232 ACROMEGALIA 



ity that is to be depicted; if he had used a normal hand as a comparison for 

 the pathologic condition he would have perceived that the former, to make 

 the comparison possible, would have to be brought the same distance from 

 his apparatus as the latter, and not be left perhaps half a yard behind, as was 

 the case in the picture portraying the condition of the feet. 



But, to return from this digression, aside from this little photographic 

 trick, a practised eye is not necessary to note in the advanced stages of the 

 disease the very characteristic condition of the face. The prominent super- 

 ciliary ridge, with the bushy eyebrows which occasionally almost meet in the 

 median line, gives the face a threatening expression; the swollen lips, the 

 very prominent zygomatic arch and the lower jaw give a somewhat bestial ex- 

 pression, and the enormous nose with its grim humor forms the only redeem- 

 ing feature. 



A similar and progressive deformity in the extremities gradually becomes 

 noticeable. The feet become plump, larger, and broader, and the hand which 

 is deformed till it is like a bear's paw appears especially conspicuous. This 

 impression is further increased by the comparative slenderness of the lower 

 arm. The X-ray picture shows that the bones are covered with exostoses; 

 these are particularly noticeable at the end phalanges of the fingers and toes. 

 According to Pierre Marie two forms of alteration of the hand are to be 

 differentiated, one of which consists in. a general enlargement, the other in a 

 thickening of the bones of the hand. In the latter the exostoses are more 

 prominent. 



Eegarding the enlargement of the internal organs, one above all others 

 becomes clinically conspicuous, and must be counted among the most impor- 

 tant and constant symptoms of the disease — I mean the tongue, which 

 may assume extraordinary dimensions. In some cases closing of the mouth 

 is no longer possible. Enlargement of the thyreoid gland is often rec- 

 ognizable. 



Of great importance, but not always present, are the symptoms which 

 point to a tumor-like enlargement of the hypophysis. These symptoms are 

 principally those of a basal cerebral tumor, but from the description of the 

 autopsy finding we shall readily understand that these symptoms need not 

 occur, even in very large tumors of the hypophysis, so long as the tumor does 

 not invade the cavity of the skull. In many cases the symptoms in question 

 are, however, well developed. They consist, first, in severe headache which 

 occurs in paroxysms, vertigo, vomiting, decrease of intelligence and, in par-' 

 ticular, somnolence. The direct pressure of the tumor of the hypophysis acts 

 most constantly upon the optic nerves, or upon the optic chiasm, and shows 

 itself in hemianopsia, amblyopia even to amaurosis, due to atrophy of the 

 stretched and compressed optic neryes. More rarely the muscles of the eye 

 are implicated, especially those supplied by the oculomotor nerve. At this 

 point I must also mention exophthalmos which has been observed in many 

 cases, and which is usually referred partly to the change in the bones of 

 the orbit, and partly to enlargement of the bulbus oculi. I believe, how- 

 ever, that the fact that acromegalic exophthalmos occurs periodically may best 

 be explained by the assumption that it is not due to organic changes in the 



