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and Legnani was followed by cessation of de- in February 1913. They summarize their velopment and a tendency to obesity. The epi- work as follows: (1), Piqure of hypophysis in physeal ossification was delayed, teething oc- the rabbit is comparable in its glycosuria recurred late and sexual organs remained infan- sponse to a piqure of Bernards so-called sugar tile. The thyroid showed colloid atrophy, thy- center in the fourth ventricle. (2), Stimulamus premature involution being one-fifth nor- tion of the superior cervical ganglion by faradimal volume, spleen atrophic and cirrhotic, mal- zation or by manipulations necessary for expighian follicles has disappeared, the fasicular posure caused glysuria in dog, cat and rabbit. and reticular zones of the suprarenals reduced (3), Stimulation of superior cervical ganglion to one mixed layer. The longest survival was after exclusion of all possible downward imeight months. Aschner recently declared that pulses to abdominal viscera by way of vagi, the pituitary body was essential so far as de- cervical sympathetic trunks or spinal cord leads velopment is concerned. He noted no genital to glysuria. (4), Stimulation of superior cerchanges following removal of the posterior lobe. vical after separation of all synapses of the Sweet and Allen very recently announced that sympathetic system by administration of nicothe entire canine hypophysis can be removed tine causes glysuria. (5), Direct faradic stimwithout danger to life.

ulation of the hypophysis itself after exposure Very interesting carbohydrate tolerance ex- by a transphenoidal operation gives glycosuria periments were reported by Goetsch, Cushing even after preliminary transection of the spinal and Jacobson in 1911. Simple operative mani

cord and cervical sympathetic trunks. (6), If rulation of the infundulum produced a tran

the posterior lobe of hypophysis was previously sient hyperglycaemia and for a few days an removed by operation the usual stimulation of alimentary glycosuria. This they attributed to superior cervical ganglion failed to give glycosetting free of a reserve deposit of posterior suria. (7), Direct faradic stimulation of hypolobe secretion which acted upon the liver caus- physis provoked glycosuria even after transecing a sudden release of glycogen. If a consid- tion of spinal cord above the splanchnics. (8), erable portion of the posterior lobe with its A Bernards piqure will likewise cause glycoepithelial investment was removed or the secre- suria even after transection of spinal cord above tory discharge through the infundibulum inter- the splanchnics. These results were obtained fered with by damaging it or by scar tissue

only when there was mobile glycogen in the later, the temporary lowering of tolerance was

tissues. followed by an abnormal increased tolerance Our knowledge concerning the pathology of for sugars. This would be lowered by the in- this small organ is practically limited to neojection of posterior lobe extract. Removal of plasms. Munzer classifies the pathological the anterior lobe partly resulted similarly to processes as follows: 1, atrophic conditions ; the manipulation of the infundibulum, but no 2, hypertrophic and hyperplastic conditions ; over tolerance followell, while injection of pos- 3, tumors. Scattered through the literature I terior lobe extract as before reduced the toler- find reports of the following types of tumors: ance, anterior lobe extract being inactive or granulomata, colloid and cystic enlargements, far less potent in this respect. Thyroid extract chromophobe-cosinophile and basophile adenowas also tried with negative results.

mata, carcinoma, sarcoma, angio-sarcoma, periMetabolism in nearly hypophysectomized epithelioma, endothelioma, teratoma (Hecht), , dogs was observed by Benedict and Homans:

glioma and psammoma. the development of the animals ceased, their Circulatory changes, anemia, hyperemia and sexual activity did not develop and if already hemorrhages are stated to occur. Lewis finds established was profoundly affected, excessive that the most common tumors of the infundifat deposits occurred and accounted for the in- bulum develop from inclusions of the craniocreased weight, body temperature remained pharyngeal duct and may be cystic or solid. slightly subnormal while pulse and respirations These are more frequently, associated with became slow. Total metabolism as measured Frohlich's syndrome than any other type of by CO2 output was markedly decreased. Asch- intra-cranial tumor. Struma and adenoma of ner and Porges have demonstrated a decreased the anterior lobe are the most frequent and consumption of oxygen after loss of the pitui- practically constant findings in acromegaly. tary body.

Fischer has emphasized this fact most forcibly Further studies in carbohydrate metabolism recently. Erdheim considers an eosinophile were reported by Weed, Cushing and Jacobson adenoma characteristic of acromegaly. Pars intermedia tumors are rare having found three activity of the anterior lobe or cells derived in the literature, cases of Erdheim, Cushing from it. Recent surgical results both here and and Boyce and Beadles. Lewis further finds abroad support this view. that hypophyseal cells tend to reproduce sar- Nothdurft recently reported a basophile mma morphology when proliferating and ad- adenoma of the neurohypophysis found in a rises that growths should be stained with stains case that died as a result of an endothelioma that differentiate the granules of the hypo- of the dura in the vault. This case had no physeal cells.

symptoms referable to the hyophysis, the adeTumors may excavate the sella turcica, even noma being the size of a millet seed. Whether open the sphenoid sinus and discharge cerebro- these basophilic cells had invaded the posterior spinal fluid from the nose, further they may

lobe from the anterior lobe or whether the infiltrate the surrounding brain tissue or as

tumor had extended into the posterior lobe the tumor increases in size compress adjacent

from the anterior lobe, he could not determine. narts. As a rule the malignancy of pituitary

He believes this case illustrates another point tumors is relatively low with very slight ten- in favor of the adenoma hyperplasia or adenodency to metastasis. Hecht states that hypo- ma as the cause of acromegaly. hrsis tumors are on the whole slow growing. Acromegaly does not occur with all hypo

Specific hypophyseal symptoms, symptoms physeal changes, on the contrary autopsies have due to disturbances of the internal secretion

shown marked alterations without acromegalic may occur alone or in combination with symp

phenomena, also acromegaly has occurred withtoms due to enlargement of the gland, alter- out macroscopic changes in the gland; but Erding the intracranial relations and conditions. heim has proven that more careful microscopic

examination of the latter reveals alterations. ACROMEGALY-HYPERPITUITARISM.

Lewis has pointed out that the pharyngeal This condition was first described by Marie

hvpophysis may be hyperfunctionating, should in 1886 believing it the result of lessened func

the hypophysis be normal. Fischer believes tion of the gland. Messalongo, Benda and

that the cases of acromegaly reported without Starch thought acromegaly was due to increas

eosinophile hyperplasia or adenoma in the hypoed activity of the gland, Gauthier endorsed by

nhvsis can be shown to be cases of syringomyelia Strumpell and Arnold construed acromegaly

with gigantism or some other disease. as a metabolic disorder manifested first in hypo- Acromegaly is characterized by an physeal change. Mayer agrees with Stumme

growth of the skeletal and soft tissues especialthat possibly the first impulse leading to acro- lv pronounced in the face and the extremities. megaly lies in the generative organs. Marburg

The onset is insidious: indefinite symptoms as suggested hyperfunction of pituitary results in headache, dullness, dizziness, nervousness, weakacromegaly while hypofunction in general adi- ness, fatigue, flatulence, constipation and episposity and genital atrophy, if complete absence taxis may occur. Usually the earliest manifesof function to a severe cachexia, Keith explains tations appear in the hands and feet, often cause somewhat differently, the acromegalic preceded by neuralgic pains or paresthetic senchanges being in the nature of a true growth

sations. and probably due to a pituitary substance sen- Keith has made a very careful study of the sitizing the tissues, the actual cause of the changes in the skeleton. The osseous-vascular growth being mechanical stimuli arising from system is altered, the capillaries and venous muscular action and mechanical movement. sinuses are increased in number and size, the The growth changes in acromegaly are similar surface of the bone is pitted and marked by to those occurring normally in the anthropoids numerous vascular foramina and impressions. and the neanderthal race. Munzer regards The cranial vault is thickened, commencing in acromegaly as a disturbance of the polyglan- the forehead and spreading backward limited lular system, not primarily hypophyseal and on each side by the temporal lines. The caobserved that with the hypophysis other glands nacity is probably somewhat increased in height. of internal secretion were affected. Since the Frontal sinuses greatly expanded. Supraormost common pathological finding and a prac- bital ridges exaggerated and thickened. The tically constant one is an eosinophile hyper- whole outer orbital wall is actually prolonged plasia or adenoma of the anterior lobe, Benda, and moved forward. The inion is moved upSternburg, Lewis, Cushing and Fischer con- ward on the occiput from 8 to 10 mm. Sella clude that acreomegaly is a result of hyper

turcica is expanded or excavated. Temporal

over

of complications. Operative intervention may also modify the course. Sternberg states that true sarcoma of the hypophysis runs an acute course, usually less than four years.

GIGANTISM. The occurrence of both acromegaly and gigantism with hypophyseal lesions has lead many observers to believe that they are manifestations of the same morbid condition. Massalongo concluded that acromegaly was delayed or abnormal gigantism; if the onset of the condition occurred in youth, gigantism would result, if in adult life acromegaly; while if during adolescens and extending into adult life a combination of both would result, a mixed type. Sternberg found that 40 per cent. of all giants were acromegalics, when both occurred the former always appeared first.

fossae increased in height. Mastoid processes are wider apart. The external auditory meatus is larger, deeper and depressed 10 mm. or more. The mandible projects downward and forward, the ramus markedly shortened. The temporomaxillary joint presents an apparently worn away articular eminence until its anterior parts form merely a margin to the glenoid fossa. Palatal area is actually diminished especially that of the lower dental arcade. The teeth are separated. Ribs and cartilages are often enlarged. Cervico-dorsal kyphosis usually present in advanced cases.

Changes in the soft tissues occur coincident with the skeletal alterations. The facies are quite characteristic: the face is increased in length, the features are course, eyelids are thickened, ears large, nose large and heavy, mouth large with thickened lips. The tongue is hypertrophied and fills the mouth. The larynx is large and voice may be deep and strong. The chest is large and the clavicles and sternum usually protrude. Hands are large and greatly thickened, fingers spade-like, thenar and hypothenar eminences enlarged. Feet huge and usually flat. The skin, mucous membrane and viscera are usually hypertrophied. Connective-tissue may

be increased throughout the body, especially about nerve trunks and may crowd around the nails. The nails may be thin and small. The sexual organs may be enlarged or on the other hand atrophic. General muscular weakness is frequently pronounced. Falta and Nowacxynski have recently demonstrated that acromegalies on a purin-free diet excret often more than twice the normal amount of urea. Ellis's case showed a creatinuria. Borchard states that 35.5 per cent. of the cases of acromegaly have glycosuria and an additional 5 per

cent. lowered sugar tolerance.

There may be a tendency for acromegaly or hyperpituitarism to be transformed into a hypo-active state leading to obesity, increased sugar tolerance, polyuria and lowered blood pressure, males becoming impotent and females developing amenorrhea. These types are termed dyspituitarism. Von Bonin believes pure cases of either hyperpituitarism or hypopituitarism are infrequent but both types are usually mixed.

The course is usually chronic, the onset is insidious, the early subjective symptoms often cbscure and not understood. Much depends upon the type of growth in the hypophysis, the extent of the intracranial pressure and the question of metastasis, and also the occurrepce

LEONTIASIS OSSEA. Bassoe suggests that gigantism, acromegaly, leontiasis ossea, osteomalacia and osteitis deformans may have an etiological relationship. Hoppe more recently believes that leontiasis ossea may be a form of acromegaly. FROHLICH'S SYNDROME—HYPOPITUITARISM.

First described by Frohlich of Frankl Hochwart's clinic in 1901 as a symptom-complex which occurs with hypophyseal disease. It is characterized by atrophy of the generative organs with accompanying diminish and loss of function, impotence in the male, amenorrhea in the female. Associated with the sexual disturbance is a marked general deposit of adipose tissue, hair frequently becomes brittle, perspiration is decreased and skin becomes coarse. If the onset of the condition occurs before complete development, dwarfism or infantilism result and the hair of axilla, pubis and face is deficient. Males may show feminine characteristics and females masculine characteristics. Cushing's cases showed polyuria, polydipsia and increased tolerance for carbohydrates. Not infrequently genital and sexual disturbances precede adiposity, but the adiposity may be absent or followed by a cachexia. Lewis has found cystic degeneration of the tumor in the cases with cachexia. These tumors resembling somewhat the multilocular cysts of the jaw. Low blood pressure is common. Temperature may be subnormal which Cushing considers due to lowered metabolic activity. Appetite is often ravenous, sometimes a peculiar craving for sweets is present. Dullness, drowsiness, early fatigue, weakness and psychic disturb

cases

ances may appear. Cushing has frequently ob- tions causing a stasis of the posterior lobe seserved epileptiform attacks and suggests that cretion leading to this syndrome transmit presan undue excitability of the cerebral cortex may sure to the anterior lobe, the anterior lobe may be a consequence of posterior lobe insufficiency, respond by a hyperlasia and hyperactivity of though the cases unmistakable uncinate gyrus the anterior lobe and its cells. This may be seizures showed an interpeduncular extension followed by an increase of growth in conjuncof the growth, which doubtless irritated the tion with the dystrophy-adiposia-genitalis. This adjoining uncinate gyri.

is known as Cushing's Syndrome. Various theories have been advanced as to

ADIPOSIS DOLOROSA. the origin of this condition; Frohlich considers it due to a lessened secretion of the Whether adiposis dolorosa is related to this anterior lobe. Erdheim denied this believing syndrome has not been definitely proven alit due to injury of as yet some unknown center though Burr's case showed a glioma of the in the base of the brain, possibly pressure on

hypophysis and Price's two

showed the nervous structures in region of the infundi- changes resembling adeno-carcinoma in the bulum and near the third ventricle, since the gland. syndrome occurred without pituitary disease

DIABETES INSIPIDUS. proper. Fischer disagrees with Erdheim main

The relation of the hypophysis to increased taining that dystrophia adiposia genitalis does urinary excretion is not as yet clear. Magnus not occur through pressure on an unknown cen- and Shafer demonstrated that the posterior (or ter but by damage to the pars nervosa and the possibly the pars intermedia cells) secretes a infundibulum. Whether this damage or de- diuretic substance causing a vascular dilatation struction of the nervous part leads to inter- and stimulation of the renal cells resulting in ference in the transmission of the secretion of polyuria. the anterior lobe is not known. Stumpf thinks Clinically acromegaly and Frohlich's synthe relation between the brain and the hypo- drome are not infrequently accompanied by physis is disturbed either by the interruption polyuria at some stage in their course. of nervous pathways or by insufficiency of se

Frank reported a skull bullet wound, in cretion of the anterior lobe into the infundi

which the bullet lodged in the sella turcica rebulum or neurohypophysis. He states that in

gion as shown by the X-ray, followed by diaincreased cerebral pressure the anterior lobe is betes insipidus. He states there are often (ompressed before the nervous part, even with family cases of idiopathetic diabetes insipidus considerable pressure the histological structure and concludes there is an inherited increased is preserved independent of the phenomena of function of the pars intermedia. Simmonds dystrophia genitalis and that high-grade adi- recently reported a case with a mestatic growth posity with genital atrophy may occur in in the clivis and posterior saddle destroying the chronic hydrocephalus without sellar changes. posterior lobe but not the pars intermedia and ('ushing assumes that a pathologic hypoplasia concluded that since Shafer had shown that the of both lobes of the gland has occurred. He anterior lobe extract caused no polyuria, the states that most cases previously recorded have pars intermedia was the cause of the diabetes been either interpedunular cysts or teratomat- insipidus present. Lewis and Matthews exous growths arising from an anlage related to

perimentally produced polyuria resembling diathe original pharyngeal pouch which serves to betes insipidus in 9 of 18 animals by hypocompress the gland directly. In the typical physis trauma. The frequency with which cases, the symptoms date back from childhood

polyuria occurred in posterior lobe and infundiand as a consequence of anterior lobe involve- bular stimulation and the character of the ment the patient remains small.

urine excreted suggested that diabetes insipidus Other tumors adjacent to the hypophysis is dependent on the hypersecretion of the diuhave been reported causing this syndrome:- retic substance, secreted by the pars intermedia Zak's case showed a psammoma of the dura cells into the posterior lobe. Haushalter and mater compressing the infundibulum, Otten- Lucein have reported a case of simple polyuria bergs case a calcified fibro-endothelioma of the in a child of 6 years which existed for 9 months dura in the sella and Kummel's case an aneur- with no other symptoms than polydipsia and ism of the circle of Willis. Both compressing polyuria, when the child suddenly had a conthe infundibulum and the neurohypophysis. vulsion which was followed by coma and death.

Should pressure conditions or other condi- At autopsy a tubercle size of a small nut was

severe.

found in the base of the gland. Cushing's case hypophysis. Cushing considers profile measshowed a gumma of the anterior lobe which he vrements exceeding 15 mm. antero-posteriorly interprets as having stimulated the pars inter- and 10 mm. in depth as indicating an enlargemedia into abnormal activity.

ment of the organ in the adult. The normal Fleeting glycosurias of basal fractures Cush

measurements as given by Keith are anteroing thinks may be due to pituitary trauma di- posterior 10 to 12 mm. and 8 mm. in depth. rectly or transmitted.

Progression of the disease may sometimes be The hypophysis being located in such a small noted by repeated radiograms. cavity the neoplasms of this gland either en

PLURIGLANDULAR PHENOMENA. large the sella, often eroding its walls or they

Possibly the altered functional states of the grow inward intra-cranially and thus disturb intra-cranial relations, giving rise to either

pituitary body or any other gland in the infocal phenomena involving individual nervous

ternal glandular system leads to a modifica

tion in the internal secretion of the other structures or general increased intra-cranial

glands. Alterations in the various glands have pressure symptoms, often both. Increased intra-cranial pressure symptoms :

been demonstrated at autopsy. Thus the oc

currence of sexual disturbances, impotence and headaches, often frontal in type, varying in

amenorrhea, glycosuria, pigmentation, hyper or intensity, sometimes occurring paroxysmally. hypotrichosis, asthenia, vaso-motor disturbIn most of Von Eiselsberg's cases it was very

ances, enlargement of the thyroid and emaciaRath states it was present in 81.6 per

tion may be significant of involvement of the cent. of his cases. Deep orbital pain may be

generative organs, pancreas, adrenals, thyroid present. Vomiting occurred in 75 per cent. of

thymus or hypophysis. cases in Frankl Hochwart's clinic while Cushing found it less frequent. Subnormal temper

TREATMENT. ature, Bartels and Rath state is always present. The treatment of pituitary lesions lies chiefPulse may be slow but Bartels found it con- ly in the realm of surgery. Cushing has treated stantly increased. Convulsive and epileptiform some cases with the glandular extract with attacks may occur. Venous stasis may be rotable improvement especially in cases of hyevident in the large veins of scalp. Psychic popituitarism. Recently Cauvin reported a behavior of the patient may be quite affected, case of acromegaly due to a hypophysis neoshown by intellectual deterioration, melan

plasm with marked visual disturbances treated cholia, delusions, stupor, dullness, delirium and with extract and the X-ray with marked imperverted or excessive appetite. Hyashi ex- provement in vision and relief of intra-cranial plains the psychic disturbances by the pressure pressure phenomena; but no improvement in exerted on the frontal lobes. Focal phenomena acromegalic findings and the amenorrhea. are evidenced chiefly in the involvement of Indications for operative procedure differ vision and the oculo-motor nerves. Visual dis- somewhat with the surgeon. turbances appear during the course frequently Cushing and Hochenegg have operated in a late due to encroachment of the growth on the few cases of active acromegaly with some beneoptic chiasma. Should these growths be vascu- ficial result; but in Cushing's case improvelar or cystic in type and vary in size or rup- ment was only temporary. ture, the findings will vary. The onset is usu- Von-Eislsberg does not consider simple ally slow. Bitemporal hemianopsia is common acromegalic or dystrophia adiposo-genitalis though at first may be unilateral. Evans finds phenomena without increased intra-cranial that 50 per cent. of the cases show partial or pressure or visual disturbances as indications complete primary atrophy. Photophobia, for operation, nor cases in which minor visual amaurosis, amblyopia, nystagmus, exopthal- disturbances are stationary under frequent obmos, concentric contraction of visual field, servation of an oculist, nor cases with irreparparalysis of the third and sixth nerves and able ocular conuitions and headache absent or complete ophthalmoplegia may occur. Wer- mild, but yielding to narcotics. Hirsch agrees nicke hemiopicpupil phenomena Evans found with Von-Eiselsberg that acromegaly without rarely present.

visual disturbances is not a sufficient indicaOppenheim has called attention to the im- tion for operation; but further states that portance of the X-ray in the diagnosis of pitui- every case with disturbed vision no matter tary disease. Any change in the sellar outline whether the growth be intra-cranial or intramay be correlated with a definite change in the sellar, operation is indicated.

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