ACEOMEGALY 80 9 



at all proven. Bleibtreu's case of acromegalic gigantism following trauma 

 and showing at necropsy destruction of the hypophysis by old hemorrhage 

 is unique and difficult to interpret. 



Fright is frequently mentioned as having preceded the onset, appar- 

 ently only in female cases. Pel(c) has observed three instances and is con- 

 vinced that it should be accepted as an etiologic factor, supporting him- 

 self on analogous claims made in connection with Graves' disease and dia- 

 betes. One of his patients, however, was pregnant at the time of the fright. 



The Clinical Picture of Acromegaly. 



If the facts stated in our definition are borne in mind it will be easy 

 for the reader to become oriented in regard to the complex and unusual 

 symptomatology. In order to be an acromegalic it is necessary for a per- 

 son to have had at one period or another of his life a state of overactivity 

 of the anterior lobe of the hypophysis. A certain train of symptoms accom- 

 panies this active stage: headache of a "pituitary" type, lowered sugar 

 tolerance and tendency to glycosuria; accentuation of secondary sexual 

 characteristics in the case of the male, and acquisition of certain male 

 characteristics in the female; finally the permanent enlargement of the 

 "acra" (nose, lips, lower jaw, hands, feet). The active stage may last 

 only a few months but the patient is indelibly marked as an acromegalic 

 for the rest of his life. From the mere external appearance of the patient 

 we cannot tell whether the case is an active or a quiescent one, an instance 

 of primary hyperpituitarism or one of secondary glandular overactivity as 

 the result of nature overreaching herself in an attempt to correct a primary 

 glandular deficiency which in turn may have been but part of a complex 

 ductless gland disorder. This is well brought out by Timme(a) in his de- 

 scription of a "new pluriglandular compensatory syndrome" with four 

 stages, the first in childhood and largely due to endocrin deficiencies, the 

 second at puberty with certain eunuchoid features, including rapid skele- 

 tal growth and deficient sexual development. In the third stage, between 

 the ages of 20 and 30 years, general gigantism or acromegaly may set in, 

 and the sella turcica becomes enlarged. The fourth stage is one of arrest 

 with persistence of the morphologic acromegalic features, or of progres- 

 sion, depending on whether or not compensation has become established. 

 The cases of pituitary disturbance in young people, described by Beverley 

 K. Tucker, with especial attention given to mental disturbances, are in- 

 structive since those reported as "preadolescent hyperpituitarism" 

 showed an acromegalic trend and in them evidences of pluriglandular dis- 

 turbances existed. Thus, the first patient, a woman of 26 years, had fully 

 developed breasts at nine years, menstruated at 11 years, and at 15 her 

 entire arms were covered with hair. The cheek and jaw bones were promi- 



