336 INTERNAL SECRETION 



to deny the theory of hypersecretion in the causation of acrome- 

 galy. He pointed out that cases occur in which the hyperplasia 

 and adenomatous struma of the hypophysis are associated with 

 multiplication of the chromophile cells, but in which the symptoms 

 of acromegaly are not present. Moreover, cases of acromegaly 

 with adenoma of the hypophysis are observed, in which the 

 adenoma do not contain chromophile cells. It must be borne in 

 mind, however, that the chromophile cells are, almost certainly, 

 not the only secreting element, and that, as Erdheim and Stumme 

 showed, in the hypophysal hypertrophy of pregnancy, it is the 

 chromophobe cells which play the leading part. That acromega- 

 lous thickening of the nose, lips and hands frequently takes 

 place during pregnancy is another piece of evidence in favour 

 of the hyperpituitary origin of acromegaly, although it contradicts 

 Benda's assumption of the primal importance of the chromophile 

 cells. 



The whole of the anatomical material which we at present 

 possess points to the hypophysal tumour, and consequent 

 increased hypophysal internal secretion, as the causative factors 

 in the production of the symptom-complex of acromegaly. The 

 weightiest argument in support of this theory is the fact that, in 

 all cases where hypophysal tumour is associated with acromegaly, 

 the tumour is composed of true hypophysal tissue. 



It remained for operative surgery to prove, in so far as 

 experimental measures permit, the dependence of acromegaly 

 upon hypophysal affection, and by this means to provide decisive 

 evidence in favour of the theory of hypersecretion. 



Sir Victor Horsley was the first to recommend the extirpation 

 of the hypophysal tumour in acromegaly. The operation was 

 first performed by Caton and Paul in 1893, but without success. 

 In 1906, Horsley described the results of thirteen operations, 

 without, however, supplying information as to the indications and 

 symptomatic features of these cases. He obtained access to the 

 hypophysis by opening up the dura mater from the central cranial 

 fossa. Schloffer next considered the question as to whether or 

 not the hypophysal tumour is operable, and by what methods; he 

 concluded that the extracranial nasal method was the most prac- 

 ticable. In one instance,- he operated for hypophysal tumour with 

 what at first appeared to be favourable results, but after two and 

 a half months the patient died. v. Eiselsberg next performed 

 hypophysis operations upon three patients, one of whom presented 

 the clinical signs of acromegaly and died as the result of acute 

 sepsis. The other two cases will be described later. Borchardt 

 also describes the result of extirpation of a hypophysal tumour 

 in an anacromegalous case, the operation, in this instance, lead- 

 ing to an improvement of the headache. 



Hochenegg (1908) was the first to succeed in removing, by 

 way of the nose, a hypophysal tumour from a woman of 30 



