HYPOPHYSIAL DYSTROPHY 325 



associated with marked cachexia. This we saw, for instance, in case G 

 (Observation XLV). Very marked retrogression of the genitalia and of the 

 secondary sexual characters leads one to think of associated involvement of 

 the suprarenal cortex. Attention should also be especially directed to myx- 

 edematous skin alterations and to pigmentations, hypotonia, and reduction in 

 the amount of sugar in the blood. When these symptoms are present, we 

 should consider the associated involvement of the thyroid gland or of the 

 chromamn tissue. In an adiposo-genital dystrophy of hypophysial origin, 

 the exact differentiation of the processes that lead to an impairment of the 

 hypophysis is often very difficult or impossible; and yet this would be of 

 great practical importance for the indications for operation. Here the X-ray 

 examination furnishes important information. 



Tumors that proceed from the hypophysial apparatus itself, deepen, when 

 they lie intraseliarly, the floor of the sella. If they proceed from the hypo- 

 physial duct they dilate chiefly the sellar introitus, but can also, if they are 

 large, deepen the floor of the sella. An intracranial process chiefly sharpens 

 the clinoid processes to a point (Erdheim, Schuller) . Later it may erode them. 

 Then the X-ray would readily lead to faulty conclusions; in such cases ero- 

 sions are mostly found, however, in other places. Exceptionally a similar 

 destruction here I follow the dissertation of Schuller may be produced by 

 an aneurysm of the carotid artery, by an endothelioma of the dura mater, or 

 by basal tumors of the middle fossa of the skull. In tuberculous caries or in 

 primary tumors of the body of the sphenoid bone, the infiltration of the 

 sphenoid bone is shown in the X-ray plate, thus enabling differentiation. 

 Finally the clinoid processes may be eroded and sharpened from behind by 

 tumors of the cerebello-pontiie angle. The finer details of the bone erosions 

 are alone of value for the X-ray diagnosis, for as Schuller mentions, the 

 tumors themselves are only visible in the X-ray picture when they calcify or 

 when they penetrate in one of the pneumatic cavities of the skull. Apart 

 from the X-ray examination, the presence of early pressure symptoms on the 

 part of the more distant cranial nerves or symptoms of a hydrocephalus 

 speak against the primary involvement of the hypophysial apparatus. 



Treatment. To-day operation stands in the mid-point of therapy. 

 Schlojjer and v. Eiselsberg in the cases of v. Frankl-Hochwart, O. Hirsch, and 

 Gushing first carried out operation in hypophysial adiposo-genitalis, with 

 partial good results. The methods now used are all intracranial. Sckloffer 

 and v. Eiselsberg made a path to the hypophysis by making a flap of the nose, 

 O. Ilirsch by operating endonasally. The result consisted at all events chiefly 

 only in the combating of the symptoms of brain pressure; the tormenting 

 headaches disappeared, and the visual power improved, but only in few cases 

 did there result in addition a recession of the dystrophic manifestations, and 

 did the patients lose some kg. of their fat; in certain cases hair even disap- 

 peared on the pubis and in the axillae; in one case erections occurred, in 



