354 CLINICAL CONSIDERATIONS 



found as the only pathologically observable source of the dis- 

 order. 102, 1388, 4U - 662 



The question, therefore, arises as to what part the adrenals 

 play in producing Cushing's syndrome. Broster and Vines 95 

 have suggested that all cases of the syndrome may be associated 

 with a change in the adrenals manifested by a different staining 

 reaction of the juxta-medullary tissue. If this suggestion of 

 Broster and Vines is substantiated, one might consider Cush- 

 ing's syndrome as a manifestation of adrenal virilism, primarily 

 induced perhaps by the pituitary basophilism. Basophilic 

 adenomata of the pituitary are frequently found at autopsy 

 in patients who in life manifested no clinical symptoms. 351 

 Crookes 139 has suggested that it is only such basophilic cells 

 as are characterized by a distinctive hyalinization of their 

 cytoplasm that are associated with Cushing's syndrome. 



Further investigation is obviously necessary before one can 

 decide the relative importance of the pituitary and the adrenal 

 in causing Cushing's syndrome. It may be that the pituitary 

 basophilism initiates the observed clinical picture by sup- 

 pressing the ovarian function which in turn elicits a reaction 

 of the androgenic zone. As we have seen in Chapter IV, 

 castration in mice also causes an hypertrophy of the androgenic 

 tissue. The observed disorder might according to this view 

 be caused either by a primary hyperplasia of the androgenic 

 tissue of the adrenal or by an hyperplasia of this tissue induced 

 primarily by a disorder of the pituitary. 



Finally, attention may be called to those cases in which sex 

 changes occur which are identical to those observed in adrenal 

 virilism but in which, at operation or autopsy, no discoverable 

 cortical abnormalities are evident on superficial examination. 

 In Broster and Vines' 95 patients the adrenals in these cases 

 showed a staining reaction of the juxta-medullary tissue which 

 differentiated it from normal cortical tissue. This juxta- 

 medullary tissue, in the author's opinion, is identical with what 

 we have denoted as the androgenic zone and is probably the 



