with other collections
at Midwestern university libraries, which were also searched. ERL Databases were
searched from the MSU library system. Other potential references were identified from
articles and books.

The intemet search system was also used to find references to skeletal remains
designated as acromegalics and giants. A request for information was circulated on a

biological anthropology list serve. Contacts were made through referrals from people

10

 

with information of private collections or other sources such as museums and private
libraries. Smithsonian records and materials were made available, as were materials
housed in the Mutter Museum and Library, located in Philadelphia. In addition, one
private collection of documents, photographs, and medical records dealing with
nationally and internationally recognized giants was examined. Skeletal case studies
were included only if no medical treatment was involved, and they were used as
examples of acromegaly or giantism in the medical and archaeological literature.

After reviewing the available literature regarding acromegaly and giantism, it
was apparent that a fundamental problem existed. Overall, it was difficult to determine
from the literature on giantism/acromegaly a generally accepted definition of

’9

individuals with “giantism” or “acromegaly. This paper, therefore, will attempt to
take information from archaeology, medical literature and physical anthropology and
synthesize a single view of acromegaly and giantism from the varying literature. In this
way, a single concept of diagnosis will be achieved out of the very different views and
definitions of what it means to be a “hyperpituitary giant” or an “acromegalic”.

Because modern medical interventions will add more variables than can be
addressed within the scope of this research, modern cases will be included in the study
only as long the individual was not treated. The cited examples of acromegaly and
giantism used in this project will be re-examined, types of pathologies and locations
will be noted, and differential diagnoses will be carried out.

In her research on tuberculosis, Jane Buikstra incorporated modern examples of

pathology resulting from similar disease states. These examples were then used as the

pool for comparison with her data. She emphasizes “ ...that an attempt was made to

11

use sources that described pathology in the absence of modern chemotherapy and
surgical treatment. Although other texts were surveyed, greatest weight was given to
earlier sources, provided that accurate diagnosis had been made.” (Buikstra 19762325)
She then uses a process of elimination or differential diagnosis, to remove from the list,
disease forms which were least likely to be associated with the characteristic

pathologies. This thesis will follow a similar methodology.

CHAPTER 2

METHODS

Differential diagnosis, the second stage of this research, examines the pattern of
distribution of lesions throughout the entire skeletal system. This assessed pattern is
then compared to the distribution of lesions of known diseases with similar
presentation. If there is a good fit between the observed and expected pathology
distribution, a diagnosis is made. If not, the process begins again with a new set of
parameters/possible diseases being chosen. If the individual was diagnosed with
giantism or acromegaly by other sources, it remained in the study although the
documented diagnosis would be evaluated.

Differential diagnosis is a tool used by medical practitioners to identify disease
states of patients so that treatment can be initiated. Physical anthropologists have
modified this tool for work with skeletal material. Diagnosis becomes differential
diagnosis when two or more diseases could be the causative agents for the clinical
presentation (Bouchier and Morris 1982229). Bouchier and Morris (1982:29) represent
the diagnostic process through a number of steps: (#1) Acquisition of data, (#2)
Therapeutic decisions OR (#1) Acquisition of data, (#2) Analysis of Data, (#3) Are the
Data Accurate?, (#4) What is the Problem?, (#5) What is the Cause?, (#6) Therapeutic
Decisions. This diagnostic system will be modified for use in this project since
therapeutic decisions are not relevant with skeletal material.

To examine the diagnosis of the cases presented, phrases that were used to

describe the skeletal characteristics of acromegaly will be noted for each case. These

13

phrases will be condensed into a comprehensive list of all the characteristics mentioned
in all the cases in an attempt to judge the accuracy of diagnosis overall (see Appendix
2). Buikstra (1976) states that accurate diagnosis is essential to generate an accurate
profile of a population.

Diagnosis of each case will be given as described in the literature. The
diagnoses used are giantism, acromegaly with giantism and acromegaly. Heights are
stated in centimeters for ease in analysis. The characteristics are ranked according to
the frequency in which they were used amongst all the cases, all the acromegalic cases,
all the hyperpituitary giant-acromegalic cases and all the hyperpituitary giant cases. In
this manner, it will be possible to assess what characteristics were actually being
provided as evidence for each diagnosis. A list of the characteristics used in the
literature is presented in Appendix 1.

Individual diagnosis is examined in differential diagnosis. A t-test will then be
used to examine these diagnoses as a distinct population to better understand differential
diagnosis of acromegaly and giantism as used in the literature. This statistical testing
will be presented in the Analysis and Discussion chapter-

An examination of what is not present will also be conducted for each individual
case study. For example, the absence of characteristics in the presence of an eroded
sella turcica should be noted as well, thereby allowing comparison between expected
characteristics and those actually observed. In addition, this will define what was noted
as not present as opposed to what characteristics were not used. Hamwi et a]

(1960:698) stated that, “A review of 30 clinical cases of acromegaly showed

radiological evidence of sella abnormalities in only 25”. Therefore, acromegalics do
not necessarily present an enlarged sella turcica.

Conversely, since destruction of the sella turcica can occur as a result of tumors
that do not affect hormone secretions (Aufderheide and Rodriguez-Martin 1998:326), it
is possible to have an eroded sella turcica without having giantism or acromegaly. It is
interesting to note that Aufderheide and Rodriguez-Martin (1998:328) do not equate an
eroded sella turcica with giantism, but Ortner and Putschar (1981:298) do. These
examples underscore the need for a thorough and systematic definition of giantism and

acromegaly in skeletal remains. Understanding the disease process is key to diagnosis.

Diflerential Diagnosis

As has been mentioned, differential diagnosis is a tool commonly used in the
medical field to treat patients. Cummins and Eisenberg (l986:xvii) describe the process
as follows:

”Step One: Clinical information is gathered. . ..

“Step Two: Possible diagnoses come to mind... .

“Step Three: Possible diagnoses are evaluated and refined. . ..
“Step Four: A tentative diagnosis is selected...

“Clinicians evaluate the possible diagnoses primarily by asking
further questions. There is an enduring clinical axiom that most
diagnoses are made during the history-taking. .. Research into clinical
problem — solving suggests that the central strategy clinicians use is
“feature-matching” or family resemblance. Clinicians possess
knowledge about various diagnoses. They attempt to match the features
of the patient’s problems with their prior knowledge of the diagnoses
they consider possible. They catalog features from the patient’s history,
physical examination, or laboratory tests that might match a mental
picture of various diagnoses” (Cummins and Eisenberg 19861xv).

 

It is important to note that Bouchier and Morris (1982:31) state that the
diagnostician affects the success of the diagnosis by the fullness of his or her knowledge
base. The more possible disease states that the clinician is familiar with, the greater
potential for successful diagnosis.

Medical diagnosis is an art and not a science. This is true for physical
anthropologists also. Diagnosis is based upon the experience of the observer. Medical
diagnosis is not like a test for syphilis, where a sample is tested in a lab with the results
either being “yes/present” or “no/not present”. It is not that simple. A test gives data, a
diagnosis gives results after data is analyzed. For example, there is no height divider
when dealing with giantism and acromegaly. A long, prominent chin is not conclusive
evidence of acromegaly. It is a constellation of symptoms that indicates “giantism”
and “acromegaly” in modern medical diagnosis. Modern diagnosis is based on the
observation of the whole and on the presence or absence of certain characteristics.
Within the diagnostician’s mind, when doing a diagnosis, it is a process of matching
observed characteristics as the best fit to a specific disease (Cummins and Eisenberg
l9862xv).

Differential diagnosis in paleopathology begins with understanding/noting the
provenience of the individual in regard to time and space, which helps to place the
individual in context of a population. A biological profile of the individual is
preformed and recorded; a biological profile includes sex, age, ethnicity, height and
describes lesions and other markers present (intentional modifications, taphonomic
changes, etc). A list of the general condition of the skeleton and the bones present is

therefore generated.

Age and sex might be determined before any pathological processes can be
explored. Aging of those with hyperpituitarism is unfortunately suspect, as will be
discussed later. Sexing acromegalics might prove difficult as well as acromegalics can
exhibit severely coarsened facial features and overgrowth in the area of the pubic
symphysis. This implies that sex, age and ethnicity should be re-examined after
differential diagnosis is initially performed to discern how the diagnosed disease-state
could affect conclusions in these three areas.

As has been stated, lesions present are noted. These lesions are referenced with
other diseases that have concordant lesions to find a best fit. The constellation of
lesions are compared to the constellation of lesions of similar disease states. The lesion
pattern of the skeletal material is found to have a convincing match or not to an array of
lesions that are commonly associated with a given disease. The more characteristics
that are in common between the known array with the sample, the more convincing the
diagnosis. The compiled list of lesions noted in the literature for acromegaly is found in
Table 2 and for giantism in Table 31. Some characteristics are more strongly associated
with a specific disease than other characteristics. For example, a remodeled or enlarged
sella turcica with other lesions strongly suggests hyperpituitarism. However, lack of an
enlarged or remodeled sella turcica if there are other acromegalic lesions, does not mean

than acromegaly is not a possible diagnosis.

 

1 In some cases, different descriptions were used in the literature to potentially refer to the same
condition. For this project, ALL descriptions used in the literature are presented without interpretation.

l7

Table 2: Compiled List of Lesions Associated with Acromegaly.

Malocclusion

Periosteal Reaction

Cranial Vault Thickened

Enlarged Frontal Sinuses

Prognathism

Kyphoscoliosis

Vertebral Arthritis

Scalloping of Vertebral Bodies

Robust Skeleton

Cystic Bone Lesions

Rugged Face

Bony Obliteration of Skull Structures
Spondylosis

Robust Skull

High Temporalis Origin Markings
Robust Zygoma

Hypertrophied Nasal Bones
Osteoporosis in Skull

Blunt Mandible Angle

Fusion of Vertebrae

Degenerative Changes in Epiphyses
Fan-Shaped Position of Anterior Teeth
Enlarged Sella Turcica

Elongation of Ribs

Fractures

Enlarged Supraorbital Ridges

Tufting of Terminal Phalanges
Elongation of Mandible

Enlarged Mandible

Enlarged Occipital Protuberance
Osteoporosis

Arthritis-Not Vertebral

Prominent Chin

Increased Bone Deposition at Insertions.
Large Face

Pigeon Breast

Postcranial Exostoses

Enlarged Maxillary Sinuses

Increased Pneumatization of Mastoid Cells
Narrowing of Phalangeal Shafts, Broad Bases and Heads
Thickening and Squaring of Shafts of Metatarsals
Hyperlordosis of Lumbar Vertebrae
Enlarged Sinuses

Evidence of Weight Loading in Vertebrae

Table 3: Compiled List of Lesions Associated with Giantism.

Kyphoscoliosis

Vertebral Arthritis

Excessive Height

Degenerative Changes in Epiphyses
Proportional Growth

Enlarged Sella Turcica

Fractures

Osteoporosis

Arthritis-Not Vertebral

Epiphyses Not Closed
Hyperlordosis of Lumbar Vertebrae
Evidence of Weight Loading in Vertebrae

A difficulty encountered in the diagnosis of giantism and acromegaly are the
concepts of “greater than average height” and “extremely or unusually tall”.
These terms can add to the confusion of the diagnoses of these diseases. Many authors
and sources (Roberts and Manchester 1983, Brothwell 19812162, and Egypt
Government Document 1907, Wells 1964 and Brothwell 1970) emphasize height in the
diagnosis of acromegaly and giantism. It is the purpose of this work to describe
acromegaly and giantism in such a way that other characteristics will also be considered
during diagnosis.

The cultural context of the observer is also important in medical diagnoses.
When many of the physicians involved in the skeletal case studies presented in this
thesis observed their patients, the diseases “acromegaly” and “giantism” had not been
labeled as a disease. They had no idea that the symptoms were indeed related to a
pituitary tumor, or what caused the physical changes. However, they did recognize that

these patients were unique. By conducting autopsies and assessing characteristics, such

19

as pituitary tumors, skeletal changes, and soft tissue changes, etc., they were able relate
the observed changes to a single, common condition (Cushing 192711-5)

Often, their first impression of something being “abnormal” with individuals
expressing gigantism or acromegaly was that the individuals were “tall” within the
physician’s own cultural context. The individual was also evaluated based on his/her
family history and population characteristics. Moreover, since “physician” was a
Western concept, the Western cultural concept was used to identify those individuals
who were “abnormally” tall. Because physicians, and archaeologists, were historically
interested in the extremes of the populations they were observing, only those
individuals (either alive or skeletal) who were labeled as “abnormally tall” by the
observer were considered for further study. The entire process of differential diagnosis
is linked to the experience, culture, and affiliation of the individual doing the diagnosis.
The existence of “abnormal height” is therefore in the eye of the beholder

Modern archaeological samples can be designated “giant” because individuals
fall within the upper third of the height distribution of a population (Wells 19642107,
Aufderheide and Rodriquez-Martin 19982327). These individuals studied may or may
not have characteristics of giantism or acromegaly by the modern medical definition.
They are just studied because they are the biggest bones in the sample. This study will
produce a list of observed characteristics for giantism and acromegaly that have been
used in the literature. Hopefully, this list will be used by people working with skeletal
material to recognize the many variations in skeletal lesions found in acromegaly and

giantism.

20

Diflerential Diagnosis in Physical Anthropology and Archaeologv

Differential diagnosis has been borrowed by physical anthropologists as an aid
in identifying and describing pathologies present in skeletal material. Unlike those in
the medical field, anthropologists are not able to get a history from the patient nor are
we/they able to do diagnostic tests on soft tissues or body fluids/secretions. This limits
the ability of the physical anthropologist to definitively diagnosis a disease from
skeletal materials. This difficulty is increased with some diseases such as giantism
since the presentation of lesions is variable (Aegerter and Kirkpatrick 19751377).

Although not common, both giantism and acromegaly have been noted in the
archaeological record (Ortner and Putschar 1981, and Gladykowska-Rzeczycka 1998),
in museum collections (Ortner and Putschar 1981), and in a modern forensic case
(Sauer and Marushia 1997). The small sample size from archaeological material could
be due to several representative factors. Since life span in general was shorter, the
diseases may not have reached the advanced stages more recognizable in more modern
populations. Also, examples of the disease would be decreased due to earlier death
from the disease. Lastly, women who were acromegalic or hyperputitary giants could
be “lost” as males as these diseases are often associated with enlarged bone diameter,
increased bone rugosity, larger chins, enlarged supraorbital ridges, and prominent
muscle attachments. Renewed growth also occurs in the pubic symphysis, which
remodels areas used in sexing individuals.

As stated previously, other conditions might potentially be confused with
giantism and acromegaly. In the past, the diagnosis of acromegaly and giantism in

skeletal material has not been systematic. Such conditions as Marfan Syndrome,

21

adrenal tumors and genetic predisposition to extreme height could be confused with
acromegaly (Wells 1960:107 and Gladykowska-Rzeczycka 1998). It has been
suggested that hypertrophic osteoarthropathy (HOA) and Paget Disease of Bone have
also been confused with acromegaly (Carcassi 1992).

Because of the confusion that can occur in distinguishing acromegaly and
giantism from other diseases, it is important that a person have experience with many
other disease states. Since differential diagnosis is based upon the experiences of the
observer, it is necessary to keep abreast of new information and re-examine previous

cases to minimize error.

22

CHAPTER 3

DISEASES COMMONLY CONFUSED WITH ACROMEGALY AND
GIANTISM

A number of disease states and conditions have been mistaken with acromegaly
and giantism. In addition to the five disease states Marfan Syndrome, HOA, Secondary
HOA, Paget Disease of Bone and Adreno-Genital Syndrome, two other classifications,
“genetic predisposition for greater than average height” and “Neandertal” will be

discussed (see Appendix 1).

Marfan Syndrome

Marfan Syndrome appears to be due to a mutation in the fibrillin-l gene located
on chromosome 15 (McKusick (a) 1986). One quarter of all affected individual’s
disease results from new mutations. Paternal age is thought to be a factor in some new
mutations. Expression of Marfan is variable. Homozygous and heterozygous forms
have been reported although this is still under discussion (Fairbank 1976: 152-155).
Researchers agree that Marfan is autosomal dominant, but there is conflicting evidence
regarding a recessive form of the disease (Fairbank 1976:152-155, McKusick (a) 1986,
and Aegerter and Kirkpatrick 197511 87-190).

It is estimated that the frequency of incidence in the human population is 1.46
people per million (Fairbank 1976:152-155). Diagnosis usually becomes apparent in
the first few years following birth, however mild cases can exist that are not diagnosed

even into adulthood. Life expectancy of people with Marfan is thought to be shorter

23

than average, however, Silverman et al (1995) reported an increase in life expectancy
for Marfan patients of over 25% from 1972-1995. They attributed this increase to
advancements in medical care and an increase in the life expectancy of the population in
general (McKusick (a) 1986). Although males and females are equally affected in
numbers, life expectancy of men is much less than that of women. Severity of the
disease was seen as the best independent indicator of life expectancy. The average age
at death is 30 to 40 years of age. Cardiovascular involvement is common and often life-
threatening (Robbins and Cortan 1979: 236). A primary cause of death is rupture of
aneurysms, followed by cardiac failure (McKusick (a) 1986).

Primarily three systems manifest characteristic changes in fibrous connective
tissue —the ocular, the cardiovascular and the skeletal. Myopia, cataracts, increased
axial globe length, corneal flatness, retinal detachment and secondary glaucoma and
subluxation of the lenses are common clinical findings (McKusick (a) 1986, and
Fairbank 1976:152-155).

Cardiovascular findings include valve prolapse and aortic involvement including
aortic aneurysm and aortic dissection. Skeletal features include maxillary overbite,
crowded teeth and a highly arched palate. Increased height, disproportionately long
limbs, abnormal vertebral curvature, pectus excavatum or anterior chest deformity, and
narrow shoulder girdle are common appendicular and axial characteristics. This
syndrome has also been referred to as arachnodactyly (spider fingers) due to the
increased length of the extremities especially the fingers. Spider fingers and general
joint laxity are characteristic of this syndrome (McKusick (a) 1986, and Robbins and

Cortan 1979: 236).

24

Marfan Syndrome differs from giantism in that the increased height of Marfan is
disproportionate in the extremities. While many characteristics of Marfan can be found
in giantism, there are two characteristics, which are not associated with giantism: spider
fingers and maxillary overbite (McKusick (a) 1986, and Fairbank 1976:152-155).

Marfan Syndrome has been described in a skeleton housed in the Museum of
Pathological Anatomy, Vienna, Austria. This skeleton was initially diagnosed as
“physiologically tall stature”. It was later re-diagnosed as Marfan Syndrome. The
skeleton is 191cm (6 feet 3 inches) in height with limb length disproportionately long
compared to the trunk. Arachnodactyly or “spider fingers” is evident, but there is no
noted tufting of the terminal phalanges. The skeleton does not exhibit any acromegalic
characteristics other than increased height. A photograph of the skeleton confirms this
observation. The mandible shows neither prognathism nor overgrowth. Supercilliary
ridges and points of muscle attachment are not prominent; there is no visual evidence of
overgrowth. The skull looks small in comparison with the remainder of the skeleton

(Beighton, P. et a1 1993).

Primary Hypertrophic Osteoarthropothy (HOA) or Pachydermoperiostosis
Idiopathic

This is primarily an autosomal dominant disease. Recessive forms of the
disease seem to exist but with less frequency. HOA has been recognized in people of
all geographic areas and nationalities. Males are affected more frequently and with
more severity than females (F airbank 19762118-119), and the disease is not indigenous

to any one country (J affe 1972:292).

25

There are none of the causative factors in Primary HOA, such as the pulmonary,
cardiac, gastrointestinal or hepatic disorders that are associated with Secondary HOA
(Singh and Menon 1995). Secondary HOA will be discussed more fully later.
According to Ortner and Putchar (1981:294-297), the disease begins in puberty and
progresses throughout life. Because the disease is self-limiting, a normal lifespan is
usual. The physical characteristics and symptoms of HOA have similarities to those
described in acromegaly. Hyperhidrosis (sweating) is the major symptom, but if there
is joint involvement, there can be diffuse joint pain. Skin becomes thickened. Facial
features become coarser with a concurrent increase in oiliness of the skin. The ends of
the fingers can exhibit clubbing, usually due to the soft tissue changes. The extremities
can appear disproportionately large, although height is not affected (J affe 1972:291-
300, and Ortner and Putchar 1981:294-297).

Thickening of the calvarium and base of the skull occur with the disease and the
“frontal and paranasal sinuses are enlarged” (Fairbank 1976:118-1 19). The vertebral
bodies are affected and the vertebral foramina often become narrowed. The extremities
can be disproportionate to body height, but height is usually within normal limits.
Subperiosteal reaction usually occurs in the distal ends of radius, ulna, tibia and fibula
(Ortner and Putschar 1981:297, and Jaffe 1972:291-3). This reaction produces
periosteal bone which and is deposited on the original cortex, that is consistently thick,
rough and irregular (Carcassi 199224, and Jaffe 1972:296). In advanced cases of the
disease, the diameter of the long bones show a marked increase and spinal ligaments
and interosseous membranes may be ossified (Ortner and Putschar 19812297, and J affe

1972:291-3).

26

 

 

 

 

In the past, HOA has been confused with acromegaly. It is distinguishable from
acromegaly as all the bones show periosteal build up or hyperostosis, not just areas of
cartilage as in acromegaly. Tufting of the terminal phalanges is not characteristic of

HOA (Fairbank 1976:118-119, Singh and Menon, 1995, and Carcassi, 1992).

Secondary H 0A

Secondary HOA is primarily associated with pulmonary diseases, however, it is
defined by the same characteristics as HOA in all other respects. Metastatic or primary
cancer of the lung, breast cancer, tuberculosis or other pulmonary lesions can initiate a
lymphocytic infiltration of the periosteumz. Diffuse periosteal hyperostosis, found at
the ends of long bones or at mid-diaphyses, and cortical bone resorption with
pronounced vascular grooving often occurs. The bones of the trunk are rarely affected
(Jaffe 1972:286-300). Metacarpals and metatarsals are affected more than the
phalanges; the terminal phalanges usually remain unaffected. The skull is usually
unchanged, except for infrequent occurrences of bone deposition on the inner table
(Jaffe 1972:286-300).

Secondary HOA, just like HOA has been confused with acromegaly. It is
distinguishable from acromegaly because all the bones show periosteal build up or
hyperostosis. Tufting of the terminal phalanges is not characteristic of Secondary HOA

(Fairbank 1976:118-119, Singh and Menon, 1995, and Carcassi, 1992).

 

2 This is the only difference between the two diseases, though authors make distinctions based on specific
case studies they have experienced. Since Secondary HOA is assoicated with such diseases as cancer and
tuberculosis, Secondary HOA rarely reaches advanced stages.

27

 

Paget Disease of Bone (PDB)

There seems to be evidence linking the occurrence of Paget Disease of Bone
(PDB) to several factors. Because of the identification of virus-like inclusions in Pagetic
bone, many researchers are exploring the hypothesis that PDB is linked to viral
infection. Autosomal dominant inheritance with a high penetrance by the age of 65 has
been presented as a possible route of inheritance (Van Hul et al. 1997, McKusick (b).
1986). A locus on chromosome 6 has also been tentatively linked to PDB and is
referred to as PDBI. Another locus on chromosome 18 has been potentially linked with
PDB and is referred to as PDB2 (McKusick (b). 1986).

Since the disease is very rare before the age of forty, a population incidence of
3% has been estimated from several populations above the age of forty. Incidence
seems to increase with age. Men apparently are more often affected than women are,
by a proportion of four to three (Fairbank 1976: 120). Populations with low incidence of
the disease are those of China and Africa. European, North American and Australian
populations have a higher incidence, as the disease is relatively common. Interestingly,
Jamaicans of European or African ancestry have a similar incidence of the condition
(McKusick (b). 1986, Hamdy 1981:4, Barry 1969217).

As previously mentioned, Paget disease often goes unnoticed until the fifth
decade of life (Barry 1969217). Pain in the affected bone is often the first symptom.
Enlargement, deformity or pathological fractures of the bone can also be presenting
features of this disease. Any bone may be involved, but some bones are more
commonly involved than others are. The vertebral column is most often involved. In

descending order of frequency, other commonly affected bones are» the right femur,

28

the skull, the pelvic bones, the left femur, the tibia and fibula and the arm bones. The
mandible and teeth can also be affected. The hands and feet are rarely affected and it is
uncommon for the whole skeleton to be involved. One or more bones can be involved,
but the presentation is usually asymmetrical (Hamdy, 1981 :12).

The affected bones go through phases of destruction and sclerosis. During the
lytic or destructive, phase there is increased vascularization in the resulting spaces.
Vascularization decreases during the sclerotic phase, as areas of increased bone density
become apparent. Both phases can exist concurrently. Life expectancy is normal and
for the most part the people with this condition are surprisingly fit (Fairbank 19762120).

The only confusion of Paget Disease of Bone and acromegaly and giantism is
that increased bone density of the skull can occur in both conditions. Although skull
thickness can be increased in PDB, the bone would be porous. The diploe or the space
between the inner and outer tables of the cranial vault contains nodular bony masses,
which give the appearance of pumice. However, radiographs show patchy areas of
sclerosis and increased thickness. Giantism and acromegaly show involvement of the
facial bones, while PDB usually does not involve the facial bones even if the skull is
involved. Bony overgrth similar to that found in acromegaly also occurs in Paget’s
disease. Unlike acromegaly, the distribution is not confined to areas of cartilage and
remodeling of the jaw, as is found in acromegaly, is not characteristic for Paget Disease

of Bone

29

 

Adrenal-Genital Syndromes

Adrenal (suprarenal) tumors can affect the production of hormones necessary for
normal growth and development. Over or under-production of certain hormones such
as testosterone and estrogen can delay or inhibit puberty and physical development.
Puberty is associated with the closure of epiphyses that coincide with the cessation of
growth. If puberty is delayed, growth can continue. However, although grth occurs
faster than usual, height is not usually dramatically increased in adulthood (Weinreb

1984:288-294, Hayles 19802164, and Aegeter and Kirkpatrick 1975 :378).

Eunichoidal giantism is characterized by periosteal bone growth is inhibited in
hypogonadism, which results in a gracile skeleton. Since endochondral growth is
increased, the upper and lower limbs can be of greater than usual length compared to
the rest of the body. Elongation of the mandible and proganthism can result as well.
Castration in boys would result in a tall, long-legged, gracile skeleton. This would also
be true of any tumors that would severely limit or stop testosterone production. Growth
and development would also be affected for girls with hypogonadism. Skeletal
manifestations of these processes would not necessarily include modifications in the
sella turcica unless a pituitary tumor was involved in creating the hormonal imbalance
(Hayles 19802164, and Aufderheide and Rodriguez-Martin 1998).

Anderson and Kissane (1977:378) describe eunichoidal giantism as a condition
of males where descent and maturation of the testes are halted or where castration

occurred before puberty. Delayed epiphyseal closure would allow for a longer period of

30

 

 

growth, which would account for the greater height. Height would be found

disproportionately in the lower extremities

Genetic Predisposition for Greater Than Average Height

Height can be influenced by many factors. Genetic limits on an individual’s
height are determined by the genes provided by the parents. Nutrition has also been
shown to be an important factor in stature. An individual with a genetic propensity for
increased height who has nutritious food available in plentiful amounts may reach their
maximum height (Wells 1969:454). Psycho-social events may also limit height. In
other words, stress can also affect height3 (Weinreb 19842299, and Wells 1969).

It is important to remember that an individual is part of a population. A person
who is taller than average in one population may not be taller than average in another.
Known population heights are important to determine where an individual falls within

the population distribution of heights.

The Neandertal Question

Keith (1931) discussed the similarity in characteristics of acromegalics and
Neandertals. This brings up two very important points to remember in the assessment
of a disease. It is necessary if possible to study the skeletal material as both an
individual and as a member of a population. Keith’s discussion of the Gardar skull
clearly illustrates the potential difficulty in diagnosing “lesions” that are in fact the

normal variation within the population in question.

 

3 Height for all individuals is potentially affected by the same factors such as nutrition and genetics.

31

Archaeologically, provenience of skeletal material is essential to provide a firm
foundation on which to base further study/analysis. The skull found at Gardar, southern
Greenland, was said to have been found in a 12‘h century Norse graveyard. However,
the features resembled those designated as “Neandertal” according to Hansen. Since
the base of the skull was missing, this diagnosis has been questioned by many including
Keith. The discussion engendered by the analysis of the Gardar skull highlights the
concept that ancestral, ethnic, and geographical variation can occur which may mimic
pathology. In short, ancestral features must be considered when performing a
differential diagnosis when generating a biological profile.

Similar characteristics assigned to the Neandertal and the Gardarene Skull
include: robust features, thickened skull table, prominent supraorbital ridges, and an
enlarged occipital bun. Another distinguishing feature of the Neandertal is a “football”
shaped vault. The Gardarene Skull also had this characteristic (Keith 1931). Keith
(1931) determined that Neandertal and acromegalic characteristics were similar, though
differences could be discerned. The Gardarene Skull had a longer face, large mastoid
processes, and an especially narrow skull.

Trinkaus (1985:528) examined the following characteristics in Neanderthals and
acromegalics: malocclusion, excessive development of chin, expansion of the paranasal
sinuses, large supraorbital tori, projecting external occipital protuberance, enlargement
of the sella turcica, increased cranial vault thickness, excessive apposition of bone on
vertebral bodies, kyphosis, marked rib elongation and curvature, thick cortices of
diaphyseal bone, increased rugosity of musculoligamentous insertions, degeneration of

articular cartilage, and apposition of bone on the pubic symphysis. Trinkaus concluded

32

 

that only two characteristics were remotely similar for Neanderthals and acromegalics;
large distal phalangeal tuberosities and slightly-thickened cranial vault bones, both of
which could be confused with acromegalics.

Neandertal morphology is discussed in this paper as it relates to the differential
diagnosis of acromegaly. Some features ascribed to the Neandertal population have
been thought by some to also be characteristic of acromegaly. Keith’s (1931)
discussion of the Gardar skull illuminates the difficulty in assessing pathology of
incomplete materials and the need to place “pathology” in context of normal physical
variation within a population and the provenience of the skeletal remains. Keith
concluded that the Gardar skull was acromegalic, based on his comparisons with other

acromegalic and Neandertal skulls.

 

 

 

CHAPTER 4

ACRONIEGALY AND GLANTISM: SKELETAL AND SOFT TISSUE
CASE STUDIES

Presented in this chapter are the reported skeletal case studies of 17 individuals
that make up the primary data for this project. These case studies are presented as
information/data to understand and define the diagnosis of giantism and acromegaly.
Embedded within this presentation of data is an analysis of each case study. Found in
the appendices is data regarding the individuals as a group. In addition, the original
diagnosis of each individual will be re-examined (using the flow charts presented in

Appendix 2).

I. The Polish Giant (Gladykowska-Rzeczycka 1998)

This individual was found in the area of Lenogora, Poland and was dated to
between the end of the 11th Century to the beginning of the 14th Century. The
skeleton’s height was estimated by the authors at 215.5 cm (7 feet 1 inch) using the
Trotter and Glesser stature method (Gladykowska-Rzeczycka 1998: 147, 153).
Analysis of the skeleton suggested a female of 25-30 years of age. She was diagnosed
as having giantism. The authors of this article gave a thorough presentation of the
material. Photographs were plentiful and detailed descriptions of all lesions present

were related. The criteria mentioned for the diagnosis were enlarged dimensions of all

34

 

 

bones4 and a disproportionately large mandible with “a fan-shaped” configuration of the
anterior teeth. The skull was thickened especially in the anterior region. The jugular
foramen and fossa were almost obliterated, and the sella turcica was enlarged and
flattened (Gladykowska-Rzeczycka 1998: 169).

Postcranial lesions were present as well, with the vertebral column being
particularly affected. Diffuse degenerative changes were noted in the entire vertebral
column and the epiphyses of all bones. Fusion and partial fusion of thoracic and lumbar
vertebrae was noted. Ossification of the right anterior longitudinal ligament was
apparent, and exostoses were present on the vertebrae. Evidence of extensive loading
on the vertebral column included such lesions as scoliosis, Schmorl’s nodes and
flattened vertebral bodies. Fractures in the right humerus and left tibia were also noted
(Gladykowska-Rzeczycka 1998: 169).

Harris lines were visible on the radiographs. This is an interesting fact if there is
any validity to the correlation between nutritional stress and the generation of Harris
lines. In cases of extreme growth, often the body systems are stressed by extreme size
(weight stress fractures, as an example). Ironically, inadequate nutrition could have
decreased this woman’s size so that she was less afflicted by acromegaly that she might
have been. Adequate nutrition might have caused even more weight bearing lesions!

I would concur with the authors that this individual probably suffered from a
pituitary tumor that caused giantism and acromegaly. For a thorough review of
characteristics, see Table 2. Compared to her contemporaries she was at the extreme

end of the distribution of height for both men and women.

 

4 Gladykowska-Rzeczycka also states that there is excessive body height (19982169) and enlarged
dimensions of all bones (1998: 153), which suggests proportional body build or growth.

35

The diagnosis of “acromegalic giant” is imbedded in the text, although the
article’s title suggests a diagnosis of “hyperpituitary giant.” A clear example of this is
found in the GIadykowska-Rzeczycka et al.’s Summary of Conclusions (1998:169-170),
which states “. ..the female from Ostrow Lednicki suffered from serious disturbances of
the pituitary gland which caused gigantism at a young age and acromegaly after
epiphyseal closure.” Many characteristics are used to assess the health state of the
individual. Differential diagnosis is used by the authors to define the cluster of traits.
The diagnosis appears to be accurate, based upon the information presented by the
authors. The age and the sex are not consistent with a diagnosis of PDB. As this
individual was described as having all bones enlarged, Marfan and Adreno-Genital
Syndromes can also be eliminated. HOA and secondary HOA are not likely because
height is not affected and the bone was not described as being thick, rough, and

irregular.

Table 4. The Polish Giant Authors’ Described Characteristics

Male/Female Female

Age 25 to 30

Height 215.5 cm (7 feet 2 inches)
Documented Diagnosis Both Acromegaly and Giantism
Cranial Vault Thickened

Enlarged Frontal Sinuses

Prognathism

Kyphoscoliosis

Vertebral Arthritis

Bony Obliteration of Skull Structures

Tall (Excessive) Height

Osteoma

Fusion of Vertebrae

Degenerative Changes in Epiphyses

Fan-Shaped Position of Anterior Teeth

Proportional Growth

36

Enlarged Sella Turcica

Length and Diameter of All Bones Enlarged
Fractures

Enlarged Mandible

Enlarged Maxillary Sinuses

Increased Pneumatization of Mastoid Cells
Evidence of Weight Loading in Vertebrae

2. The T ergenesse Giant Werhlich et a1. [99] and 1994, and Pirsig et a].
1994)

Nerlich et a1. (1994) presented a poster on Thomas Hasler, the Tergenesee
Giant. His skeleton is maintained at the Institute of Pathology at Munich University.
During life, he was reported to have attained a height of 235 cm (7 feet 8.5 inches).
His skeleton as measured by Nerlich et al. was 210 cm (6 feet 10.6 inches) in length.
Hasler died suddenly in 1876 at the age of 25. He showed symptoms of acute cerebral
distress (cerebral hemorrhage) as a cause of death.

Analysis of his skeletal remains revealed an “extensively” enlarged and
thickened skull. The frontal bones measured up to 7 cm (2.75 inches) in thickness.
This cranial bone overgrowth noticeably decreased the cranial capacity. The mandible
was described as very prominent. The sella turcica was significantly enlarged with
indications of a cystic defect at the posterior border. A microcystic bone pattern was
reported upon cross section of cranial bone.

Bones were elongated but proportional throughout the entire skeleton. All
epiphyseal plates were open. The lower extremities showed several lesions. The left
fibula was widened irregularly throughout its length with no compact bone

involvement. Pathological fractures were present. The left femoral head showed a

 

change in position that was attributed to a healed fracture. The femoral shaft adjacent to
the healed fracture seemed to be widened and enlarged. Lastly, the skeleton showed
signs of “Spondylosis with focal osteophytic bone formation” (Nerhlich et al.

1991 :S90). Spondylosis is the term used when a major portion of the neural arch
separates from one or more vertebrae (Ortner and Putschar 19812357).

Pirsig et al. (1994) used radiology and endoscopy to examine Thomas Hasler’s
skeleton. They found obliteration of ~the left optic canal and left nasal lacrimal duct, a
compressed left internal acoustic canal, the left nasal canal filled with bone, both
cribiforrn plates thickened and lacking foramina, an atretic left ear and reduced volumes
in the oral cavity and pharynx.5 Cystic bone replaced normal bone structure in the
skull, especially the mandible. Cystic lesions of the long bones of the left upper and
lower extremities and the left 05 illium and left clavicle also showed a small rim of
sclerotic bone. Histological examination of the skull disclosed trabecular bone that was
made up of immature woven bone which is typical of fibrous dysplasia".

Nerhlich et al. (1991 and 1994) and Pirsig et al. (1994) concluded that Hasler
was affected with giantism and with a form of fibrous dysplasia. I would argue that
since his skull enlarged enormously with advancing age, his mandible was very
prominent and cranial thickness of up to 7 cm (2.75 inches) was noted, that acromegalic
characteristics were present as well as those of giantism. Fibrous dysplasia can cause

thickening of the cranial vault, but has not been found to affect either the length of the

 

5 Nasal canal is the author’s term. It is unclear what the author is specifically referring to, however it is
important in that nasal structures were compromised by abnormal bone growth.

6 Fibrous dysplaia is a condition of the bone in which the normal structure is replaced by lesions of
fibrous tissue and poorly-formed, woven bone trabeculae (Robbins and Cottran 1979:1496). These
lesions may appear in one of three distributions: monostotic, polyostotic (rarely in the spine), and
Albright’s syndrome characterized by polyostotic fibrous dysplaia, cafe’ au lait spots and associated

38

mandible nor the size of the skull. (Ortner and Putscharz315-322). Fibrous dysplasia is
more frequently found in females than males, and often begins in childhood, but ceases

upon epiphyseal closure or end of the growth period (Uehlinger 19602283).

Table 5. The Tergensee Giant Authors’ Described Characteristics

Male/Female Male

Age 25

Height 210.0 cm (6 feet 10.6 inches)
Documented Diagnosis Hyperpituitary Giant

Cranial Vault Thickened

Cystic Bone Lesions

Bony Obliteration of Skull Structures
Spondylosis

Tall Height

Robust Skull

Enlarged Sella Turcica

Length and Diameter of All Bones Enlarged
Fractures

Elongation of Mandible

Epiphyses Not Closed

3. The Mutter Giant (Hinsdale 1898, Humberd I939, McFarland 1938)

Housed at the Mutter Museum in Philadelphia, Pennsylvania, this individual’s
origins are shrouded in mystery. The “American Giant,” as he was called, arrived
during the hey-day of interest in giants and other human “freaks.” During the 1700’s
through early 1900’s, there was a society interest in viewing “giants”—alive and dead.
“Giants” such as Charles O’Brien were pursued by individuals interested in possessing

the “giant’s” skeleton after death. (It might be interesting to psychoanalyze the pursuers

 

endocrine dysfunctions such as precocious puberty in females, hyperparathyroidism, hyperthyroidism,
acromegaly or Cushing’s syndrome.

39

 

 

and their need to possess the biggest human body but it is beyond the sc0pe of this
work.)

The Mutter Giant was brought to the museum in 1877 at which time it was
prepared for display. The skeleton was described as that of a twenty-three year old
male. Dr. Hinsdale (1898) estimated that the Giant was 22 to 24 years old. Humberd
gave an age of 17 years old (Mutter Museum Archives). His height was 235.6 cm, or 7
feet 8.75 inches. Estimating age has been an admitted problem in this instance due to
the reliance upon methods that involve areas of cartilaginous growth. Epiphyseal
closure was not complete, according to Humberd (Mutter Museum Archives). The
delay in epiphyseal closure leads to the difficulty in aging this individual. Epiphyseal
closure delay is a characteristic of giantism (Aufderheide and Rodriguez-Martin 1998).

Hinsdale (1898) in his essay “Acromegaly” described the lesions present in the
remains. The skull was described as being proportionate to the size and height of the
axial skeleton, but dolicocephalic. The frontal sinuses were enlarged. An enlarged
pituitary fossa was recorded by Hinsdale (1898). The mandible, which was slightly
prognathous, was also massive. The sacrum consists of four vertebrae, and the coccyx
consists of three vertebrae.

The ribs were long and narrow. The thorax was large but narrow. Periosteal
inflammation was apparent on the borders of the pelvis. Arthritis was evident in the
iliac crests and above the acetabulum. Thin bone was noted in the acetabula and the

iliac bones. Hinsdale (1898) notes that the femora were slender, but proportionate to

40

 

the rest of the bone.7 The shafts were well formed and not “unduly curved.” The
femoral heads were misshapen, and the necks were semi-lunar in cross-section.
Compact bone was very thin at the extremities of the femur, barely covering the
cancellous bone. The fibulae were curved and lie posterior to the tibiae. McFarland
(1938) added to this account that the individual had a pigeon breast and ununited
epiphyses.

The array of features presented strongly supports the literature’s consensus of
giantism with acromegalic features. However, unlike other individuals in the case
studies presented, this individual’s bones were not disproportionately enlarged (which is
one of the identifying characteristics for acromegaly and giantism). Bone diameter
could have been decreased by two factors. One is muscle wasting which would
decrease the forces placed upon the bone thereby affecting modeling. The second is that
eunichoidal giantism with the pituitary tumor has characteristics of slender bones and
longer extremities with increased height. However, the height was stated to be
proportional. Eunichoidal giants and individuals with Marfan tend to have
disproportionately longer legs. Remodeling of the jaw is unusual in PDB. HOA and

secondary HOA are associated with hyperostosis of all bones of a skeleton.

 

7 This observation seems contradictory. Hinsdale could be noting that the femoral length is proportional
to the other bones or that the femora were slender but not so slender as to be extreme. Both can be

41

 

 

Table 6. The Mutter Giant Authors’ Described Characteristics.

Male/Female Male

Age 17 to 24
Height 235.6 cm (7 feet 8.75 inches)
Documented Diagnosis Both Acromegaly and Giantism
Enlarged Frontal Sinuses

Prognathism

Kyphoscoliosis

Tall Height

Blunt Mandible Angle

Proportional Growth

Length and Diameter of All Bones Enlarged
Elongation of Ribs

Elongation of Mandible

Enlarged Mandible

Arthritis-Not Vertebral

Large Face

Epiphyses Not Closed

Pigeon Breast

Enlarged Maxillary Sinuses
Dolichocephalic

Evidence of Weight Loading in Vertebrae

4. The Persian Giant (Ortner and Putschar 1981, Fuchs 1935, and

Material from the Collection of Warren Raymond).

Ortner and Putschar (19812298) present a skeleton housed in the Pahlavi

University Medical School as an example of giantism. The features presented include

“giant” stature, massive bone apposition and acromegalic features. However, the

overgrowth present throughout the whole skeleton and the irregularity of the surfaces of

the bones as visualized in the photograph suggest an additional diagnosis, perhaps HOA

or neurofibromytosis.

 

characteristic of giantism.

42

 

 

Accounts are given of a “giant” in Persia in the 19303 (See Fuchs, 1935).
F uch’s gave a presentation regarding this person to the Society of Physicians in 1935.
His presentation, which included photographs, was noted in the 1935 Journal of the
American Medical Association. Unfortunately, the photographs were not reproduced in
the notice. Associated with this “giant” individual are clinical accounts and a diagnosis
(Fuchs 1935, Hayles 1980, and the Collection of Warren Raymond). The individual
was said to be 19 years old and 220 cm, or 7 feet 2.6 inches, tall (Hayles 19802164).

Fuchs (19352490) described the individual as being from Persia, and was:

.. 10 feet 6 inches (3.2 meters) tall and was 19 years old. He had
developed normally up to his tenth year, when he began to grow
enormously. Mighty humps developed on his forhead, chin and behind
the ears. The head became so heavy that the man could not hold it up.
The humps on the forehead caused a great forward curvature. They have
the appearance of tumors. There are many other lighter, loose nodules in
the wrinkled skin. In the enormous head the eyes appear, in spite of their
normal size, extremely small; the vision is good and the teeth are normal.
The extremities are of an enormous length, the proximal phalanx being as
long as the index finger of a normal man. The legs are too weak to enable
him to walk, so he is generally lying down; but he is able to stand up
when supported by a cane. His intelligence is almost normal; he
complains frequently of vague pains. Recklinghausen’s disease has been
considered as the etiologic factor and it is assumed that an early
localization of the process in the hypophysis or in the growth center is
responsible for the giant growth. The patient was unable to ride in an
ordinary carriage and he had to be placed on a boat by means of a crane.
His weight exceeded 200 Kg. (450 pounds)”

It is possible that the giants described by Fuchs and Ortner and Putshcar are not
the same individual. However, I am confident that the skeleton found in the Museum is

the same person represented in photographs from a private collection (Collection of

43

 

 

Warren Raymond)8. The clinical information, albeit from secondary sources, seems to
fit both the photographs of the living man and the skeletal photograph. The individual’s
skeleton seems to have a depression of at least one rib to the left of the sternum as is
described in the clinical accounts. The side View of the person’s face as compared to
the photograph of the skeleton is quite compelling. The supraorbital torus is unique, as
is the projection of the mandible. It would be amazing to think that two individuals
from Persia (present day Iran) would both manifest with such distinctive skeletal
changes.

The museum specimen is diagnosed by Ortner and Putschar (1981:298) with
giantism and acromegaly. They do not mention sella turcica enlargement or height. A
measurement of height was given to Charles C. Hart as being 220 cm (7 feet, 2.6
inches) (Letter from the Honorable Charles C. Hart to person unknown, date unknown,
from the private collection of Warren Raymond)9, which is the same height given by
Hayles 19802164). Increased diameter of bones was visible, and bone apposition on his
face and skull was readily apparent. Upon physical examination, his tongue was found
to be of normal size. Acromegaly often causes a great increase in the size of the tongue.
Scoliosis was described as curving to the right. Fingers and toes began enlarging at ten
years of age. Exostoses were found upon examination (ibid, Collection of Warren
Raymond).

Given the clinical information of the living individual, a diagnosis of giantism,

with some other major contributing disease process, is likely. PDB is eliminated as the

 

8 Warren Raymond has a collection of documentation on unusual human variation both sofi tissue and
skeletal. Mr. Raymond has been consulted for numerous television programs and museum exhibits.

9 Based on evidence found within the Fuchs (1935) and Hayles (1980) articles, the date of this letter is
probably between 1934 and 1935.

44

 

skeleton showed widespread periosteal overgrth involving the facial bones. Marfan
and Eunichoidal giantism are less likely as the skeleton was described as massive.
HOA and secondary HOA are possible, as both are associated with widespread skeletal
hyperostosis. Fuch’s giant had a family history of tuberculosis, which has been
associated with secondary HOA (ibia’, Collection of Warren Raymond). With the
information from the document research (which was probably not available to Ortner
and Putschar), other diagnoses present themselves. Potentially Von Recklinghausen’s
Disease, as suggested by Fuchs) is likely as well.

Von Recklinghausen’s Disease (neurofibromatosis), caused by an autosomal
dominant allele, presents an extremely varied array of lesions. It has tumors throughout
the body that arise from nerve sheets. Fairbank (1976:148-149) describes the disease as
follows; “Fibromatous skin tumours and multiple tumours of nerve trunks are typical
features, varying in size from a few millimetres to several centimetres, together with
hypertrophy of one limb, or part of it, or of other areas, such as the skull. This local
gigantism may affect the underlying bone as well as the soft tissues.” Hayles (1980: 164
goes on to say, “An occasional patient with neurofibromatosis has been quite tall, often
with asymmetric growth, but none has been of exceptional height.”

Ortner and Putschar (19812325) also describe the disease as having a

characteristic type of kyphosis. They state that:

“A special type of kyphoscoliosis can occur in neurofibromatosis,
a condition characterized by formation of multiple nerve sheath tumors
on spinal and peripheral nerves. In this disease, the maximal scoliotic
deformity more frequently involves the cervical spine. The tumors of
spinal nerves in this condition lead to smooth widening of interspinal
foramina in the affected area. This feature would permit recognition of

45

 

 

such a scoliosis as due to neurofibromatosis even on the dry skeleton”

(Ortner and Putschar 1981:325).

Re-examination of the skeleton of the “Persian Giant” could therefore
provide more information for a more definitive diagnosis of this individual.

Clinical information is rarely if ever available to test the accuracy of
paleopathological diagnosis. This case afforded me the opportunity to assess the
diagnosis with the added clinical information. It would of course be necessary to
examine the skeleton housed at the Pahlavi University Medical School to support my
assumptions of identity. It is brought up here to show that literature research can give
potentially electric information about the lives of individual people through historic

skeletal remains.

Table 7. The Persian Giant Authors’ Described Characteristics

Male/Female Male

Age Either 19 or 42

Height 220.00 cm (7 feet 2.6 inches)
Documented Diagnosis Both Acromegaly and Giantism
Cranial Vault Thickened

Tall Height

Length and Diameter of All Bones Enlarged
Enlarged Supraorbital Ridges

5. Smithsonian Individual #2 (Ortner and Putschar 1981:301-302)

Documentary evidence suggests that this individual was a Native American
male from Tennessee. Age was estimated to be 35-45 years at death. The individual

lived in the historic period before the 1900’s. In general, the skeleton was massive and

46

 

 

the skull was rugged. The temporalis muscle origins were found close to the saggital
suture. The mandible showed overgrowth past that of the maxilla. The chin was
prominent and had bony projections on the anterior inferior border. New grth on the
mandibular condyles and an increased angle between the ramus and the mandibular
body were evident on the roentgen film. The pituitary fossa was large, but according to
the authors, not unusually so, and there was secondary growth on the rib ends“).

The long bones were elongated and heavy. Stature was estimated for this
individual as being 189.75 cm (6 feet 3 inches). Hands were large but proportionate to
the rest of the skeleton. “This suggests greater pituitary function during growth, but
with major morphological changes occurring after the normal grth period had ended”
(Ortner and Putschar 19812302). Diagnosis in this account was “possible acromegalic.”

Given the above information, my diagnosis would be giantism with acromegaly.
Epiphyseal closure occurs later in those whose secretion of GH is increased before
puberty. Therefore, manifestation of acromegalic symptoms would be delayed, though
present, as growth would not yet be restricted to only areas of cartilage. This might
account for the decreased severity of the acromegalic skeletal lesions. Remodeling of
the jaw suggests that PDB is not a probable diagnosis. As the long bones were
elongated and heavy, Marfan and Adreno-Genital Syndrome are unlikely. HOA and
secondary HOA are unlikely as the skeleton does not exhibit widespread periosteal

overgrowth of all bones.

 

l0This case presents an excellent example that an enlarged sella trucica alone is not indicative of giantism
or acromegaly. Conversely, a sella turcica that is of normal size does not rule out giantism and

47

 

 

Table 8. Smithsonian Individual #2 Authors’ Described Characteristics.

Male/Female Male

Age 35 to 45
Height 189.75 cm (6 feet 3 inches)
Documented Diagnosis Acromegaly
Prognathism

Robust Skeleton

Tall Height

Robust Skull

High Temporalis Origin Markings

Blunt Mandible Angle

Proportional Growth

Length and Diameter of All Bones Enlarged
Elongation of Ribs

Tufting of Terminal Phalanges

Elongation of Mandible

Prominent Chin

6. Smithsonian Individual #3 (Ortner and Putschar I 981298-300)

Vienna was home to another skeleton of an individual used as an example of
acromegaly by Ortner and Putchar. Described and pictured were the skeletal remains of
a reported 39 year old male of undocumented ancestry (Ortner and Putschar 1981:298).
Enlargement of the sella turcica was visible due to the pressure erosion of a tumor.
Marked elongation of the mandible was apparent; especially the ramus, which
produced a pronounced prognathism and malocclusion. A prominent chin,
malocclusion of teeth and prominence of the inferior and superior nasal spines were
also present. A photographic view of the cranial interior (skull cap removed) showed
enlarged frontal sinuses and the previously noted enlarged sella trucica accompanied by

resorption of the anterior and posterior clinoid processes. Tufting of the terminal

 

acromegaly. See Harrison 1991:1899.

48

 

phalanges and periosteal hyperostosis was evident in the hands. Vertebral involvement
included subperiosteal apposition.

Height was not mentioned for this individual. Since, the authors suggested that
there was no gigantism, only acromegaly exhibited in this individual, it is assumed that
height was not increased. Marfan, PDB, HOA, Secondary HOA, and Adrenal-Genital
Syndromes were excluded as tufting was observed in the distal phalanges. The
information provided in the above paragraphs supports a diagnosis of “acromegaly” for
this individual. It would be interesting to have this individual’s height measurement, to
examine the heights of acromegalics used as examples of acromegaly in the literature as

a population. H

Table 9. Smithsonian Individual #3 Authors’ Described Characteristis.

Male/Female Male

Age 39

Height Unknown
Documented Diagnosis Acromegaly
Malocclusion

Enlarged Frontal Sinuses

Prognathism

Vertebral Arthritis

Hypertrophied Nose Bones

Enlarged Sella Turcica

Tufting of Terminal Phalanges
Elongation of Mandible

Prominent Chin

Increased Bone Deposition at Insertions

 

H A list of other lesions characteristic of acromegaly were also given by Ortner and Putschar, although
they are not specifically attributed to this individual (Ortner and Putcharl9812298-299). These included
exaggeration of the supraorbital ridges and of the posterior occipital protuberance. Paranasal sinuses and
facial bones were enlarged and the cranial vault was thickened. Marginal build up of bone on the
alveolar process caused separation of the teeth. Increased diameter of the thorax was caused by
elongation of the ribs. All prominent points on the bones demonstrated increased rugosity. Kyphosis is
common due to muscle weakness in acromegalic individuals.

49

 

 

7. Gardarene Skull (Keith 1931)

Keith (1931) describes a fragmentary skull from Gardar, Greenland dated to the
twelfth century. The individual had been determined to be a male of 40-50 years of age
by Professor Hansen in the late 1920’s. The skull was not completely preserved: only
the skullcap and a major portion of the posterior part of the mandible survived.
Unfortunately, the chin portion was missing. The angle of the Gardarene mandible and
the width of the ascending ramus were greater than those of O’Brien (see next case

”12. The skull was “extraordinarily”

study). The torus occipitalis was “enormous
narrow. Keith suggested that the skull was distorted due to taphonomic forces.

Although some of the other males buried in the graveyard were strongly built,
the Gardar skull was massive in comparison. The skull shape was long and low, similar
to Neandertal. The bony attachment for the neck was enormous. The temporal lines
that mark the attachment of the upper boundary of the temporal muscles, almost met
along the saggital suture. Professor Hansen, in communication with Keith (1931:488-
489), suggested that these traits were not acromegalic but a genetic throw—back to
“early man” because he had noted similar traits, though of lesser degree, in other
members of the Norse cemetery population. Knowing what these similar traits for the
Gardar individual’s population were would also be helpful in re-assessing Keith’s
diagnosis.

Dr. Barnard Davis, a craniologist from the mid-Victorian era, compared the

Neandertal skull presented by Huxley (1863) to an example of an acromegalic skull

(with an enlarged sella turcica) in his possession. Keith (1931) compared the same

 

‘2 Actual terms that were used by the authors were used whenever possible to decrease error of
translation.

50

materials as did Davis and came to the same conclusion that Neandertal and
acromegalics share similar characteristics. However, he noted that acromegalic features
were indicative of an endocrine disorder, whereas Neandertal characteristics were not
pathologic for that population.

Keith judged the skull to be that of an acromegalic not a throw back to “early
man”. With the information available, I would not be comfortable making a diagnosis

of acromegaly or any other disease.

Table 10. Gardarene Skull Author’s Described Characteristics.

Male/Female Male

Age 40 to 50

Height Unknown

Documented Diagnosis Both Acromegaly and Giantism
Robust Skull

High Temporalis Origin Markings
Enlarged Supraorbital Ridges
Elongation of Mandible

Enlarged Mandible

Enlarged Occipital Protuberance
Increased Bone Deposition at Insertions

8. Charles Byrne or O’Brien (Bergland I 965, Landolt and Zachmann
1980, and McAlister 1974)

Although there was documentary evidence of O’Brien’s life, he was included in
this work because his skeleton is viewed as one of the primary examples of a giantism.
During his lifetime and up until 1912, the involvement of a pituitary adenoma in the
disease process was unknown. Many years after his death, O’Brien’s skull was opened
to reveal an expanded sella turcica (Hayles 1980: 166). O’Brien died in 1783 at the age

of 22 years. He had reached a documented living height of 8 feet 2 inches (250 cm)

51

 

 

(Bergland 19652265-269). Two hundred thirty-one centimeters was the recorded
measurement of standing height by Landolt and Zachman (1980: 131 1).

O’Brien’s skeletal maturation was retarded. He had the skeletal development of
17 years as estimated by epiphyseal closure, though he was 22 years old at death.
O’Brien’s height was proportional; suggesting that gonadotrophin production was not
affected. In other words, he did not have eunuchoidal giantism (Landolt and Zachmann
1980:1311-1312). Acromegaly was suggested by the thick skull, large sinuses, and
wide protuberant mandible (Keith 1931). PDB is not probable as he was much younger
than 40 years of age. Marfan would be excluded as his height was proportional and an
enlarged sella turcica was present. HOA and secondary HOA would be unlikely as
there is no suggestion of widespread hyperostosis and height was above average. Given
the above information, I believe Charles O’Brien had acromegaly and giantism. The
decreased severity of his acromegalic features was due to delay in the process of

epiphyseal closure.

Table 11. Charles O’Brien Authors’ Described Characteristics.

Male/Female Male

Age 22

Height 231.00 cm (7 feet 8.4 inches)
Documented Diagnosis Both Acromegaly and Giantism
Cranial Vault Thickened

Tall Height

Robust Skull

Enlarged Sella Turcica

Elongation of Mandible

Enlarged Mandible

Prominent Chin

Epiphyses Not Closed

Enlarged Sinuses

52

 

 

9. Rhine ’s New Mexico Acromegalic (Rhine 1985:210-219)

Stanley Rhine presented an acromegalic individual in his paper, “A Possible
Case of Acromegaly from New Mexico.” Differential diagnosis suggested that
acromegaly was present in an individual from the pre-Columbian New Mexico pueblo
of Pottery Mound. This individual was estimated to be a 30-40 year old male from “just
immediately pre-contact” (Rhine 1985:212). His stature was calculated to be 165 cm (5
foot 5 inches), which is only 2 cm above the Pottery Mound male population mean of
163 cm (5 foot 4 inches). Examination of the sella turcica was problematic as the
condition of preservation of this area was poor. However, radiologists found the sella to
be within normal limits upon radiograph. Mastoid, frontal and maxillary sinuses were
deemed large, and the “ungunal tufts” were enlarged13 .

Diagnosis was made both with individual and population characteristics kept in
mind. In comparison to the individual’s counterparts, this individual was quite robust.
His cranial vault was thickened with enlarged supra orbital ridges and a “deep”
mandible.

Rhine (1985) used Lang and Bessler’s ( 1961) report on the radiographic features of

acromegaly as diagnostic criteria. These criteria include:

Enlargement of the sella trucica

Enlargement of the maxillary sinuses
Prominence and enlargement of frontal sinuses
Prominence of brow ridges and zygomatic arches
Greater pneumatization of the mastoids
Prominence of the occipital torus

Localized thickening of the skull

 

13 Ungunal tufts are equivalent to distal phalanges.

53

 

 

Coarsening of trabecular patterns

Enlargement and elongation of the mandible

Abnormally large joint spaces

Degenerative osteoarthritis, with exostoses at origins and insertions of
muscles

Enlargement of ungual tufts of terminal phalanges

Narrowing of phalangeal shafts, broad bases and heads

Thickening and squaring of shafts of metatarsals

Kyphosis of upper dorsal spine, hyperlordosis of lumbar

Scalloping of vertebral bodies (formation of bone collar on centrum) from
Stuber and Palacios (1971)

Rhine used a systematic method with detailed and clear criteria to diagnose the
individual from New Mexico. Unfortunately, they were intended for diagnosis of a
living person, so a few of the characteristics were not applicable to skeletal material.
Characteristics were noted as being either present or absent. A diagnosis was made
upon the majority of criteria being present. Enlargement of the sella turcica is not
characteristic of all cases of acromegaly”. Acromegaly is not defined exclusively by
increased height in any way shape or means. PDB is eliminated because of the wide
distribution of skeleton involvement, as are Marfan and Adreno-Genital Syndromes
because the person is of average height. HOA and Secondary HOA are possible as the
pattern of bony overgrowth was not discussed. His argument was convincing that the
individual had acromegaly. No photograph was available, so it is difficult to assess

what other, if any indicators of disease were present.

 

‘4 See Case I of the soft tissue case studies. The individual was diagnosed with acromegaly during life
but showed no appreciable enlargement of the sella turcica.

S4

 

 

 

Table 12. Rhine’s New Mexico Acromegalic Author’s Described
Characteristics.

Male/Female Male

Age 30 to 40

Height 165 cm (5 feet 5 inches)
Population Mean 163 cm (5 feet 4 inches)
Documented Diagnosis Acromegaly

Cranial Vault Thickened

Enlarged Frontal Sinuses

Kyphoscoliosis

Vertebral Arthritis

Scalloping of Vertebral Bodies

Robust Skeleton

Rugged Face

Enlarged Supraorbital Ridges

Tufting of Terminal Phalanges

Elongation of Mandible

Prominent Chin

Increased Bone Deposition at Insertions.

Postcranial Exostoses

Enlarged Maxillary Sinuses

Increased Pneumatization of Mastoid Cells

Narrowing of Phalangeal Shafts, Broad Bases and Heads

10. Egyptian Skull (Brothwell 1981)

Brothwell (1981) refers to an example of acromegaly in an Egyptian, probably

early dynastic, skull retained in the British Museum (Natural History). Sex is ascribed

as female. Brothwell (1981) notes the extreme length of the face as the diagnostic

feature of this individual. He notes that the supra orbital ridges were not abnormally

large which he suggests was a due to the fact that the individual was female.

55

Differential diagnosis of acromegaly as outlined by Brothwell (1981) included

Disease of adults

Tumor of pituitary

Growth reinitiated especially in hands, feet, and skull

Enlarged vertebral bodies

Enlarged ribs

Considerable thickening of long-bones

Enormous development of supraorbital ridges

Thickening of occipital bone in region of nuchal crests

Enormous development of frontal sinuses

Lengthening of face due to reinitiation of grth in the mandibular and .
palatial regions 1

The diagnosis of acromegaly was based upon the appearance of the mandible
alone. No other information was given regarding the condition of the post-cranial
skeleton, if it existed at all. While acromegaly is not incompatible with the evidence
presented, the evidence presented is wanting. Mandibular growth is one of, if not the,
most conspicuous characteristics of acromegaly but it is not the only one. Sellar turcica
condition was not discussed as present or absent. Sinuses were not discussed, nor were
a number of other characteristics. Overall, Brothwell’s description of this individual
was incomplete. A more detailed description of the skeletal material would be necessary
to allow for an independent assessment of diagnosis. The variation of features of the
population would also be helpful to determine the diagnosis.

Examination of the photograph of the front of the skull shows indeed that the
person’s face was quite long. In addition, it appears that the lower jaw has an underbite.
Given the list of markers that Brothwell used in diagnosis, it is not convincing that the

individual is acromegalic. A radiograph would give more information regarding the

56

internal structure of the skull, revealing the size and configuration of the sinuses, the

shape and dimensions of the sella turcica, and the thickness of the cranial vault.

Table 13. Egyptian Skull Author’s Described Characteristics.

Male/Female Female

Age Unknown
Height N/A
Documented Diagnosis Acromegaly
Elongation of Mandible

I I . Marushia/ Sauer Individual (Sauer and Marushia I 99 7)

An individual identified in a forensic case was diagnosed with acromegaly and
giantism by Sauer and Marushia in 1995. A biological profile was generated from the
almost complete skeleton: male, 35 to 50 years in age, race/ethnicity was Caucasian,
and height was estimated to be between 6 foot 2 inches and 6 foot 6 inches (193.04 cm
by femur length). The individual was later identified by dental records, and was
determined to be a 35 year old male, 6 foot 6 inches (198.12 cm) in height . This
individual presented an unusual opportunity to compare a skeletal diagnosis with some
life history information.

The individual was not diagnosed during life with a pituitary tumor or
acromegaly/ giantism. However, skeletal characteristics were noted, which suggested a
possible diagnosis of acromegaly. The individual was of great height and robustness.
Growth appeared proportional, although no measurements were performed. The skull

was robust, with prominent supraorbital ridges, and occipital and zygomatic

57

protuberance. The skull was also long and narrow in shape, with a noticeable sagittal
keel

The mandible was elongated and enlarged. Upon radiographic and visual
examination, increased vault thickness, enlarged paranasal sinuses, and an enlarged and
remodeled sella trucica were noted. Arthritis and osteophytic lipping were noted in the
vertebral elements. PDB is excluded as the skeleton shows evidence of extensive
skeletal involvement. As the bones were not slender and an enlarged sella turcica was
present, Marfan and Adreno-Genital Syndromes are discarded as possible diagnoses.
HOA is disregarded as hyperostosis was not noted in all bones. Upon re-examination of

the evidence, the conclusion of “acromegaly with possible giantism” is correct.

Table 14. Marushia/Sauer Individual Authors’ Described Characteristics.

Male/Female Male

Age 30 to 50
Height 193.04 cm (6 feet 5 inches)
Documented Diagnosis Both Acromegaly and Giantism
Cranial Vault Thickened

Enlarged Frontal Sinuses

Vertebral Arthritis

Robust Skeleton

Tall Height

Robust Skull

Robust Zygoma

Proportional Growth

Enlarged Sella Turcica

Length and Diameter of All Bones Enlarged
Enlarged Supraorbital Ridges

Elongation of Mandible

Enlarged Mandible

Enlarged Occipital Protuberance
Arthritis-Not Vertebral

Enlarged Maxillary Sinuses
Dolichocephalic

58

 

12. San Cristobal Individual (Brauer 199122)

Bauer (199122) described a late prehistoric female from the San Cristobal Ruins,
New Mexico; an adult of no specified height. An enlarged and elongated mandible,
with a massive chin growth, was noted. The frontal sinuses were enlarged, as was her
remodeled sella turcica. Areas of bone and muscle insertion showed increased bone
deposition. Severe arthritis and osteoporosis were present throughout the entire
skeleton. Recovered thoracic vertebral bodies showed bony build-up on the anterior
body. The condition was described as severe.

Acromegaly, as diagnosed by Bauer is a convincing conclusion. PDB was
unlikely as the lesions were widely distributed throughout the skeleton. Marfan was
ruled out because of rugosity of insertion points. Adreno-Genital Syndrome was not
likely because the individual is female. HOA and Secondary HOA present with
periosteal build-up evenly over all the bone, not just areas of muscle insertion. The list
of characteristics fits the characteristic profile of acromegaly. The severity of the
disease suggests that the process was adult onset, as pre-puberty onset delays the
epiphyseal closure, thereby decreasing the severity of the lesions. “Severe” arthritis and
osteoporosis was an indicator of severity, as was massive chin growth. These
observations suggest that the disease has been occurring for a longer time or with

greater severity than the Marushia/Sauer individual (see Skeletal Case 12).

59

 

 

 

Table 15. San Cristobal Individual Authors’ Described Characteristics.

Male/Female Female
Age “Adult”
Height Unknown
Documented Diagnosis Acromegaly
Enlarged Frontal Sinuses

Vertebral Arthritis

Enlarged Sella Turcica

Elongation of Mandible

Enlarged Mandible

Osteoporosis

Arthritis-Not Vertebral

Prominent Chin

Increased Bone Deposition at Insertions

I3. Dick’s Mound Skull (Morse 19692124)

Morse (19692124) describes the skull of a Native American male from Dick’s
mound, Adams County, Illinois dating to ca. AD9OO (Late Woodland). He stated that
the individual “probably suffered from acromegaly.” Characteristics noted were
elongation and thickening of the long bones and elongation of the mandible. The teeth
were not separated by large spaces and the frontal sinuses were not enlarged. There was
no mention of the size or shape of the sella turcica though a radiograph was presented in
the account.

Several characteristics are mentioned as indicative of acromegaly in this
skeleton. A radiograph is even included. Due to the lack of clarity of the reproduction
or my ability to read radiographs, it is difficult to determine the configuration of the
sella turcica. There is no mention of the condition of the sella trucica. Again, as in
several other of the skeletal case studies it would be more convincing if more

information was presented regarding the absence of characteristic lesions. For example,

60

phalangeal tufting was not mentioned as being present or absent nor were prominent
insertion sites. The variation of features of the population would also be helpful to
assess the diagnosis.

With the paucity of information it is almost impossible to do an independent
diagnosis for this individual. PDB cannot be ruled out. Marfan and Adreno-Genital
Syndromes are unlikely since the bones were described as thickened. HOA and
Secondary HOA are a possibility since the long bones were described as thickened.
While it is possible and probably likely that Brothwell’s diagnosis of acromegaly is
correct, a more detailed and complete description of the lesions present and absent

would make a stronger presentation for this diagnosis.

Table 16. Dick’s Mound Skull Author’s Described Characteristics.

Male/Female Male

Age Unknown
Height Unknown
Documented Diagnosis Acromegaly
Length and Diameter of All Bones Enlarged
Elongation of Mandible

I 4. Hosovski Individual (Hosovski I 991 :2 73-2 79)

Hosovski describes an individual with acromegaly who lived in the Central
Balkans in the 1411' or 1511. century. The skeletal remains of a male estimated to be
about 30 years of age are described. Much of this individual was missing, with the

following bones available for analysis: the skull with lower jaw (but no teeth), the right

61

 

 

clavicle, two right ribs, thoracic vertebrae #12, lumbar vertebrae #1, the right “iliac”
bone, both femurs, and the right fibula.

The skull was described as being “characteristic in appearance” (Hosovski
19911275). Hosovski (19912275) refined this description by stating that all bones of the
skull were changed by a “hyperplastic process.” Growth was described as uneven with
the glabella and supra orbital arches, zygomatic bones and arches showing the most
growth. Thickness and mass in skull bones was increased, although there were holes
present, which the author attributes to osteoporosis.

The lower jaw was elongated. The bite was modified with a progenia mandible
(prominent chin) present. The paranasal sinuses were enlarged while the sella turcica
showed normal dimensions (Hosovski 1991:276). Examination of the post-cranial
skeleton revealed robust bones with exostoses present; the exostoses were found in
greater frequency on the femurs and vertebrae. Osteal-stemal dysostosis with the signs
of osteoporosis of newly-formed bone, osteoarthrosis, bilateral coxarthrosis (a
condition of bone overgrowth in the joint of the femur head and acetabulum) and
gonarthrosis (a condition of bone overgrth in the area of the knee or femoral
condyles), and proliferous periosteal reaction (fibulae especially) were evident. Height
was calculated by Hosovski to be about 173 cm or 5 feet 8 inches tall. The right femur

was significantly larger than the left (Hosovski 19912277).

Hosovski generated his diagnosis from a list of skeletal features attributed to

Matovinovic and Kicic (Hosovski 1991:274). This list of characteristics is reproduced

here:

62

 

 

 

o The increase of the skull, with all the bones of face and skull being thicker,
and due to disproportional growth of jaws, orbital arches and nose, the
patient has an unusual
appearance. There is an increase in all the paranasal cavities, especially of a
front sinus, the mastoid cells, and cavities of temporal and zygomatic bone.

0 Sella turcica is often broadened (over 20mm).

0 Due to longitudinal growth, the lower jaw is prolonged and separate from
the upper one, so that prognathism appears, and because of the complex
remodeling of a bite, a
blunt angulus mandibullae is formed (“a jaw in the form of a lamp”)

0 On all the bones, and especially on finger phalanges, there is periosteal
thickening of bones (“a hand in the form of a shovel”).

o Periosteal thickenings are located especially on muscle joints, which are
manifested in the form of a (sic) exostoses.
In rare cases osteoporosis is found
0 As terminal cartilage plates of spine vertebrae can create a bone
permanently, their growth begin in ante-posterior direction, and due to static
changes, kyphosis appears with reduced capability of spine flexibility.
0 After proliferation of joint cartilage in many joints there is
osteoarthrosis(sometimes with deformations), etc. (Hosovski 19912274)
Hosovski systematically examines this individual using a list of specific criteria
for acromegaly as described above. Giantism was ruled out due to the relatively
“normal” height of the individual, although a population mean was not given.
However, the author implied that the case appeared mild even, though the estimated age
at death was 30 years of age. This estimated age might be older than the chronological
age of the individual. Aging was estimated using the condition of the saggital suture
and the heads of the femurs attributed to Ferembach et al. (Hosovski 1991:274).
Estimating age in individuals with acromegaly by standard aging methods is suspect
(this concept will be explored more fully in the Discussions Chapter). The state of
epiphyseal closure throughout the skeleton was not mentioned. As previously

mentioned, epiphyseal closure is often delayed in those with a pre- and pen-puberty

onset of the condition. As in the case of O’Brien, the decreased severity of the

63

Hosovski individual’s acromegalic features could be due to a delay in the process of
epiphyseal closure and the fact that he died young (thereby decreasing the length of

time the disease would affect him).

PDB is possible, but unlikely, as the asymmetrical growth is associated with
discrete areas of periosteal exostoses, not an overall reaction of the right femur. The
fibula also shows involvement, which would be unusual in PDB (Ortner and Putschar
1981: 314). Marfan is unlikely as height was described as “normal” and the skeleton,
“robust”. Adreno-genital syndromes exhibit greater than average height and
disproportionately longer legs. HOA would produce a periosteal overgrowth that would
be evident in all bones of the individual. Hosovoski’s diagnosis of acromegaly is

credible, however giantism should be considered.

Table 17. Hosovski Individual Author’s Described Characteristics.

Male/Female Male

Age 30

Height 173 cm (5 feet 8in)
Population Mean 171.3 cm (5 feet 7 inches)
Documented Diagnosis Acromegaly
Periosteal Reaction

Cranial Vault Thickened

All Sinuses Enlarged

Prognathism

Vertebral Arthritis

Robust Skeleton

Rugged Face

Robust Skull

Robust Zygoma

Hypertrophied Nose Bones

Osteoporosis

Blunt Mandible Angle

Length and Diameter of All Bones Enlarged
Enlarged Supraorbital Ridges

 

Elongation of Mandible

Enlarged Occipital Protuberance
Increased Bone Deposition at Insertions.
Postcranial Exostoses

15. The Norfolk Giant (also called the Suflolk Giant) (Wells 1964 and
Brothwell I 96 7)

Wells (1964) described a skeleton, determined to be male, from an Anglo-Saxon
cemetery at Burgh Castle, Norfolk. This skeleton dated from the Middle Saxon period
0. AD 650. The height of the individual is estimated to be 232.52 cm (7 feet 7.5
inches). Severe, well-healed fractures were apparent on the right humerus, both ulnae,
the right talus and calcaneus. Brothwell (1967:523) suggested that, though this
individual might represent an individual whose height is at the upper limit of the normal
curve of stature variation, the fractures may actually be indicative of giantism. No other
information was given. It is apparent that a more thorough analysis of this individual’s
skeleton would be needed to determine a diagnosis. The variation of features of the
population would also be helpful to assess the diagnosis.

The list of what was not mentioned, potentially not even considered, include the
condition of the sella trucica, scoliosis, muscle and tendon insertion points, state of
epiphyseal closure, cranial thickness, arachnadactyly etc. Age estimation of the
individual including assessment of epiphyseal closure would also help in diagnosis.
Since the diameter of the bones in relation to bone length for the Norfolk Giant was not
indicated, Marfan syndrome should also be considered as a possible diagnosis. With

the available information, a diagnosis of giantism is unconvincing.

65

 

Table 18. The Norfolk Giant Authors’ Described Characteristics.

Male/Female Male

Age Unknown

Height 232.52 cm (7 feet 7.5 inches)
Documented Diagnosis Hyperpituitary Giant
Rugged Face

Tall Height

Fractures

16. The Archaeology of Nubia #1 (Egyptian Government Document
1 90 7:4 7)

A massive skeleton of a phenomenally big man was found in a Nubian cemetery
dated to the12th —20th Egyptian dynasty. Height must have exceeded 189 cm (6 feet 2.5
inches (see subsequent case). The researchers stated that there was no evidence of a
pathological cause of his giantism. The average height of men in the cemetery
population was 164.8 cm (5 feet 5 inches).

This individual was designated “giant” on the basis of height alone as he showed
no pathologies according to the 1907 Egyptian government document. This individual
fits the diagnosis of “giant” based upon the criteria set forth by Wells (1969) that a
“giant” is defined as an individual above three standard deviations above the mean
height of their population, but this individual does not necessarily fit the medical
definition of the term “giant.”

An examination of the skeletal material would need to be conducted to better
define this individual’s disease status. It was not mentioned whether the sella turcica or
any other hyperpituitary giant and acromegalic characteristic was examined or not.
Only the conclusion that no pathologies were present was recorded. Epiphyseal closure

could also give more information regarding the cause of this individual’s greater than

66

 

 

normal height, especially as it relates to estimated age at death. No photographs were
available for viewing this individual. Analysis of the skeleton, if done, was not
available. The variation of features of the population would also be helpful to assess the
diagnosis. For these reasons, the appellation “giant” is not consistent with the diagnosis

of giantism as outlined in this thesis.

Table 19. The Archaeology of Nubia #1 Authors’ Described
Characteristics.

Male/Female Male

Age Unknown

Height 189.0 cm (6 feet 2.5 inches)
Documented Diagnosis “Giant”

Rugged Face

Tall Height

1 7. The Archaeology of Nubia #2 (Egyptian Government Document
1 90 7 :4 7)

Another male skeleton was discussed in the same book because of his extreme
height and massive size. This individual dated to between the first and the twelfth
dynasty, Nubian Egyptian. Height was measured as 189.0 cm (6 feet 2.5 inches).
Again, it was stated that there was no evidence of a pathological cause for his giantism.
The average height of males in the cemetery population was 166. 1 cm (5 feet 5.4 inches)
in height.

This individuals was designated “giant” only on the basis of height as he showed
no pathologies according to the 1907 Egyptian Government Document. The height of

the individual was at the extreme upper limit of the normal curve of stature for his

67

 

population. This individual fits the diagnosis of “giant” based upon the criteria set forth
by Wells (1969) that a “giant” is defined as an individual above three standard
deviations above the mean height of their population, but this individual does not
necessarily fit the medical definition of the term “hyperpituitary giant.”

An examination of the skeletal material would need to be conducted to better
define this individual’s disease status. It was not mentioned whether the sella turcica or
any other hyperpituitary giant and acromegalic characteristic was examined or not.
Only the conclusion that no pathologies were present was recorded Epiphyseal closure
could also give more information regarding the cause of this individual’s greater than
normal height, especially as it relates to estimated age at death. No photographs were
available for viewing this individual. Analysis of the skeleton, if done, was not
available. The variation of features of the population would also be helpful to assess the
diagnosis. For these reasons, the appellation “giant” is not consistent with the diagnosis

of giantism as outlined in this thesis.

Table 20. The Archaeology of Nubia #2 Authors’ Described
Characteristics.

Male/Female Male

Age Unknown

Height 189.00 cm (6 feet 2.5 inches)
Documented Diagnosis “Giant”

Tall Height

68

 

 

Soft-T issue Case Studies

The following soft-tissue case studies fulfill a third purpose for this project,
which is to integrate soft-tissue case study information into a better understanding of the
skeletal analysis of an individual with acromegaly and giantism. These case studies will
allow the comparison of clinical life histories that can be associated with skeletal
changes. The soft-tissue case studies also lead to a fourth purpose for this project,
which is to present a better understanding of the lives and experience of those
individuals with acromegaly and giantism as it impacted them personally, as opposed to
life experiences based on postmortem conjecture (see Appendix 4).

The purpose of this section is to examine the soft-tissue and skeletal
manifestations of acromegalics/giants who had detailed clinical histories and post-
mortems. The first four case studies were gathered by Cushing and Davidoff as an aid
in “diagnosis and mild examples of the disease” (Cushing and Davidoff 1927281 ). The
four case studies described by Cushing and Davidoff ( 1927) demonstrate the variability
in the physical presentation of acromegaly and giantism.

Cushing and Davidoff’s (1927) work followed a number of individuals’ clinical
courses. Two of the individuals donated their bodies to allow the examination of their
skeletal system as well. These people’s gifts allowed the association of skeletal changes
to the documented progress of their disease. (It is to these people that this work is
dedicated.) Reconstruction of the life of an individual is often based on conjecture with
little documentary evidence. The association of a life history with skeletal pathologies

will allow the bio-archaeologist/forensic anthropologist to infer possible skeletal

69

 

changes to the individual’s lifestyle. How the person was affected physically can be

explored with a concept of the individual’s perception of the disease.

Case Histories of Individuals with Acromegaly

Case I

Individual number one (Cushing and Davidoff 1927) was a 42 year old man, a
teacher, who first sought medical treatment for “incapacitating headaches associated
with obvious acromegaly”. As a young man at the age of 23, the individual was
described as delicate-featured and light complexioned. He graduated that year as
valedictorian of his college class. A photograph indeed represents a well-groomed and
dressed young man of delicate feature and light complexion. He was 23 years old, 6

feet tall (182.88 cm) and weighed 140 pounds.

“The first of these reports concerns a man who had faced his
disfiguring and painful affliction with extraordinary fortitude. He had
become greatly interested in the disease to which he was a victim, had
written an autobiographical account of his individual case, and had left
instructions for an autopsy. He had submitted frequent reports to the
senior author regarding the progress of his malady up to the time of his
death which occurred in his home in 1921, 10 years after he first came
under observation at the John Hopkins Hospital.” (Cushing and Davidoff
192726)

The acromegaly began sometime after his graduation; the exact time of onset
was impossible to define due to its insidious presentation. However, the year of
presentation is given as 1892, the year he graduated from college. At 27 years of age,

surgery was performed for “enlarged cervical glands”. The author suggests that

70

 

 

 

 

 

 

overgrth was sufficiently obvious to be noticeable to the surgeon. He married at 30
years of age, 1898, but there were no children born to the couple.

In 1900 at 32 years of age, he sought medical advice for “increasing” headaches.
These headaches were to plague him the rest of his life. Measurements were taken at
this time. Height had increased to 6 feet 2 inches (187.96 cm), weight had increased to
202 pounds, and his collar, shoe and hat sizes had also increased.

The headaches were suboccipital but became more generalized over time. Any
muscular effort increased the accompanying “bursting” feeling. Erect posture also
increased his cephalgia or headache. Horizontal positions provided some relief.

There was no nausea or vomiting. Mental and physical inertia became more difficult to
live with as the duration of the affliction increased. Numbness in the extremities was
constant. He often experienced shortness of breath, which was linked to an occasion of
“pseudo-angina” or false cardiac pain. He felt that he was very susceptible to
infections. His hypertrophied nasal bones caused increasing obstruction to his
breathing, as did his enlarged tongue especially during sleep. He sweated copiously
night and day. Sexual libido and testes’ size decreased progressively over time.
Diabetes was not diagnosed.

A photograph records this man’s appearance at 42 years old, about 15 years after
the disease became apparent15 . Comparison of this photograph to his college graduation
photograph showed increased facial length and larger features. In the later photo, a
huge skeletal frame with noticeable signs of acromegalic growth was apparent.

Rounding of the shoulders was not visible upon external examination. X-rays showed

 

‘5 This time span is important for understanding the development of the disease and will be discussed
later in this chapter.

71

 

closed epiphyses in the hand with characteristic tufting of the terminal phalanges.
Rontgenography of the sella was not a highly developed procedure at the time, but the
sella was not increased in size. The clinoid processes were heavy with tips that
appeared to be fused or overlapped.

His head was large (length of 27 cm), with enlarged supraorbital ridges. The
alveolar arch of the jaw was heavy with no apparent prognathism nor increased spacing
between teeth (prognathism appeared later). There was enlargement of his thyroid
gland.

A right subtemporal decompression was performed in July 1, 1910, but the
headaches resumed. Glandular extracts were prescribed in large amounts. Certainly, on
the basis of an active hyperpituitarism, this was distinctly contraindicated. Whether it
had anything to do with the continued accession of skeletal growth is unknown. At this
time, it was also noticed that the individual had a decreased temperature.

During the 10 years that followed the failed operation, his headaches increased.
He became tired easily, yet he continued to teach. Skeletal overgrth was continuing.
His lower jaw finally became so large that it was almost impossible for him to chew.
He had a stroke, which produced transient right-sided hemiplegia (paralysis) with some
residual weakness. He retired from teaching in 1918, as he could no longer concentrate.
In the time that followed until his death, he experienced increasing weakness and
drowsiness along with the previously described headaches. He was alert and optimistic
until his death on April 16, 1921.

A post-mortem examination was conducted per the gentleman’s wishes. He

died of broncopneumonia at the age of 52. Tufting of the terminal phalanges had

72

 

 

increased, with the greatest size change in the great toes. The sella turcica had not
increased in size since it was visualized on a x-ray in 1910. However, the floor was
found to be partially absorbed. The outline of the gland was distinct and appeared to be
of normal or even sub-normal size. A histological examination described a pituitary
adenoma.

All body measurements had increased slightly in his last ten years of life. The
bones were markedly hypertrophic or enlarged, but they were said to show no
histopathological alterations. Cortex was thin with a large medullary cavity, and there
were hyperostotic changes in the vertebral centrums. Ribs were broad and heavy
configured with an abnormally large anteroposterior diameter. The skull was greatly
thickened, especially the frontal (2 cm). The increase in the thickness was observed to
occur in the inner table, which showed rough hyperostoses over much of the frontal
bones. The occipital bone was thinner (1 cm), and the longitudinal sinus was noticeable
as it was broad and deep. This case is important because no enlargement of the

pituitary was visible.

Case 11 -

Case number two (Cushing and Davidoff 1927) was of a 35 year old man, a
farmer, who had a childhood onset of acromegaly”. A family history was given by the
individual. His father was six feet (182.88 cm) tall and weighed over 190 pounds, while

his mother was described as having massive features. He was the oldest of six children,

 

‘6 Acromegaly, in Cushing and Davidoff 1927, is used to describe acromegaly specifically, and giantism
and acromegaly generally, much like hyperpituitarism is currently used.

73

and weighed 10-12 pounds at birth. No physical abnormality was noted until he
reached 13 at which time he began to grow rapidly.

By 19 years of age, he was 6 feet 4 inches (198.12 cm) tall and weighed 200
pounds. He was alert, powerful and intelligent, with what was described as “an
uncontrolled libido”. A severe undefined illness was noted in his 23rd year; the major
symptoms were polyuria or frequent urination and persistent furunculosis.

The author states that a photograph taken at 25 shows no signs of acromegaly.
Growth resumed for this man at 27 years of age, when a diagnosis of acromegaly was
made. During this period, he experienced intense frontal headaches and pain in the
arms and legs. Blood and muco-haemorrhagic discharge from the nose gave respite
from these headaches. His vision was impacted at this time with diplopia, or double
vision, and bitemporal blindness. He later became crippled by his excessive
overgrowth. He experienced a loss of vigor, weakness, drowsiness, and became easily
fatigued and impotent. Although his height increased two inches from 1904-1910, his
spine exhibited a progressive bowing.

In 1910, his height was 6 feet 6 inches (198.12 cm) and his weight was 269
pounds. His frontal sinuses were greatly enlarged. The mandible was protruded and
tilted, and the diameter of the thorax was increased. A lateral x-ray of the cranium
showed a sella turcica that had been greatly expanded. It was described as being heavy
and hypertrophied, with a posteriorly tilted dorsum sellae. Increasing blindness and a
divergent squint was attributed to pressure against the optic chiasm. An attempt was
made to relieve the inter-cranial pressure affecting the eyesight with a transphenoidal

operation.

74

 

 

 

Hospitalization was necessary in 1914 due to the level of severity of the
symptoms; he could no longer stand erect. A photograph of the naked man standing
next to a fully clothed, average man was included to show the patient’s stature, acral
enlargements, and crippled posture. Spinal changes occurred that resulted in the
bowing and rigidity of the spine. His facial features had enlarged even more since the
last documented observations. His skin and underlying structures had become loose
and fluid-filled. Fibromata mollusca (skin tags) were apparent over his back and chest,
and his scalp had become very thick with deep corrugations. He vomited occasionally
and his temperature was subnormal. Reclining offered relief from the intolerable
headaches that were at times accompanied by vomiting. The individual was often
drowsy. Another surgery was preformed as an attempt to offer some relief from the
excruciating headaches.

Five months of hospitalization ensued. Headaches and projectile vomiting
continued. At the behest of his family, a final surgery was preformed in an effort to
provide some comfort to this man. “He gained his release by death the following day”
on February 15, 1915. He was forty years old and had lived with acromegaly for
approximately 27 years. Permission was granted for an unrestricted autopsy with
removal of the skeleton. All that was noted of the skeletal changes was “(a)cromegaly

with typical skeletal changes” (Cushing and Davidoff 1927:42).

Case 111
Individual number three (Cushing and Davidoff 1927) was a male, married, who
was referred to hospital admission in 1913 at 34 years of age, with a diagnosis of

acromegaly and complicating diabetes. He had not sought medical help before this

75

 

time, although symptoms of acromegaly could be traced back to his twentieth year. It is
recorded that he worked as a Canadian fisherman up until just a matter of weeks before
this admission.

Family history revealed no family members of outstanding stature, and he had
the usual childhood diseases. He had pronounced prognathism but was unaware of the
progression of this feature. He did not recognize that he had this prominent feature
according to the authors. They suggested that this reflected his generally unobservant
nature.

When he was twenty years of age (1899), he began to increase in size. His
hands and feet became so large that he had a difficult time finding shoes and gloves to
fit them.

During this period, he found that his appetite increased notably, although he had always
had a good appetite. He did not keep track of his weight, but he did state that he had
gained 50 pounds in 2 years. In 1908, he weighed 220 pounds according to his
recollection. He married at 29 years of age (1908), soon after which, he became
impotent. He and his wife had no children.

Throughout the following years, he suffered from night sweats and profuse
sweating during the day and his hands and feet were often numb. Even with these
physical problems, he did not change his daily activities. His life was impacted in 191 O
at the age of 31 when he noticed that he was increasingly drowsy and that his output of
urine increased. Dispositional changes were noted by family and friends from 1910 up
until his hospital admission. He was irritable and more forgetful. He had noted

headaches occasionally in previous years, but now they were occurring every few

76

 

weeks. Vomiting often relieved the pain. Seizures and nocturnal attacks, which left
him unconscious, had started about one year before he sought out this only episode of
medical help.

Physical examination at the age of 34 described a man who was a “distractable
(sic), drowsy and irritable acromegalic of 5 foot eight inches in height, weighing 178
lbs. Vision was normal” (Cushing and Davidoff 1927:45). He was diagnosed with
diabetes as well as acromegaly.

On April 29, 1913 a transphenoidal operation was carried out with no particular

 

difficulty. The sella floor was almost completely eroded, and the tumor was found to be
eosinOphilic adenoma. After the operation, he found some relief from his mild
headaches as well as a decrease in the swelling of his hands and feet.

One year later, March 13, 1914, a very cyanotic, dyspnoeic, orthopnoeic and
irrational man was admitted to the hospital. He was edemotous. He died twelve hours
later (the autopsy results are presented in Appendix 4). An additional finding was that
the calvarium was thinner than that of other acromegalics (in the opinion of WT.
Councilman, who performed the autopsy) with few frontal endostoses. The greatest
thickness of the skull was measured as 6mm. Pacchionian digitations (thin areas) were
marked and a few perforated the skull. Prognathism was extreme, and the lower jaw
was significantly wider “across” than the lower jaw. A goiter was present, and the

testes had atrophied.

Cushing and Davidoff (1927) provided a comparative study of Case 11 and Case

111 to illustrate the skeletal differences between an acromegalic-hyperpituitary giant

77

 

 

 

individual and an acromegalic individual. Both individuals displayed tufting of the
terminal phalanges and enlargement of the sella turcica. Case H, although a
hyperpituitary giant, had evidence of severe vertebral exostoses. Cases H and 111 both
had mandibular lengthening and prognathism. Case 11 shows a greater increase in the
mandibular angle.

An enlarged sella turcica is not always inevitable, as the cases in this section
will exemplify. It is only when the enlarging lesion remains long confined within the
sellar envelopes that the fossa becomes hugely distended. When, as in Case 111, the
growth had broken through the envelopes early in its progress the sella may remain
relatively small, or when the adenoma never attains any considerable size the fossa as in
Case I, may not appear enlarged at all (Cushing and Davidoff 1927285).

Transphenoidal surgery can also modify the acromegalic skull. Within the
Cushing and Davidoff (1927) article, it is mentioned that the maxillary spur and the
vomer can be removed in such a surgery. These missing structures (and possibly
others) in a skull diagnosed with acromegaly can imply that transphenoidal surgeries

were preformed.

Case IV

Individual number four (Cushing and Davidoff 1927) was a woman who was
diagnosed with acromegaly when she was 51 years of age. She entered the hospital at
that time due to headaches. Her family history showed no indications of potential

diagnosis, with her personal history being unremarkable as well. This might have been

78

 

due to ”the patient’s want of observation and inaccuracies of memory” (Cushing and
Davidoff 1927267).

Menstruation began at 15 years of age and continued regularly until an abrupt
menopause occurred at 40 years of age. She married at 18 to a man of her own age.
She had no miscarriages nor were any children born to the couple. She had surgery to
cure glaucoma, in 1903.

Numbness of her hands and feet following began when she was about thirty
years old. At around forty years of age, she noted increasing drowsiness, lethargy and
lack of ambition. Restlessness, inability to concentrate and dull, diffuse pains in her
abdomen and back were also noted at this time. About 1905, the headaches, usually
located in the temporo-frontal region, became more severe. At age 43, friends noticed
that her fingers were increasingly stubby and pudgy. She noticed that her nose was
enlarged, and her dentist noted a change in the palate and alveolar arches conformation.
He diagnosed her with acromegaly.

At this time, she was 5 feet 2 inches (157.48 cm) and weighed 151 pounds.
Physical examination indicated that she had tufting of the tenninal phalanges,
prognathism, and that the sella turcica was greatly enlarged. On July 16, 1915 a surgery
was performed. The headaches stopped, but two months later she was readmitted. She
had numb feeling in her hands, but her drowsiness had decreased. She was readmitted

on Jan 21, 1916, when she became comatose and died.

79

 

CmeV.

Geddes (1911) describes the case history of a woman with acromegaly in
“Report Upon An Acromegalic Skeleton”. A brief clinical history is presented with a
series of photographs as well as a description of the skeleton.

For individual number five, age of onset of acromegaly was given as 25 years of
age, at which time the woman, a lady’s maid, sought medical treatment for a sore throat.
A photograph of the woman was presented to show her appearance before the onset of
the acromegalic symptoms. She has a narrow nose and fine lips, and her skin was fair
and clear. A few weeks after this episode, her hands started to grow and were painful.
Menstruation stopped shortly after, and only occurred again once, five years after onset.
Extreme lassitude was the next recorded symptom to appear. Growth of the feet and the
coarsening of facial features were noted some short time later. Coarsening of hair and a
“marked “ increase in tongue size were documented as appearing in the same time-
period. A photograph of the woman at 26 years of age, during the first year with the
disease, documents the thickening of the lips, the enlargement of the nose and ears and
the coarsening of the hair.

The next new symptom, increase in the thyroid, was stated as occurring at about
the twelfth year after onset. At age 40, the fifteenth year of the disease, she became
blind in her right eye. At forty-two, her boot size was recorded as size 7 (she had
previously worn a size 3). A photograph recorded her appearance in this, the
seventeenth year of living with acromegaly. Her right eye diverges due to its blindness,
and freckles were apparent, although none were noted in earlier photographs. She was

neatly dressed with well-groomed hair.

80

 

She lived for eight more years during which time her “condition gradually
progressed” (Geddes 19112258). A photograph records her appearance at 49 years of
age, after living with acromegaly for 24 years. Continued progression of facial changes
is noted in the text as well as the increased divergence of her right eye. Again, she is
well groomed and neatly dressed; she wears a lace collar pinned in the middle with a
broach.

Death occurred at the age of 50, 25 of those years she had lived with
acromegaly. A post-mortem photograph of the woman is presented: “To show
especially the hair” (Geddes 19112261). A pituitary tumor was found at autopsy, when
her skeleton was described in detail. In general, there was increased vascularization of
the bone, especially in the bones of the cranial vault. Rheumatoid arthritis was noted in
every movable joint. Every bone was abnormal in shape and appearance. The femoral
length (head to internal condyle) was Right, 421 centimeters, Left, 423 centimeters.

Most striking were the length of her face, the “buccal gap”, the great height of
the maxilla, and the prominent nasal bones. There also was asymmetry of the skull, a
thick cranium, an enlarged pituitary fossa, the foramen magnum was reduced to a slit,
and the maxillary sinuses were enormously expanded. The length of the individual’s
face versus stature (according to Cushing and Davidoff 1927 ) was enough to distinguish
acromegaly from giantism. She also had enlargement of the anterior ends of ribs,
marked cervico-dorsal kyphosis, a type of osteomalacia, and reduction of the spinal
foramina. Her pelvis had a flat sub-pubic angle; she had a great width of sacrum, which
was rugged but atrophic (quite thin), and growth at the pubic symphysis and the sacral

alae.

81

 

Case VI.

Thomson (1890) gives another description of acromegaly in “Acromegaly, With
The Description of a Skeleton,” published four years after M. Pierre Marie’s original
description of acromegaly. Cunningham originally presented the autopsy information
on this individual in 1879. Individual number six was a male fireman, 36 years of age.
Due to his great size and distinctive features, his condition was of interest to the medical
community of the time. Dr. C Muirhead provided care during this man’s two-month
hospital stay. His height was recorded as 6 feet 0.5 inches (184.15 cm) post-mortem.
Muirhead’s 1878 analysis was written about 8 years before M. Pierre Marie’s original
description of acromegaly. For this reason, a diagnosis of acromegaly would have been
impossible at that time. Thomson (1890) makes the diagnosis of acromegaly years
later.

Notes of the case were from the hospital ward-book were presented by
Thomson and Cunnigham. The diagnosis of the hospital admission was “a case of
strongly-pronounced diabetes mellitus”.

They quote from the hospital ward book as follows:

“The whole aspect and general configuration was so peculiar as

at once to arrest the attention of any observant person. His frame was so

huge, his movements so ungainly, his expression so unpleasing, the brow

so overhanging, and the feet and hands so enormously large and flat as to

suggest the idea to some in the ward of a resemblance to a gorilla, and by

this epithet he was spoken of among the other patients. I was not aware

of this till after he left the hospital; and, on thinking of his appearance, I

cannot say that I recognize the likeness. His voice was as remarkable as,

and in unison with, his otherwise large development: it was strong, deep,

and hoarse—in fact, the patients used to speak of the gorilla roaring

when he called for anything he wanted.

“He had no symptom whatever of paralysis or paresis. So far

from this he was in the habit, when he first came into hospital, of going
to the kitchen to help the nurse to carry up the breakfast and dinner.

82

Farther this act of his, a purely voluntary one, showed that he was not

insensible to kindness, and a willing to oblige. But while saying this

much, I must allow that his expression indicated a low type of intellect—

it was heavy, stupid, dull, utterly devoid of anything like active

intelligence. He was quite uneducated; I believe that he could neither

read nor write. He was easily irritated, and though sometimes he gave

vent to this in a fit of passion, more commonly he exhibited it by

hysterical weeping, and in this way his fits of anger invariably

terminated” (Thompson 189025 15).

The sight and hearing of this individual were unimpaired, notwithstanding that
the optic tracts, commissure, and nerves were rendered perfectly flat by pressure. This
was also the second case in which general progressive hypertrophy has been associated
with enlargement of the pituitary body.

The individual’s head and thorax were peculiarly large; his limbs were spare,
though his hands and feet were enormous. Diabetes was the only cause of death
specified on the certificate of death. His stomach was 4 to 5 times normal size, and the
bones were very large and out of proportion to the muscular development of the subject.
Enlargement of the bone was uniform and symmetrical. A distinct depression of the
inner surface of the skull-cap was visible where a prominent fluctuating bulging of the
dura mater over the parietal lobe of the right cerebral hemisphere was observed during
dissection. The pituitary body was found to be enlarged to about four or five times its
usual size, as was the pituitary fossa in which it lay.

Thompson’s (1890:484) article gave a detailed description of erosion of his
pituitary fossa. Other findings included that the optic groove was obliterated, and the

optic foramina was flattened. The anterior fossa was shallower than usual due to the

large size of the frontal sinuses and by the encroachment of the cranial cavity of the

83

 

 

 

 

orbital plates of the frontal bone. This individual had no mastoid, sphenoidal, and
maxillary sinus dilitation, and no evidence of abnormal curvature of the spine

There were projecting processes along the superior and inferior margins of
vertebral bodies, dorsally and ventrally. These projecting processes tended to continue
over the intervertebral disc in the area of the anterior ligament. His ribs were long, and
the sternum was reported to be “gigantic”. Costal cartilage ossification was affected.

Thompson (1890:486) additionally reported that, “Such an extensive of the
cartilages , and connective tissues generally, exactly corresponding to what is seen in
cases of osteo—arthritis, viz, the development of large masses of bone in the substance
of muscles and tendons in parts of the body distant from those affected by the arthritis
itself”. There was also unusual vascularity of the periosteurn, deformity of the stemo-
clavicular articulations, which suggested osteoarthritis, and partial ossification of the

glenoid ligament. All the phalanges were broader and thicker.

84

 

 

 

 

CHAPTER 5

ANALYSIS AND DISCUSSION

Analysis of the Skeletal Case Studies

Upon reading the literature regarding acromegaly and giantism, it became
apparent that more than one definition of “giant” was in use. While the medical
differential diagnosis of acromegaly and hyperpituitary giantism is the focus of this
work, it is necessary to acknowledge that anthropology and western culture also have
definitions of what makes someone a “giant”.

In those skeletal cases of giantism where height was mentioned, 100% of the
cases were taller than 6 feet 6 inches (198.12 cm). Some were described in the reports
as giants as they related to the height of others in their population. Others were
described as giants by people in their own population. Medical diagnosis of the disease
as we know it came only after Cushing’s 1912 discovery of the pituitary (Bergland
1965:268). It was at that time that the conditions of acromegaly and giantism were
found to result from an overproduction by the pituitary.

Although the number of individuals presented in this study is not large, trends in
diagnostic criteria can be inferred from the number of times a characteristic was used in
a diagnosis (this concept will elaborated on in the discussion section). The raw data
presented in Appendix 3 is organized by individual and by characteristic. If a specific
characteristic was noted as being present in an individual case study diagnosis, then a
“Yes” was placed in the corresponding cell. If the characteristic was not noted as being

present or was noted as being “not present,” then a “No” was placed in the cell.

85

Differentiating between whether a characteristic was diagnosed as being “not present”
or was simply not mentioned is not dealt with in this study.

Following the raw data for the observed characteristics are percentage analyses
for each characteristic. Percentages afford a simple method with which to observe the
frequency certain characteristics were noted in each of the diagnoses given in the
literature: “giant”, hyperpituitary giant and acromegaly, and acromegaly. The
percentage data for each characteristic are also found in Appendix 3. The percentages
represent the anay of features that were reported by the authors of the individual cases
and will be presented and analyzed next.

The acromegalic/giantism characteristic most commonly referred to in the
skeletal case study literature was “tall height,” which was ascribed to 100% of the
“giant” cases, 83.33%, hyperpituitary giant and acromegalic and 14.28% of the
acromegalic individuals. Elongation of mandible was mentioned in 100% of
acromegalic diagnoses, 67% of hyperpituitary and acromegalic cases and 25% of those
cases designated “giant”. Elongation of the mandible is a characteristic associated with
acromegaly (Ortner and Putschar 1981, J affe 1972).

The Tegemsee Giant was described as having an elongated mandible (Nerhlich
1991 and Pirsig 1994). As he was 25 years of age, it is possible that he was entering the
acromegalic stage even though he had an epipyhseal age of 17. Growth in height was
often documented in other individuals even at the age of 28. Acromegalic
characteristics were noted in those individuals who grew into their late twenties
(Cushing and Davidoff 1927). Prognathism was noted in 42.857% of acromegalics,

33.33% of giantism with acromegaly, and 0% of the “giants”. This relates to the bony

86

 

 

overgrowth occurring in the jaw. Individuals with giantism would not be expected to
exhibit this characteristic.

Given the cultural and anthropological definitions of the disease, the
characteristic percentage results are not surprising. Even medical books indicate tall
stature as a characteristic. People who suffer from a pituitary adenoma of the GH
secreting type can be extremely tall, but they do not have to be tall or over 6 foot 6
inches (198.12 cm) or not necessarily in the top third of height of their population! In
theory, a dwarf can be a medical hyperpituitary giant. As Brothwell (1981:162)
described giantism, “Height says it all.” Height does not say it all, it does not account
nor describe the other lesions that can exist. Roberts and Manchester (1983) suggest
that extreme height is characteristic of acromegaly. Acromegaly by definition occurs
after epiphyseal closure, therefore acromegalics do not exhibit extreme height (Jaffe
19722332). Rhine (1985) and Hosovski (1991) give lists of characteristics where height
is not mentioned.

In regard to bone size, 66.67% of giants with acromegaly, 42.857% of
acromegalics and 25% of giants were described as having all bones enlarged and
elongated; This result seems off since one would expect to have all giants described in
this matter. This result is probably due to the fact that two of the giants of the
Ptolemaic cemetery were described only as having no pathological features. No other
descriptions were available regarding these individuals. The lack of reporting for these
two individuals is probably skewing the results. These results also confirm that
“elongated” and “enlarged” were commonly used to define giantism. One would not

expect acromegalics to have elongated bones unless they had giantism.

87

 

 

Arthritis of the vertebral column is described in 57.143% of those with
acromegaly, 33.33% of those listed as giants with acromegaly and 0% of giants. Giants
often did not live long enough to develop many skeletal lesions related to their
condition (Aufderheide and Rodriguez-martin 1998:327).

The frequency of other characteristics are found in Table 21:

Table 21: The Frequency of Other Selected Characteristics.

 

 

 

 

 

 

 

 

 

: Acromegalics Acromegalyanfldfl lGiantisrn
Characteristic .................... inv ....................................... Giantism ............................ iQnIv ...............
CranialVaultThickened 28. 57 _ . 65:537...- _ . ____25
Enlarged Fronta'S'nuses 57143. ._ - v.50 25
Enlarged Sella TUFCIca 283.71 250 _, ..... 25
Propomona' 14285 , 5Q 0
KyphoscolIOSIS , ..__._..1f1,-,2,3§-,--- - 33 33L. _ ,_ 0.
Robust Skeleton .. , 14:233.... _.‘. -...33 33:. _ .....0
130W Obliteration 0 1567 25

 

Fractures. 0 .. 166750

Ir. ., ..........

 

 

The severity of acromegaly has been linked with the severity of the lesions
presented. In other words, the more characteristics of acromegaly and/or giantism that
are presented, the more severe the case the longer the assumed duration of the disease
within the individual. One would not expect to see severe acromegaly in a
hyperpituitary giant of extreme height. With the accompanying physiological stresses,
death would be likely before acromegaly would become too pronounced (Aufderheide
and Rodriguez-Martin 19982327).

The presence of the enlarged sella turcica with other features is the most

convincing of diagnostic criteria. However, a series of lesions with the characteristic

88

 

 

 

 

distribution defined previously is also suggestive. Unlike working with living

individuals, there are no further tests available at this time to confirm diagnosis.

If we compare these results with data from living individuals, we see that a
variable presentation and severity of lesions is not uncommon. In an example presented
by Cushing and Davidoff (1927), the sella turcica showed no enlargement, though a

diagnosis of acromegaly was made.

T -test Results and Analysis for the Skeletal Case Studies

Mean height of the skeletal case studies will be compared with the mean height
of the modern US. population using parameters collected by the United States
Department of Health and Human Services (DHHS) (19872 27). Height is examined
because it is one of the primary markers associated with giantism. This characteristic
has been described in the literature as .. the subjects become extremely tall...” (J affe
19722333). This section will look at how “extremely tall” compares with the average
height of the modern United States population, since those making the diagnoses tend to
be operating from within the context of Western populations.

For the purpose of this analysis, the mean of the skeletal case study heights will
be compared with the mean of the US. population (DHHS 1987227). The case studies
will further be divided to examine how those individuals diagnosed as being “giant” 17,

“acromegalic-hyperpituitary giant”, and “acromegalic” compare with the mean height

of the US population. “Giants,” as defined in the literature, should demonstrate heights

 

‘7 The placement in categories is based upon the diagnoses of the skeletal case studies as determined in
the literature.

89

greater than the mean height. Acromegalics, as defined medically, should show a mean
height similar to the individuals’ population of origin (or the mean of the modem US.
population, in this case). An acromegalic population should also follow a normal curve
for “height,” since acromegaly affects adult individuals randomly and regardless of their
pre-onset height.

The small number of individuals in this sample precludes any convincing
conclusions about these issues, but the results are interesting and set the stage for
further inquiry. Heights derived from skeletal material were used unless they were not
available, in which case, heights attributed to the living individual were used. The
important factor for diagnosis was the perceived height of the individual being
diagnosed.

Since it is expected that the mean height of this sample population will be higher
than the US mean height, a one—tailed t-test will be employed. One-tailed t-tests are
used when there is strong evidence to suggest that the given difference between the
sample and the population mean lies entirely within only one tail of the population
distribution. A test statistic that falls in the region of rejection in a one-tailed test may
not fall in the region of rejection of a two-tailed test. In other words, it takes a more
extreme test statistic to reject the null hypothesis in a two-tailed test (Earickson and
Harlin 1994:169-175).

In this case, it was suspected that the mean height of the skeletal case studies
was not representative of the US p0pulation in 1977-80. The mean height in the
modern US. population was 175.5 cm (DHHS 1987227). The hypotheses to be tested

were that the mean height of the “giant” skeletal case study sub-group, the “acromegalic

90

giants” sub-group, the “acromegalics” sub-group, and the skeletal case study “total”
population each had heights that were significantly greater than 175.5 cm (Earickson
and Harlin 19942153). The null hypotheses were that the mean height of the “giant”,
“acromegalic giants”, and “acromegalics” sub-groups and the “total” population each
had heights equal to or less than 175.5 cm, or that there was no difference between these
groups and the modern United States population (Earickson and Harlin 19942151).

A t-score is calculated to standardize a value so that it can be used to compare two
means from two normally distributed but independent populations. When a value is
converted to a t-score, the value is expressed in terms of the deviation of the sample
mean from the actual mean of the population from which the sample was drawn
(Earickson and Harlin 1994: 163). The calculated t-score is then located on a standard
table to find its equivalent probability. The t-test formula for comparing means is:

X (1)— X (2) - Delta

1 :
Square Root of (S (1) Squared/N (1) + S (2) Squared/N (2))

 

where X (l) is the sample mean from population (1), X (2) is the sample mean from
population (2), Delta is the specified value to be tested (in this case, the hypothesized
difference between the population means which is 0), S (1) is the standard deviation of
population (1 ), S (2) is the standard deviation of population (2), N (1) is the size of
population (1), and N (2) is the size of population (2)18. The number of degrees of
freedom for the problem is the smaller of N ( 1) — l and N (2) — l (Earickson and Harlin

1994:169-170).

 

‘8 The standard deviation in this case is found in the US. Department of Health and Human Services
document, Anthropometric Reference Data and Prevalence of Overweight: United States, [976-80. Data
From the National Health Survey, Series 11, No. 238.

91

 

 

 

The critical t-score is read from a standard table using degrees of freedom and
the level of significance or alpha level. The probability level was set at 95%. Since
this was a one-tailed t-test the region of rejection is less than 5% or equivalent to an
alpha level
of .05(Earickson and Harlin 1994: 169-175). Degrees of freedom, which are calculated
by the equation n-l, are calculated for each sample being compared. The smaller value
is used to determine the critical t-score for each pair of samples tested. These values
can be found in Table 23. If the calculated t-score was equal to or less than the critical
t-score, the null hypothesis of “there is no difference between the mean of the sample

and that of the population mean height” was rejected.

Table 22 Heights (in centimeters) Used for T-test Analysis

The Mutter Giant 235.60 cm Acromegaly and Giantism
The Norfolk Giant 232.52 cm Giantism

Charles O’Brien 231.00 cm Acromegaly and Giantism
The Persian Giant 220.00 cm Acromegaly and Giantism
The Polish Giant 215.50 cm Acromegaly and Giantism
The Tergenesse Giant 210.00 cm Giantism

Marushia/Sauer Individual 193.04 cm Acromegaly and Giantism
Smithsonian Individual #2 189.75 cm Acromegaly

The Archaeology of Nubia #1 189.00 cm “Giant”

The Archaeology of Nubia #2 189.00 cm “Giant”

Hosovski Individual 173.00 cm Acromegaly

Rhine’s New Mexico Acromegalic 165.00 cm Acromegaly

92

 

 

Table 23 Basic Statistics for Skeletal Case Studies with Heights

 

Giantism Only A. and G. Acromegaly Only Total Grog)
Number 4 5 3 12
Sum 820.52 cm 1095.14 cm 527.75 cm 2443.4] cm
Mean Height 205.130 cm 219.03 cm 175.913 cm 203.617 cm
Range 43.52 cm 42.56 cm 24.75 cm 70.6 cm
Standard 20.771 16.634 12.625 23.777
Deviation
Degrees of 3 4 2 11
Freedom
Critical 2.353 2.132 2.920 1.796
t-score*
Calculated 62.105 5.847 0.05666 4.096
t-score

*(at 95% confidence level, p is less than 0.05)

Table 24 US. Population Statistics 1977-1980, All Races, Male,

Age 18-74
Number 5916
Mean 175.5 cm
Standard Deviation 7.2

93

 

 

 

99 (.6

The calculated t-scores for the groups “giant , acromegalic giants” and “total”
all were well above the critical t-score values of 2.353, 2.132, and 1.796, which led to
the rejection of the null hypothesis (acceptance of the alternative hypothesis) at a 95%
confidence level. This meant that the mean heights for these groups significantly
exceeded the mean height for the 1977-1980 US population. The calculated t-score for
the acromegalic individuals did not exceed the critical t-score of 2.920. Therefore the
null hypothesis was not rejected; there was not a significant difference between the
mean height of the “acromegalics” group and that of the US population from 1977-
1980.

It was expected that giants and acromegalic giants would be taller than the
average height of their contemporaneous population. They were also taller than the
mean height of a modern US population. For more comprehensive studies, the scale of
giantism should be balanced by two factors: the mean height of the contextual
population (not the observer’s), and the presence of other markers.

As a group, acromegalics were shown to have the same mean height as the US
population, but two of the three individuals in the distribution had heights above the
mean height for their populations, and the third individual was taller than the mean
height of the US 1977-1980 survey”. As mentioned throughout this work, acromegaly
is an adult onset disease, so a normal distribution of height would be expected. In
theory, one would expect acromegalics of all heights. Granted, the sample examined
was extremely small, but this study suggests that a height bias might exist that hampers

the identification of acromeglics, or perhaps the distribution of height of acromegalics is

 

‘9 Rhine’s acromegalic was 1 in. or 2 cm. above average, the Hosovski Individual was 1 in. or 1.7 cm.
Above average, and the Smithsonian Individual #2 was 5.5 in. or 14.25 cm. above average.

94

 

not normally distributed. The distribution of height for a much larger sample of

acromegalics and giants would be an interesting topic for further research.

Analysis of Soft—T issue Cases and Life Histories

The above case histories are presented to allow for examination of the changes
in the skeletal system, as a function of the duration of giantism and acromegaly as a
single disease that varies by age of onset. This allows an understanding of the timing of
appearance of lesions and their severity. Variability of the presentation of giantism and
aromegaly is widely recognized, but there is a recognizable pattern of progression
(Cushing and Davidoff 1927, and Geddes 1911). These life histories allow a more
reality-based interpretation of the life of an individual’s skeleton in forensic
investigations or in archaeological contexts. We therefore have a better idea of what
was going on in the life of someone diagnosed with this disease posthumously.
Timelines of clinical and skeletal changes are presented in Appendix 4.

Information from the clinical histories of the people presented above allows a
chronology of appearance of symptoms to be generated. It is evident that the
characteristics associated with acromegaly develop insidiously for 14-22 years and then
“all of a sudden” become quite apparent. This has been validated by the medical
literature’s description of the course of the disease as well (Nabarro 1987). These
characteristics include increased skeletal frame, rounded shoulders, larger thorax,
increased size of facial bones, phalangeal tufting, larger head, prominent supraorbital
ridges, prognathism, closed epiphyses, enlarged sella turcica, increased height, spinal

curvature, larger hands and feet. If present, it is during this time period of 14-22 years

95

after the onset of the disease process, that these characteristics become blatantly
discemable.

Increased height is described in two of the cases (Case I and Case H). Case 1
describes a man whose onset of the disease was thought to occur at about 23 years of
age. Case 11 describes a man whose condition was thought to have occurred during his
13th year. However, both males experienced a “second period of growth” near the same
age, 23-31 and 25 -27 . Epiphyseal closure of the femur in the male according to
McKem and Stewart (1957) observations occurs between 18 and 22 years of age. This
implies increased pituitary function could have been present earlier than suspected in
the individual in Case I.

Delayed epiphyseal closure has been noted in individuals with giantism, namely
O’Brien (Landolt and Zachmann 1980:1311-1312), the Hosovski Individual (1991:273-
279) the Tergeness Giant (Nerhlich et al. 1991 and 1994, and Pirsig et al. 1994). This
can be due to the influence of the pituitary, both through the physical presence of the
tumor and through changes in hormone secretion, on puberty. Following out this line of
reasoning, a characteristic of giantism could be open epiphyses in an individual whose
chronological age would suggest that epiphyses would be closed. The chronology of
the soft-tissue case studies demonstrate that a second period of grth can occur in
individuals from 23-28 years of age so that the acromegalic features would not become
marked until epiphyseal closure occurred.

Case V and Case V1, both noted growth at the costal cartilages. “Such an
extensive ossification of the cartilages is very unusual at the age of thirty—six. . . ” was

noted in autopsy report of the man’s history described in Case VI (Thompson 1890).

96

Since the rib ends are used in the determination of age in the Iscan Method (Iscan et al.
1984), age should be estimated from a variety of methods when a pituitary condition is
suspected.

Case VI also noted that the woman’s pubic symphysis and sacral alae showed
overgrth upon autopsy. Like the rib ends, the pubic symphysis is used in estimating
the age of an individual. Determination of sex is also based upon observation of this
area. Again, methods that use areas of potential grth (areas of cartilage) should not
be used when pituitary function might be affected.

Duration of the disease varied in each instance between 15 and 30 years. A
summary of the soft-tissue case studies and the duration of each case of giantism and

acromegaly is presented in Table 22.

Table 25: Summary of Giantism and Acromegaly Duration in Soft-Tissue

Case Studies.

I male from about 29 years from age 23 to 52
11 male from about 27 years from age 13 to 40
VI female from about 25 years from age 25 to 50
IV female from about 21 years from age 30 to 51
III male from about 15 years from age 20 to 35
V male from Unknown to age 36

None of the individuals was mentioned as having children. If there is any
genetic component to acromegaly, there might be a reduced transmission due to a

decreased ability of hyperpituitary individuals to procreate.

97

 

Some conclusions can be drawn from the data presented above and in Appendix
4, which are useful in diagnosing and analyzing acromegalic and hyperpituitary giant
skeletons. Enlargement of the sella turcica does not occur in all cases of
hyperpituitarism as Case I illustrates. Hyperpituitarism can occur due to the
hyperproliferation of cells or due to the hypersecretion of cells. The latter would not
necessarily be associated with a tumor of the pituitary or its enlargement.

One purpose of this thesis is to give a method of differential diagnosis to
recognize more instances of acromegaly and giantism. Pituitary tumors were found in
25% of the population at autopsy (Hanison 1981:1899). An eroded or enlarged sella
turcica is, therefore, not necessarily an indication of acromegaly/giantism by itself. A
series of other characteristics must be considered to accurately identify acromegaly and
giantism. It is a constellation of characteristics that defines acromegaly and giantism,
and not a single characteristic.

Conversely, if there is no sella turcica enlargement, but there are other
characteristic lesions, acromegaly and giantism cannot be excluded. Cushing and
Davidofi’s (1927) skeletal autopsy of two clinically documented individuals diagnosed
with acromegaly and acromegaly/giantism showed that sella turcica enlargement was
not necessary for diagnosis. In these cases, the tumor may have grown intracranially,
with no remodeling of the sella turcica. It has been documented (see Robbins and
Cotran 1979) that a tumor need not occur at all, if the cells that are responsible for GH
production increase production to abnormal levels.

The timelines presented in Appendix 3 were based upon each individual’s

observation of the changes in their bodies, and the changes noted by the medical

98

observers. Comparing the individual’s observation of their own body changes with
those of friends, as in Case IV, it is possible to see that changes are missed by the
person afflicted. The man in Case 111 was unaware of the changes in his body, much to
the astonishment of the medical / physicians since they considered his bodily changes
quite extreme. However, the man in Case I became quite attuned to changes occurring
in his body and noted them readily to the physicians. These differences in perception
will, of course, affect the notation of body changes. Perceptions of the physicians
would also vary depending upon the relationship with the patient, the focus of interest,
and their knowledge of acromegaly.

One of the purposes of this project was to examine the inconsistencies in the
diagnosis criteria used to identify individuals with acromegaly and giantism.
Individuals in this study were chosen because they were used as examples of giantism,
acromegaly, or giantism and acromegaly in the paleopathological literature. These are
examples which observers will potentially be using to diagnose these diseases in future
individuals. Many of the examples that are commonly used have not been reassessed
for over 100 years.

Few, if any, of the individual’s skeletons were diagnosed during life since
acromegaly and giantism were not recognized as disease entities until Marie’s work in
1886. As the accession of many of these individuals was shrouded in mystery due to
the passage of time or the unorthodox methods of collection or both, little is known of
their life history. This is not to say that posthumous diagnosis is invalid, but a living
diagnosis with a history of skeletal changes would help to identify those skeletal feature

exhibited in people with acromegaly.

99

 

Another purpose of this project was to point out that the two primary
characteristics used to identify acromegaly, “height” and “elongation of the mandible”
are not sufficient criteria by themselves. Giants were diagnosed primarily by tall
stature, “elongated and enlarged bone growth”. Those individuals diagnosed as “giant”
were all over 6 foot 6 inches tall. Does this mean that there are no giants under this
height? It depends on which giants you are discussing. Medically, a hyperpituitary
giant is someone who has a pituitary adenoma that secretes GH and produces greater
than usual growth. “Giant”, as defined in this study, will be an individual with
giantism, as defined medically, who also has associated lesions as detailed in Table 3.

Above average height would be contingent upon populational genetics,
individual genetics as well as environmental factors including available nutritional
resources and stress (Weinreb 1984:299, and Wells 1969). The period of greater
grth can also vary. For instance, a person who develops a secreting tumor at birth,
such as Robert Wadlow (Hayles 19802168), would be taller than an individual who
developed the disease at 12 years of age. Considering the above information, those
individuals with giantism can be of variable height.

As stated previously, the height of acromegalics should follow a normal
population statistical curve, since acromegaly is defined as occurring after epiphyseal
closure is completed (i.e. adulthood) (Robbins and Cotran 1979:1340). However, some
authors (Brothwell 19812162, and Roberts and Manchester 1997: 181) have incorrectly
defined acromegaly as being associated with increased height, which could cause

confusion in diagnosis.

100

Aging the Acromegalic/Hyperpituitary giant Skeleton

Aging an individual with acromegaly and or giantism from skeletal material
would present some difficulties. In particular, there are two aspects of the disease,
which potentially could introduce error in the assessment of age. First, giantism
presents variability in the fusion of the epiphyseal plates. In the reassessment of
O’Brien’s skeleton by Nerlich et al., they found that his epiphyses were not fused.
O’Brien was 22 years old at death, while epiphyseal closure showed 17 years of age

(Landolt and Zachmann 1980:131 1-1312). The Mutter Giant’s age was also based on

 

epiphyseal closure (Humberd, Mutter Museum Archives). This information is
supported by clinical evidence presented by Cushing and Davidoff ( 1927 ) and Geddes
(1911) that many individuals with giantism have a second period of grth in height
often around 27-28 years of age. Most long bone epiphyses in persons without giantism
are fused by that time.

Second, aging in acromegalic individuals might prove to be even more
problematic. Bone overgrth occurs in areas where hyaline cartilage is associated
with bone surfaces, such as the pubic symphysis, the costo-chondral junction and the
vertebral column. Epiphyseal closure may or may not have occurred depending upon
the age of onset of the disease. Arthritis is also common in individuals with giantism,
especially in the vertebral region. There would be more weight-bearing stress
indicators than would normally be found in an individual without giantism or
acromegaly of the same age.

Todd’s ( 1920) and McKern and Stewart’s (1957) methods use the pubic

symphysis as an indicator of age. Iscan’s (1989:1094-1 104) method uses the distal rib

101

ends to determine age ranges. Arthritic changes in the vertebral column are associated
with physical stress and increasing age (Stewart 1979). These points were made
apparent by the Marushia and Sauer (1997) case, Humberd’s personal correspondence
regarding the Mutter Museum Giant (Mutter Museum Archives), and the article
regarding the reassessment of O’Brien (Landolt and Zachmann 1980).

It is possible that the individual from Persia described in Ortner and Putchar’s
(1981) Identification of Pathological Conditions in Human Skeletal Remains represents
an example of this difficulty. Documentary evidence suggests that the individual
designated as 42 years old is actually only 19 years old. The diagnosis is also in
question due to clinical information collected for medical treatment. Documentary
evidence collected from personal collections and medical journals suggested that the
individual was not suffering from giantism alone. Von Recklinghausen’s Disease and
HOA are also possible diagnoses (Fuchs 19352490).

The age of the Mutter Museum’s Giant is questionable as well. A personal
communication from Humberd discussing the Mutter Museum Giant reads, “1 find
myself disagreeing, too, with my good friend, Dr. Hinsdale, about the age of your
specimen at death. Dr. Hinsdale’s estimate was 22 to 24 years; your own placard reads
“23 years.” I am led by a number of reasons to believe... he was only about 17 or 18
years old...” (Dr. Charles Humberd to Dr. Joseph McFarland, June 26m, 1938, Mutter
Museum Archives). The age based on epiphyseal closure for O’Brien was very similar,
although he was known to be 22 years of age at death. (see skeletal Case Study Number

8).

102

Observer Height Bias in Diflerential Diagnosis of A cromegaly and
Giantism

The stature of each individual case study was compared with a normal height
distribution for the individual’s population or a population closest in time and space.
Individual population-normal curves were estimated using the mean given for the
population and the 5 — 8 cm standard deviation range quoted by Wells (1969:454).
Individuals without means for their population were examined in relation to populations
in the same time period and the closest in geographical region as possible with the
information available.

At first, this may seem to be of little value, but upon inspection, one point
becomes clear: that all the individuals with documented heights are above the mean
height in their contextual populations. One would expect a normal distribution of
height given the fact that acromegaly is defined as occurring in adulthood after
epiphyseal closure. Giantism can apparently occur in a pure form, but it seems to be
more common in the literature to have acromegalic giants or hyperpituitarism that spans
from childhood to adulthood.

In reassessing the diagnoses of the cases, one must also assess the criteria
originally used for diagnosis. Above average height (in Western and populational
contexts) was found in 100 % of the skeletal case studies. From the data, a possible
sampling bias in diagnosis is height. Because these are sample cases, this bias can be

carried into further diagnoses of acromegaly and giantism.

103

The Role of the Mandible in the Diflerential Diagnosis of Acromegaly

Acromegaly was defined by an elongated mandible in all acromegaly cases,
including cases diagnosed as “giantism with acromegaly”. Enlarged frontal sinuses,
vertebral arthritis, prominent chin and increased bone deposition at points of muscle
insertion were cited in over half of the acromegalic cases. Enlarged frontal sinuses
were not mentioned in any of the hyperpituitary giant cases, but were described in both
individuals designated acromegalic and hyperpituitary giant.

Giants with acromegaly were diagnosed with acromegaly by virtue of their
elongated mandible. Smithsonian Individual #2 was diagnosed as acromegalic, but was
supposed to have increased pituitary “action” before puberty. His height was estimated
to be 6 foot 3 inches (189.75 cm). Under the criteria presented in this work, this
individual would have been designated hyperpituitary giant and acromegaly. This
individual probably had a producing tumor before puberty; the levels, while above
normal, were low. This is consistent with the case presented by Sauer and Marushia
(1997). The individual was just at the limit for “giant” in the anthropological sense.
Interestingly, neither individual expressed severe manifestations of the disease. This
reaffirms the possibility of slight elevations in GH levels, which might explain the
variability found in the occurrence and severity of skeletal lesions.

In dealing with remains from about 1970 onward, there is the added possibility
of human grth hormone excess being deliberately introduced from external sources,
as in cases of body building or medical treatments. The sella trucica would not

necessarily be affected. How a differential diagnosis of an individual taking exogenous

104

human GH would differ from acromegaly and giantism is a question in need of further
research (“Anabolic Steroidscom”, 1997).

This implies that skeletal remains diagnosed with acromegaly and giantism
could have come from two things; hyperpituitarism or voluntary introduction of
exogeneous human GH. The first case would be a medical disease state, the second
would result in a medical disease state, but would also imply cultural body

modification, not unlike head-shaping and tooth-filing.

105

CHAPTER 6

SUMMARY AND CONCLUSIONS

The differential diagnosis of the individuals as presented in the literature were
not always convincing. Nine of the skeletal cases were compelling in the authors’
diagnosis, eight of the cases were unconvincing. None of the cases were complete
enough to allow for a confident, independent assessment of diagnosis, though several of
the cases were more thorough than others. This finding is in accord with conclusions
made by Ortner and Aufderheide (199121) in their introduction to Human

PaleOpathology. They stated that:

“To what extent does current medical knowledge relate to the
interpretation of paleopathological specimens? Clearly our descriptive
methodology and classificatory system are currently major barriers to
comparative research. In many published reports it is virtually
impossible to evaluate the evidence presented because the descriptions
are vague and imprecise. Worse still, some authors provide a medically
based diagnostic opinion with insufficient data to permit independent
evaluation” (Ortner and Aufderheide 199121).

The medical and anthropological literature used for this project, in general,
either did not have complete skeletal analyses or presented incomplete skeletal
information. Photographs, which can be extremely helpful in the visual recognition of
acromegalic characteristics, were often not available. Most of the literature also relied
on secondary sources, which can introduce new error or transmit outdated or incorrect
information. As has previously been stated, the terms “acromegaly” and

“hyperpituitary giant” are also inconsistently defined. In addition, many individuals

106

used as models for the affects of acromgegaly/giantism on the skeletal system predate
the medical recognition of these diseases.

Ortner suggests a solution to this dilemma of diagnosis. He states that, “The
emphasis would be on careful description of abnormal conditions rather than reaching a
diagnostic conclusion” (1991210). This thesis supports Ortner’s resolution to the
problem of differential diagnosis in the paleopathology literature. A differential
diagnosis can be suggested, but should never be considered absolute.

This work also provides information on a number of additional levels. It
provides a compendium of cases of giantism and acromegaly in the anthropological
literature. A foundation is provided for examination of the disease process of
acromegaly and giantism using medical literature as well. Anthropology and medicine
have also been used together to forward human understanding of past and present
disease processes with an eye to the future as well.

Differential diagnosis, a tool borrowed from medicine, may be influenced by
other bodies of thought. “Giant” has been shown to have a different definition in the
cultural, anthropological, and medical bodies. This can lead to confusion. A
pathological “giant” would not necessarily be the same as a “giant” in the cultural or
anthropological sense. This work suggests that medical practitioners as well as
anthropologists must be aware of the interaction of cultural, anthropological, and
medical spheres in the practice of their professions.

Giantism, for all definitions, was shown to be defined by increased/extreme
height. Defined medically, giantism is primarily based upon a GH producing tumor that

occurs before epiphyseal closure. Extreme height is not a certainty. Nutritional stress,

107

 

a common condition of many populations, can decrease the height of an individual
lower than their genetic potential. This possibility could affect how giants would be
discovered in a group with low nutritional standards. Because discerning medical
giants would be hampered by the perception that height defines giantism. The
incidence of the disease would appear lower than normal. The statistic is quoted that
25% of autopsies have evidence of pituitary adenomas (Harrison 1981:1899). It would
be interesting to investigate the impact nutritional levels have on giantism. Perhaps, a
reduced calorie diet might be suggested to individuals with acromegaly/giantism as a
means to decrease grth for those not responding to present-day medical
interventions.

Diagnoses can carry with them assumptions based upon the ability to diagnose a
disease process in human remains. It is the familiar caveat, be aware that analysis of
skeletal remains is at best an estimate, not an absolute. Skeletal lesions suggest a
disease process; they do not prove it. An enlarged sella turcica was present in less than
half of the described cases with other characteristic lesions present. The same disease
process can present with different lesions in different individuals due to the length of
time the disease was present and the differences between individual responses to
disease. More case studies would allow for a greater understanding of the variability of
the disease.

An account of the lesions associated with acromegaly and giantism are
presented here as a guide in diagnosis specifically for acromegaly and giantism.
However, this work also provides the rationale of differential diagnosis especially for

the non-medical reader. Differential diagnosis is most accurate when the user has a

108

large foundation of information from which to draw. To diagnose a disease, many
diseases presenting lesions must be contemplated to provide a starting point for
comparison, as pointed out by Bouchier and Morris (1982: 31). In short, to attempt
differential diagnosis in skeletal remains as well as in living individuals, one should
have a working knowledge of the medical literature as well as osteology.

Buikstra in her 1976 paper “Differential Diagnosis: An Epidemiological
Model” makes a strong case for a contextual examination of disease. She suggests that
not only the individual lesions be examined but that they be placed within a much
broader concept of mortality, morbidity and the ecology of the disease. Tuberculosis is
the disease to which this methodology is applied. Her study provided the next step for
this study of acromegaly. Applying the model of differential diagnosis to a population
to determine the number of occurrences and the presenting characteristics of the disease
within that specific population would make an excellent Ph.D. study. First it is
necessary to define the characteristics of the disease then examine a population to
determine incidence, mortality rates, and possible etiologies.

Disease can be examined qualitatively and quantitatively. Both are necessary,
but are rarely examined in tandem in the present. Descartes is purported to be the
founder of the mind and body dichotomy still found in today’s cultural framework.
Study can be made of the physical characteristics of the disease, with little attention
given to the individual who possessed it. Anthropology can act as a representative of
the individual. Bioarchaeologists use this information to reconstruct past life histories
from human physical remains and artifacts. Forensic anthropologists use this

information to match physical and cultural profiles of missing persons with unidentified

109

human remains. Implicit in this research is the notion that disease is not only a physical
process borne by the individual, but also a process defined by culture, medicine and

anthropology.

110

Appendix 1

Characteristics of Specific Diseases

111

Characteristics of Specific Diseases20

Acromegaly

Enlarged Sinuses

Thick Calvarium

Prominent Supercilliary Ridges — Supraorbital Ridges
Prognathism

Prominent Muscle Markings (Origins/Insertions)
Phalangeal Tufting

Kyphosis/ Scoliosis

Enlarged Sella Turcica

Arthritis

Giantism

Excessive Height

Enlarged Sella Turcica

Normal Body Proportions
Scoliosis

Weight Stress Lesions

Arthritis

Fractures of Weight Bearing Bones

Marfan’s

Excessive Height

Height Disproportionate to Arms and Legs
Arachnodactyl - Spider Fingers
Long-Headed — Dolicocephalic

Bossed Frontal

Pronounced Supraorbital Ridges

Kyphosis/ Scoliosis

Pectus Excavatum — Pigeon Breast Deformity
Underbite

Paget’s

Primarily Occurs in One Bone or a Few, Not all
Normal Height

Thickened Skull, but very Porous with Nodules
Bowing of Weight-Bearing Bones

 

20 These disease criteria are synthesized from a variety of sources, the most complete being: F airbank
(1976), Ortner and Putschar(1981), Robbins and Cotran (1979), Bouchier and Morris (1982), Nabarro
(1987), Aufderheide and Rodriguez-Martin (1997), Cushing and Davidoff (1927), Aegerter and

Kirkpatrick (1975), McKusick (1986a), Jaffe (1972), and Hamdy (1981).

112

HOA

Thickening of Calvarium/ Skull Base

Enlargement of Sinuses

Height Within Normal Limits

Periosteal Reaction in Mid Distal Ends of Radius, Ulna, Tibia and Fibula
Increased Diameter of Long Bones

Spinal Ligaments Ossified

Bone is Consistently Thick, Rough, and Irregular

Secondary HOA

Thickening of Calvarium/ Skull Base

Enlargement of Sinuses

Height Within Normal Limits

Periosteal Reaction in Mid Distal Ends of Radius, Ulna, Tibia and Fibula
Increased Diameter of Long Bones

Spinal Ligaments Ossified

Bone is Consistently Thick, Rough, and Irregular

Associated with Pulmonary and Systemic Diseases

A-G Syndrome/ Hypogonadism (Can Happen in Giantism)

Gracile Skeleton

Castration

Excessive Height

Disproportionate Limb Length to Body

In Adults — Stocky Build, Thick Boned, Short
In Childhood — Tall

Greater Than Average Height

Excessive Height
Proportionate Height

Neanderthal

Thick Cranium

Prominent Supraorbital Ridges
Average Height

Robust Features

Enlarged Occipital Bun

No Foot-Shaped Vault

Robust Skeleton

113

Appendix 2

Characteristics of Skeletal Case Studies

114

Characteristics of Skeletal Case Studies

1. The Polish Giant

Male/Female Female

Age 25 to 30
Height 215.5 cm (7 feet 2 inches)
Documented Diagnosis Both Acromegaly and Giantism
Cranial Vault Thickened

Enlarged Frontal Sinuses

Prognathism

Kyphoscoliosis

Vertebral Arthritis

Bony Obliteration of Skull Structures

Tall Height

Osteoma

Fusion of Vertebrae

Degenerative Changes in Epiphyses
Fan-Shaped Position of Anterior Teeth
Proportional Growth

Enlarged Sella Turcica

Length and Diameter of All Bones Enlarged
Fractures

Enlarged Mandible

Enlarged Maxillary Sinuses

Increased Pneumatization of Mastoid Cells
Evidence of Weight Loading in Vertebrae

115

2. The Tergensee Giant

Male/Female Male

Age 25

Height 235.0 (7 feet 8.75 inches)
Documented Diagnosis Giant

Cranial Vault Thickened

Cystic Bone Lesions

Bony Obliteration of Skull Structures
Spondylosis

Tall Height

Robust Skull

Enlarged Sella Turcica

Length and Diameter of All Bones Enlarged
Fractures

Elongation of Mandible .

Epiphyses Not Closed

3. The Mutter Giant

Male/Female Male

Age 17 to 24
Height 235.6 (7 feet 8.75 inches)
Documented Diagnosis Both Acromegaly and Giantism
Enlarged Frontal Sinuses

Prognathism

Kyphoscoliosis

Tall Height

Blunt Mandible Angle

Proportional Growth

Length and Diameter of All Bones Enlarged
Elongation of Ribs

Elongation of Mandible

Enlarged Mandible

Arthritis-Not Vertebral

Large Face

Epiphyses Not Closed

Pigeon Breast

Enlarged Maxillary Sinuses
Dolichocephalic

Evidence of Weight Loading in Vertebrae

116

4. Persian Giant

Male/Female Male

Age Either 19 or 42

Height 220.00 (7 feet 2.6 inches)
Documented Diagnosis Both Acromegaly and Giantism
Cranial Vault Thickened

Tall Height

Length and Diameter of All Bones Enlarged
Enlarged Supraorbital Ridges

5. Smithsonian Individual #2

Male/Female Male

Age 35 to 45

Height 189.75 (6 feet 3 inches)
Documented Diagnosis Acromegaly
Prognathism

Robust Skeleton

Tall Height

Robust Skull

High Temporalis Origin Markings

Blunt Mandible Angle

Proportional Growth

Length and Diameter of All Bones Enlarged
Elongation of Ribs

Tufting of Terminal Phalanges

Elongation of Mandible

Prominent Chin

117

6. Smithsonian Individual #3

Male/Female Male

Age 39

Height Unknown
Documented Diagnosis Acromegaly
Malocclusion

Enlarged Frontal Sinuses

Prognathism

Vertebral Arthritis

Hypertrophied Nose Bones

Enlarged Sella Turcica

Tufting of Terminal Phalanges
Elongation of Mandible

Prominent Chin '

Increased Bone Deposition at Insertions

7. Gardarene Skull

Male/Female Male

Age 40 to 50

Height Unknown

Documented Diagnosis Both Acromegaly and Giantism
Robust Skull

High Temporalis Origin Markings
Enlarged Supraorbital Ridges
Elongation of Mandible

Enlarged Mandible

Enlarged Occipital Protuberance
Increased Bone Deposition at Insertions

118

8. Charles O’Brien

Male/Female Male

Age 22

Height 231.00 (7 feet 8.4 inches)
Documented Diagnosis Both Acromegaly and Giantism
Cranial Vault Thickened

Tall Height

Robust Skull

Enlarged Sella Turcica

Elongation of Mandible

Enlarged Mandible

Prominent Chin

Epiphyses Not Closed

Enlarged Sinuses

9. Rhine’s New Mexico Acromegalic

Male/Female Male

Age 30 to 40

Height 165.00 (5 feet 5 inches)
Population Mean 163.00 (5 feet 4 inches)
Documented Diagnosis Acromegaly

Cranial Vault Thickened

Enlarged Frontal Sinuses

Kyphoscoliosis

Vertebral Arthritis

Scalloping of Vertebral Bodies

Robust Skeleton

Rugged Face

Enlarged Supraorbital Ridges

Tufting of Terminal Phalanges

Elongation of Mandible

Prominent Chin

Increased Bone Deposition at Insertions
Postcranial Exostoses

Enlarged Maxillary Sinuses

Increased Pneumatization of Mastoid Cells
Narrowing of Phalangeal Shafts, Broad Bases and Heads

119

 

10. Egyptian Skull

Male/Female Female

Age Unknown
Height N/A
Documented Diagnosis Acromegaly
Elongation of Mandible

11. Marushia/ S auer Individual

Male/Female Male

Age 30 to 50
Height 193.04 (6 feet 5 inches)
Documented Diagnosis Both Acromegaly and Giantism
Cranial Vault Thickened

Enlarged Frontal Sinuses

Vertebral Arthritis

Robust Skeleton

Tall Height

Robust Skull

Robust Zygoma

Proportional Growth

Enlarged Sella Turcica

Length and Diameter of All Bones Enlarged
Enlarged Supraorbital Ridges

Elongation of Mandible

Enlarged Mandible

Enlarged Occipital Protuberance
Arthritis-Not Vertebral

Enlarged Maxillary Sinuses
Dolichocephalic

120

12. San Cristobal Individual

Male/Female Female
Age “Adult”
Height Unknown
Documented Diagnosis Acromegaly
Enlarged Frontal Sinuses

Vertebral Arthritis

Enlarged Sella Turcica

Elongation of Mandible

Enlarged Mandible

Osteoporosis

Arthritis-Not Vertebral

Prominent Chin

Increased Bone Deposition at Insertions

l3. Dick’s Mound Skull

Male/Female Male

Age Unknown
Height Unknown
Documented Diagnosis Acromegaly
Length and Diameter of All Bones Enlarged
Elongation of Mandible

121

14. Hosovski Individual

Male/Female Male

Age 30

Height 173.00 (5 feet 8 inches)
Population Mean 171.3 (5 feet 7 inches)
Documented Diagnosis Acromegaly
Periosteal Reaction

Cranial Vault Thickened

All Sinuses Enlarged

Prognathism

Vertebral Arthritis

Robust Skeleton

Rugged Face

Robust Skull

Robust Zygoma

Hypertrophied Nose Bones

Osteoporosis

Blunt Mandible Angle

Length and Diameter of All Bones Enlarged
Enlarged Supraorbital Ridges

Elongation of Mandible

Enlarged Occipital Protuberance

Increased Bone Deposition at Insertions
Postcranial Exostoses

15. The Norfolk Giant

Male/Female Male

Age Unknown

Height 232.52 (7 feet 7.5 inches)
Documented Diagnosis Giant

Rugged Face

Tall Height

Fractures

122

16. The Archaeology of Nubia #1.

Male/Female Male

Age Unknown

Height 189.0 (6 feet 2.5 inches)
Documented Diagnosis Giant

Rugged Face

Tall Height

17. The Archaeology of Nubia #2

Male/Female Male

Age Unknown

Height 189.00 (6 feet 2.5 inches)
Documented Diagnosis Giant

Tall Height

Appendix 3

Data and Percentages for the
Analysis of the Skeletal Case Studies

 

124

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Male/Female 592 Height
Pottery Pueblo Male 30 to 40 165
Hosovski Individual Male 30 173
NMNH 227508 Male 35 to 45 189.75
Ancient Egyptian in British Museum Female Unknown

San Cristobal Female Adult .
Vienna Male 39 .

Dick's Mound Individual Male Unknown .

Giant From Ostrow Lednicki Female 25 to 30 208.5
Persian Giant Male Either 19 or 42 220
Charles Byrne Male 22 231
Mutter Giant Male 17 to 24 235.6
Marushia/Sauer Male 30 to 50 193.04
Gardar Skull Male 40 to 50

Ptolemaic Cemetery at Meris Male Unknown 189
Iggernsee Giant Male 25 235
Ptolemaic Cemetery at Meris Male Unknown 189
Burgh Castle, Suffolk Male Unknown 232.52

 

 

 

125

 

 

 

Both A and G
Both A and G
Both A and G
Both A and G
Both A and G
Both A and G
Giant
Giant
Giant
Giant

 

126

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Enlar ed Frontal Prognathism Kyghoscoliosis ‘
mises

Pottery Pueblo Yes No Yes
Hosovski Individual Yes Yes No
NMNH 227508 No Yes No
Ancient [Egyptian in British Museum No No No
San Cristobal Yes No No
Vienna Yes Yes No
Dick's Mound Individual No No No
Giant From Ostrow Lednicki Yes Yes Yes
Persian Giant No No No
Charles Byrne No No No
Mutter Giant Yes Yes Yes
Marushia/Sauer Yes No No
Gardar Skull No No No
Ptolemaic Cemetery at Meris No No No
Te ernsee Giant No No No
Ptolemaic Cemetery at Meris No No No
Burgh Castle, Suffolk No No No

 

127

 

128

 

Individual

Ru ed

 

 

Sgondxlosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bony Obliteration
Face of Skull Structures Height
Pottery Pueblo Yes No No No
Hosovski Individual Yes No No No
NMNH 227508 No No No Yes
Ancient Egyptian in British Museum No No No No
San Cristobal No No No No
Vienna No No No No
Dick's Mound Individual No No No No
Giant From Ostrow Lednicki No Yes No Yes
Persian Giant No No No Yes
Charles Byrne No No No Yes
Mutter Giant No No No Yes
Marushia/Sauer No No No Yes
Gardar Skull No No No No
Ptolemaic Cemetery at Meris No No No Yes
Iggernsee Giant No Yes Yes Yes
Ptolemaic Cemetery at Meris No No No Yes
Buggh Castle, Suffolk No No No Yes

 

129

 

130

 

Individual
_-

Osteo orosis

 

in Skull

 

Blunt Mandible

Anal—e

Osteoma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pottery Pueblo No No No
Hosovski Individual Yes Yes No
NMNH 227508 No Yes No
Ancient Egygtian in British Museum No No No
San Cristobal No No No
Vienna No No No
Dick's Mound Individual No No No
Giant From Ostrow Lednicki No No Yes
Persian Giant No No No
Charles Byrne No No No
Mutter Giant No Yes No
Marushia/Sauer No No No
Gardar Skull No No No
Ptolemaic Cemetery at Meris No No No
Iggernsee Giant No No No
Ptolemaic Cemetery at Meris No No No
BmCastle, Suffolk No No No

 

131

 

 

132

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Progortional Enlar ed .
Growth Sella Turcrca

Pottery Pueblo No No
Hosovski Individual No No
NMNH 227508 Yes No
Ancient Egyptian in British Museum No No
San Cristobal No Yes
Vienna No Yes
Dick's Mound Individual No No
Giant From Ostrow Lednicki Yes Yes
Persian Giant No No
Charles Byrne No Yes
Mutter Giant Yes No
Marushia/Sauer Yes Yes
Gardar Skull No No
Ptolemaic Cemetery at Meris No No

' F'Legernsee Giant No Yes
Ptolemaic Cemetery at Meris No No
Burgh_Castle, Suffolk No No

 

133

 

 

 

 

 

 

 

134

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Tufting of Elongation Enlarged
Terminal Phalanges of Mandible Mandible ‘

Pottery Pueblo Yes Yes No
Hosovski Individual No Yes No
NMNH 227508 Yes Yes No
Ancient Egyptian in British Museum No Yes No

San Cristobal No Yes Yes
Vienna Yes Yes * No
Dick's Mound Individual No Yes No

Giant From Ostrow Lednicki No No Yes
Persian Giant No No No
Charles Byrne No Yes Yes
Mutter Giant No Yes Yes
Marushia/Sauer No Yes Yes
Gardar Skull No Yes Yes
Ptolemaic Cemetery at Meris No No No
Iggernsee Giant No Yes No
Ptolemaic Cemetery at Meris No No No

Burgh Castle, Suffolk No No No

 

 

 

135

 

 

136

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual lncreaseased Bone Lar e Egighyses
De osition at Insertions Face Not Closed

Pottery Pueblo Yes No No

Hosovski Individual Yes No No

NMNH 227508 No No No

Ancient Egyptian in British Museum No No No

San Cristobal Yes No No

Vienna Yes No No

Dick's Mound Individual No No No

Giant From Ostrow Lednicki No No No

Persian Giant No No No

Charles Byrne No No Yes

Mutter Giant No Yes Yes

Marushia/Sauer No No No

Gardar Skull Yes No No

Ptolemaic Cemetery at Meris No No No

T_egernsee Giant No No Yes

Ptolemaic Cemetery at Meris No No No

BugLCastle, Suffolk No No No

 

137

 

 

138

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Narrowin of Phalan eal Shafts Enlar ed
Broad Bases and Heads Sinuses

Pottery Pueblo Yes No
Hosovski Individual No No
NMNH 227508 No No
Ancient Egyptian in British Museum No No

San Cristobal No No
Vienna No No
Dick's Mound Individual No No
Giant From Ostrow Lednicki No No
Persian Giant No No
Charles Byrne No Yes
Mutter Giant No No
Marushia/Sauer No No
Gardar Skull No No
Ptolemaic Cemetery at Meris No No
Egernsee Giant No No
Ptolemaic Cemetery at Meris No No
Bumgh Castle, Suffolk No No

 

139

 

   

14o

Appendix 4

Time Lines and Data for the Soft-Tissue Case Studies

141

 

 

 

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Collections
The Collection of Warren Raymond

The Documentary Archives of the Mutter Museum

156