The pituitary body and its disorders : clinical states produced by disorders of the hypophysis cerebri. An amplification of the Harvey Lecture for 1910.

  • Cushing, Harvey, 1869-1939.
Date:
1912
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Licence: In copyright

Credit: The pituitary body and its disorders : clinical states produced by disorders of the hypophysis cerebri. An amplification of the Harvey Lecture for 1910. Source: Wellcome Collection.

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    The tumor was enucleated from its bed in the right hemisphere (Fig. 79). Its surface shows a curious verrucous irregularity. Its only point of seeming attachment was on the anterior wall of the elongated infundibulum. Here it shelled out less readily, though it cannot be certified that this was the point of origin. It is somewhat moulded by the struct- ures which it has crowded aside, the middle cerebral artery in particular having deeply grooved it. The optic nerves and chiasm have apparently been completely embedded by the growth. Most of its extension is toward the frontal rather than toward the temporal lobes. The internal carotid arteries are very large and tortuous and indent the sides of the hypophysis. Histologically the tumor appears to be a pure endothelioma (Fig. 80). The hypophysis (Fig. 81) is greatly flattened; the cell columns consisting in places of only two layers of cells, which have shrunk away from the greatly dilated sinusoids through the postmortem release of pressure. There is a normal proportion of acidophiles in the pars anterior. The posterior lobe is cellular: the neurogliar spaces wide-meshed but empty except for an occasional hyaline mass (Fig. 255, p. 192). There is a flattened colloid cyst in the pars mtermedia. Interpretation.—An unusual case, unlike any other in this series, though Case XVII of Group II will be found to possess certain similarities so far as the neighborhood distortions are concerned. Here, however, there were outspoken manifestations of hypophyseal insufficiency, from which Case XVII had largely escaped. The two cases differ, furthermore, in the position of the tumor, for in this case the growth lay anterior to the infundib- ular stalk, not behind it as in Case XVII and the tendency of its progress was upward and forward into the frontal lobes and ethmoid cells. Though in a far more advanced degree, the local conditions are pre- sumably similar to those postulated for the preceding case as well as for Cases IV and VI, and certified in Case III of the present group. The persist- ence of a morphologically intact, though thinned, sella seems to be character- istic of them all. One must not be misled therefore into the conclusion that normal sellar outlines necessarily speak against the existence of a neighbor- hood tumor. Sellar distention as we shall see is confined largely to patients afflicted with a primary glandular struma. In all of these infundibular extrapituitary tumors the hypophysis itself suffers from a pressure atrophy combined with stalk obstruction, which renders both lobes of the structure functionally incompetent. Lesser grades of a similar functional insufficiency, usually with hypopituitarism, occur with tumors situated at a distance, as will be pointed out (cf. Group IV), but with the neighborhood lesions the hypophyseal deformation and com- presson is far more obvious. It is important to note that with the ordinary methods of postmortem removal of the unembalmed brain a thinned-out saucer of gland, such as was revealed by careful dissection from below in this case, might easily be overlooked. The question naturally arises as to the duration of the condition. It would seem probable, in view of the patient's skeletal characteristics, that the anterior lobe had suffered before his normal stature had been attained; it would seem probable too that the usual manifestations of adolescence had been imperfect, indicating a secondary insufficiency of the Leydig cells which antedated puberty. Certainly some implication of the gland by the tumor was of long stand- ing. Subsequent to and perhaps due to the trauma of seven years ago, the