ACROMEGALY 811 



paresthesias in the head and face usually predominate. Mark, from per- 

 sonal experience, says that they exert a constant, all pervading influence on 

 the life of the patient and constitute his most serious handicap in the strug- 

 gle for existence. He describes a sensation as if the face were in a vise, as 

 if the antrum were tightly packed, the teeth too large for their sockets and 

 the eye pressed upon. Sensitiveness to light and to wind striking the face 

 was marked in his case. The headache, described as deep seated and 

 "splitting" by Mark, is often located deep in, between the temples, and 

 corresponds to the recently described "pituitary headache" (Pardee, Gush- 

 ing), thought to be caused by distention of the dural envelope of the pitui- 

 tary gland. The latter, as Pardee points out, is entirely surrounded by a 

 firm framework, on three sides by bone, above by dura, and only on the 

 lateral aspect is there any opportunity for expansion. The patient will 

 often place his fingers on either temple, point directly to the hypophysis 

 and say the headache is "between here." Characteristically enough, these 

 headaches in the rather larval pituitary or multiglandular cases described 

 by Pardee were frequently attended by other symptoms familiar in typical 

 acromegaly : a sense of fatigue, yawning, mental depression, and his female 

 patients showed a tendency to mustache and a masculine type of pubic 

 hair and enlargement of the bony framework. 



For a brief time there may be a feeling of increased strength com- 

 mensurate with the enlarged frame but soon a feeling of lassitude and an 

 inaptitude for work and exertion supervene. What Mark so well describes 

 as the "acromegalic state" into which he passed at intervals consists of a 

 feeling of fatigue, as of being partly under an anesthetic, a desire to keep 

 absolutely still, intolerance of noise and of strong light, a dizzy feeling, 

 dyspnea on exertion, a loss of interest in everything. Mental depression 

 and general discouragement are pronounced and may lead to actual melan- 

 cholia with suicidal trend. Polydipsia, polyuria and glycosuria are com- 

 mon during the periods of active disease, as is increased sweating. When 

 the hypophyseal tumor enlarges and breaks out of its sellar confinement the 

 "pituitary typo" of headache may bo relieved, to be replaced in the event 

 of further growth of the tumor by the ordinary brain tumor headache, 

 sometimes accompanied by vomiting, dizziness, and epileptiform attacks. 

 Pressure on the neighboring chiasma leads to optic atrophy, visual impair- 

 ment, with characteristic distortions of the visual field, notably bitem- 

 poral hemianopsia. Anosmia may result from involvement of the olfactory 

 bulbs. Exophthalmos is occasionally observed and usually attributable to 

 fatty deposits or bony changes in the orbits, or to compression of the 

 cavernous sinus. 



In the late stages cessation of active pituitary symptoms may be ac- 

 companied by definite signs of posterior lobe deficiency, such as adiposity 

 and increased sugar tolerance. This has been thoroughly demonstrated by 

 Cushing(d) who found such signs in 11 out of 14 cases of acromegaly 



