266 THE DISEASES OF THE HYPOPHYSIS 



the sella during life by means of the X-rays. Since that time X-ray technique 

 has improved wonderfully and has become of important diagnostic aid. 

 The changes in the sella may be very different; frequently when the tumor 

 is situated purely intrasellarly there exists a widening out of the sella with 

 deepening of the floor. This may bring the bony partition between sella 

 and sphenoidal sinuses to paper-like thinness or to actual perforation; even 

 when the tumors are large the clinoid processes may remain intact. In 

 very large tumors too, however, there may be a widening of the entrance to the 

 sella and final destruction of the clinoid processes. The tumor may also 

 calcify. Calcifications of the dura are not rare. 



The following X-ray finding in a typical case of acromegaly serves as an 

 example : 



Observation XXXII. U, Dec. 9. The sella turcica is not only widened on the whole 

 to twice its size (measured in the sagittal direction) but also is very roomy at its introitus. 

 This also is at least double as wide as normal. The floor of the sella turcica has its homo- 

 geneous rotundity infringed upon, and is polygonal with washed-out borders. Several 

 crumbly calcareous masses in the interior of the sella may well be supposed to be calcined 

 tumor-masses. The widening that is here present shows itself in a sharpening at its base. 



The lack of an enlargement of the sella does not militate against acro- 

 megaly. On the one hand, as we shall see later, there may be present specific 

 microscopical alterations also in hypophyses that are scarcely enlarged, 

 especially in the initial stages of the disease; and on the other hand there 

 may be present a tumor of the hypophysis in the sphenoidal sinuses pro- 

 ceeding from epithelial rests of the hypophysial duct, or such a tumor of 

 the hypophysis of the pharyngeal vault. In the first case the floor of the 

 sella may be even eroded from below, and thus the connection with the hypo- 

 physis be established secondarily (Erdheim). 



Later, in the consideration of the tumors of hypophysis, we shall come 

 back to the subject of the differential diagnostic significance of the altera- 

 tions of the sella. 



To the symptoms called into existence by the pressure of the growing 

 tumor belong also headache, and eventually dizziness and vomiting. But 

 the last two symptoms as well as paresis of the cranial nerves are relatively 

 rare in this disease. 



On the contrary there are found more frequently disturbances on the 

 part of the optic nerves, disturbances not rarely in the form of bitemporal 

 hemianopsia and hemianopic pupillary reaction; the latter according to 

 researches of Wernicke and of Dijerine almost surely indicate a hypophysial 

 tumor. 



In addition to the hemianopsia there is found, also commonly, simple 

 amblyopia; these manifestations may occur unilaterally. They can lead to 

 blindness of one or both eyes; examination of the eye-grounds shows for the 

 most part alterations of the papillae in the sense of a neuritis (in 40 per cent.) 



