The Stranger in the Photographs
In this essay How Acromegaly Hides in Plain Sight What Excess Growth Hormone Does to an Adult Body When a Pituitary Tumour Presses on the Optic Nerves The Acromegaly Diagnosis Hidden in Old Photographs Transsphenoidal Surgery: Removing a Pituitary Tumour Through the Nose Life After Acromegaly Surgery, and How the Body Recovers The bangles would not pass her knuckles. Sara had worn them since her wedding. Thin gold, six on each wrist, the sound of them part of how she moved through a room. One morning they stopped at the base of her hand. She pushed. They held. She told herself she had eaten too much salt. She was thirty-eight. For four or five years the changes had been arriving so slowly that no one, least of all Sara, had thought to add them up. Her nose had broadened. Her jaw sat heavier in her face. Her footwear, bought a half-size larger each year, no longer felt like vanity. Her voice had dropped and thickened, as though she were speaking through a cold that never quite got better. Her periods had turned irregular. The skin across her cheeks had coarsened and darkened. Her friends were kind. Her family physician was kind. Everyone agreed it was probably the start of menopause, a little early, nothing to fear. It was not menopause. It was acromegaly — a small growth hormone–secreting tumour of the pituitary gland at the base of her brain, and it had been quietly rewriting her body for years. How Acromegaly Hides in Plain Sight The body changes too gradual to notice Acromegaly is a disease of slowness. It is caused, in almost every case, by a small benign tumour of the pituitary gland that pours out too much growth hormone. The hormone does its work by fractions. A millimetre here. A half-size there. The face you meet each morning is never very different from the face you met the morning before, and so the change escapes you. By the time it announces itself, it has usually been at work for years. Across large studies, the gap between the first sign of acromegaly and the diagnosis runs to seven, eight, sometimes ten years. The face you meet each morning is never very different from the one you met the morning before. That is how acromegaly hides. The early signs are easy to explain away. Rings that no longer turn. Bangles that catch at the knuckle. Footwear bought a size larger, then larger again. A wedding band sent to the jeweller to be cut. These are the classic first complaints of acromegaly, and they are almost always blamed on something else — weight, water, age. Sara’s were blamed on early menopause. She was the right age for the suspicion to seem reasonable. It was not an unkind guess. It was simply the wrong one. What Excess Growth Hormone Does to an Adult Body Growth, after the body has finished growing Growth hormone is made in the pituitary, a gland the size of a pea that sits in a bony hollow beneath the brain. In childhood, the hormone builds height. Once the growth plates of the long bones close, that door shuts for good. A child with too much growth hormone grows very tall. An adult cannot grow taller. So the hormone turns instead to what can still enlarge — the bones of the hands, the feet and the face, and the soft tissues everywhere beneath the skin. Growth hormone does much of this through a messenger it raises in the liver, which keeps the tissues growing long after they should have stopped. The result is a face remade by degrees. The brow grows heavier. The nose broadens. The lower jaw lengthens and juts. The lips thicken. The tongue itself enlarges, and the voice deepens and roughens as the soft tissues of the throat swell. The hands broaden into something that looks borrowed from a larger person. The skin coarsens, oils and darkens. Sweating increases. The joints begin to ache. None of it arrives as an event. All of it arrives as a slow tide. When a Pituitary Tumour Presses on the Optic Nerves The peripheral vision you lose without knowing it is gone A pituitary tumour has somewhere to grow. The path of least resistance leads upward, and just above the gland lies the optic chiasm — the crossroads where the two optic nerves meet and trade fibres. When a growing tumour lifts into this crossing, it presses first on the fibres that carry the outer edges of sight. The result is a slow narrowing from the sides. Doctors call it bitemporal hemianopia: the loss of the outer, temporal halves of both visual fields. It is a cruel defect, because the person rarely notices it. The centre of vision stays sharp. Only the margins fade. Sara changed her spectacles twice, certain the fault lay in the lens. She began to clip the doorframe with her shoulder. She missed the cup set down at the edge of the table. Then her blood pressure climbed, sharply and without explanation, and her physician — uneasy at last — sent her for an MRI of the brain. The scan showed the tumour. The hormone tests that followed showed the cause. Her growth hormone was far above where it should be. The Acromegaly Diagnosis Hidden in Old Photographs A face changed by acromegaly, one year at a time When Sara and her husband Surya came to us, much of the explaining had already been done by the scan. What remained was for Sara to see it. We went through the symptoms of growth hormone excess one by one — the bangles, the footwear, the deepening voice, the coarsening skin, the irregular cycles, the vanishing edges of her sight. She listened with the particular stillness of someone recognising her own life in a description she had never been offered. No single mirror had shown her the change. The photographs, laid side by side, revealed it all
