HISTORICAL VIGNETTE

A case of pituitary adenoma: Thomas Willisrevisited

A.N. Williamsa,*, H.M. Altonb, R. Sunderlandb

aNorthampton General Hospital, Northampton, UKbBirmingham Children’s Hospital, Birmingham, UK

Received 30 December 2002; accepted 24 April 2003

KEYWORDSPituitary adenoma;

Neurology; Pituitary

tumour; Thomas Willis

Summary Thomas Willis (1621–1675) was the founder of modern clinical neuroscience.His habit of taking detailed histories with acute clinical observation oftenaccompanied by post mortem studies has left a body of work which still provokesthought and debate. While we were considering a case of pituitary tumour describedby Willis, a similar case presented coincidentally at our hospital. The two cases arecompared and contrasted.Q 2003 European Paediatric Neurology Society. Published by Elsevier Science Ltd. Allrights reserved.

But my thesis isn’t about that…. It’s about theinfluence of T.S.Elliot on Shakespeare1

Thomas Willis (1621–1675) is mainly remem-bered for his pioneering anatomical studies of thebrain, cranial nerves, spine and autonomic nervoussystem as well as first describing the function of thearterial anastamosis at the base of the brain.Besides the Circle of Willis, he is also creditedwith conceiving the word neurology thereby found-ing this speciality.2

However, in spite of all the above he was notregarded as an original thinker until William Oslerled the drive to restore his reputation as one of thegreatest physicians of all time:

Willis did two things: he made himself a goodscientific man as far as the science of that day

went, and he made himself a first-class prac-titioner, and those two sides of the man arepresented in his works.3

Willis is being increasingly recognised for havingmade many contributions both in neurology andother medical specialities. We take that processforward here by comparing one of his paediatricneurology cases from the 17th century withone from the 21st century. The first was transcribedfrom one of Willis’ lectures by Richard Lower wholived between 1631 and 1691 and was a pioneer ofblood transfusion and a celebrated physician in hisown right.

Case 1. Oxford 1664

On 24th June 1664, Richard Lower informed RobertBoyle that he had been present with Willis at a postmortem on a scholar who developed a sudden

1090-3798/03/$ - see front matter Q 2003 European Paediatric Neurology Society. Published by Elsevier Science Ltd. All rightsreserved.doi:10.1016/S1090-3798(03)00056-4

European Journal of Paediatric Neurology (2003) 7, 183–185

www.elsevier.com/locate/ejpn

*Correspondence: A.N. Williams, Consultant in Paediatrics,Northampton General Hospital, Cliftonville, Northampton NNI5BD, UK. Tel.: þ44-1604-544-188; fax: þ44-1604-545-988.

E-mail address: anw@doctors.org.uk

lethargy from which he had died within the week.Lower wrote:

His brain we found very firm, all the vessels ofblood going to and from his head very free andopen, not any way obstructed: but the ventriclesof the brain were extraordinary full of a very clearwater, and all the bottom of the brain and all thenerves drowned in the same water.The passage ofthe infundibulum was not obstructed, but in theglandula pituitaria there was a cavity not unlikethat of the pelvis of the kidney, which cavity wasfilled quite up with a clear jelly to the bigness of abean, so that it probably obstructed the passageof the water out of the ventricles of the brain:whereupon it broke the pia mater at last, whichencompasseth and encloseth the brain, theventricles and so fell down outside the brain,upon the medulla oblongata and the nerves,whence came these little convulsions first, andafter, by the increases of the same water,lethargy: and this was the most probable reasonwe could find of his death and disease, there beingno other way to convey away the water fromventricles of the brain, but through the glandule4

The history with the necropsy findings of agelatineous pituitary tumour resulting in obstruc-tive hydrocephalus is consistent with an endocrinemacroadenoma, craniopharyngioma or sarcoid.

While we were discussing the possible diagnosesin this boy the second case presented to one of ourclinics.

Case 2. West Midlands 2001

A seven-year-old boy was referred because ofgross obesity. Physical examination confirmedsimple obesity with no striae or buffalo humpand minimal restriction of the temporal visualfields. There was no papiloedema. Other examin-ation was normal (including no goitre). A grand-mother had thyroidectomy for thyrotoxicosis, agreat-aunt and great-grandmother were hypothyr-oid. Initial investigations confirmed biochemicalhypothyroidism due to an autoimmune thyroiditis.

Test Result NormalRange

TSH .500 uU ml 0.4–3.5 uU mlT4 1.9 pmol/l 13.8–22.5 pmol/lProlactin 704 miu/l 114–283 miu/lAntithyroidperoxidase

4289 iu/ml ,50 iu/ml

MRI of the brain demonstrated a well defined,non cystic, non calcified 9 £ 4 mm mass in thepituitary fossa, with a ‘cottage loaf’ appearance(Fig. 1). There was no hydrocephalus and the rest ofthe brain scan was unremarkable. Although theadenoma touched the optic nerves and chiasma,they were not distorted. The imaging and chemistryfindings were consistent with a pituitary adenoma,secondary to autoimunne thyroiditis. The differen-tial diagnosis would include a pituitary macroadenoma, solid craniopharyngioma, lymphoma orsarcoid (unlikely at this age).5

He was commenced on Thyroxine with rapidimprovement in general condition and loss ofweight. Repeat MRI brain scan 10 weeks latershowed no abnormality of the pituitary gland(Fig. 2). Serial assessment of his visual fields showedan initial left inferior quadrant defect whichresolved fully.

Discussion

Thomas Willis is regarded as the founder of modernclinical neuorscience and laid a foundation that hasa profound ongoing influence on clinical practice.These two cases illustrate how modern experienceallows us to re-evaluate past medical reports. Weview the past through the lens of the present, whichchanges with our experience. We live in an age ofgreat and notable cures. The lame walk, the deafhear and the blind see now that we have hipreplacement, cochlear implantation or cataractreplacement. John Bunyan, a contemporary ofWillis, challenged doctors:

Figure 1 Cottage loaf appearance of pituitary adenoma.

A.N. Williams et al.184

Let them fetch one to life that was dead, letthem recover one to his wits that was mad, letthem make one that was blind to see, or let themgive ripe wits to a fool.6

How would Bunyan or Willis view transplan-tation, resuscitation and intensive care, antipsy-chotic medication, cataract surgery or thyroxinereplacement for cretinism? A layman may not

believe that tablets alone removed this child’sbrain tumour.

David Lodge recognised how experience changesperception. His novel ‘Small World’ gives sharpobservation of academic pressures and is based on apost-graduate student whose thesis shows howreading Elliot changes our perception of Shake-speare. We offer a less literary, but equallyinsightful experience of the effect of moderntechnology on our reading of Thomas Willis.

References

1. Lodge D. Small World. London: Penguin Books; 1983. Smallleaf p. 51.

2. Hughes JT. Pioneers in neurology: Thomas Willis (1621—1675). J Neurol 2000;247:151—2.

3. Viets HR. A patronal festival for Thomas Willis (1621—1675)with remarks by Sir William Osler. Bart. FRS. Ann M Hist 1917;1:118—24.

4. Boyle’s works, op cit vol. 6 P471 quoted in Dewhurst, K. WillisOxford Lectures Sandford Publishers; 1980. p. 109.

5. Hope RA, Longmore JM, Moss PAH, Warrens AN. OxfordHandbook of Clinical Medicine, 2nd ed. Oxford: OxfordUniversity Press; 1989. p. 560.

6. Bunyan John, quoted in Osler, W. Aequaniminitas and othermedical writings. 2nd ed. Of books and Men London: H.K.Lewis; 1928. p. 222. Chapter X11.

Figure 2 Resolution of pituitary adenoma.

A case of pituitary adenoma: Thomas Willis revisited 185