HYPOPHYSIS CEREBRI 331 



who have reached the adult stage; the predisposing cause is 

 unknown. The first symptoms are manifested through the nervous 

 system ; they are lassitude and muscular pain, progressive apathy 

 and somnolence, and eventually headache. Derangement of 

 sexual activity occurs very early in the course of the disease, 

 shown in women by the cessation of menstruation and in men 

 by impotence. The first pathognomic symptoms consist in 

 changes in the external appearance of the patient; the face be- 

 comes distorted, due partly to unequal growth of the soft portions 

 and partly to enlargement of the facial bones. In advanced cases, 

 the entire face is enlarged, the eyebrows are prominent, the eye- 

 lids thickened, the nose enormously increased, the lips swollen 

 and the zygomatic arches and lower jaw extremely salient. The 

 peculiar appearance of persons with acromegaly is enhanced by 

 the over-development of the soft parts of the mouth, the tongue 

 in particular being so large as almost to prevent the closing of the 

 mouth. 



Simultaneously with these appearances or somewhat later, 

 gradual progressive deformity of the extremities takes place. The 

 hands and feet become clumsy larger and broader than the 

 normal the long bones, however, remain almost unaltered. The 

 enlargement of the ends of the extremities is due in part to a 

 thickening of the skin, especially of the subcutaneous tissue, and 

 in part to a characteristic growth of the bones of the terminal 

 phalanges of the ringers and toes. 



The clinical appearances of acromegaly are generally, though 

 not invariably, accompanied by symptoms which point to the 

 presence of a cerebral tumour. These are : headache, giddiness, 

 vomiting, failing intelligence, and somnolence. Other symptoms 

 permit of the localization of the tumour and point to the hypo- 

 physis as the site of the lesion. Of these, the most important are 

 disturbances of vision, which consist, in the first instance, of 

 bitemporal hemianopsia, followed by progressive amblyopia and 

 amaurosis. At first the fundus is normal, later on there is pri- 

 mary atrophy of the optic nerve and, occasionally, choked disc. 

 Exophthalmos is by no means rare, but it is noticeable that the 

 projection of the eyeballs, like the derangement of vision, is 

 periodic in character and is obviously dependent upon changes 

 in the volume of the tumour. Paralytic symptoms are sometimes 

 observed in other cerebral nerve areas. A valuable aid to the 

 diagnosis of hypophysal tumours has recently been furnished by 

 radiological methods. Skiagrams show a deepening of the sella 

 turcica, the floor of which appears to be thinner; the dorsum 

 sellas shows usure and appears elongated. Where the tumour is 

 outside the sella turcica and is developed from the cranio-pharyn- 

 geal canal, the sella is flattened and the entrance to it is enlarged ; 

 the further growth of the tumour may completely destroy the 

 floor of the sella turcica (Schliller). 



