582 OBESITY AND ADIPOSITAS DOLOROSA 



(Vitaiit'i. In addition there have been described, however, a series of ac- 

 cessory symptoms, that consist especially in disturbances on the part of the 

 motor, sensory, and vegetative nerves. 



The distribution of the fat tumors may vary. Vitaut first distinguished : 



(a) Nodular, asymmetrical fat tumors, disposed asymmetrically in and 

 under the skin lipomatose nodulaire. 



(b) Circumscribed, diffuse, not sharply delimitable fat growths, lipo- 

 matose diffuse localisee. 



(c) General diffuse fat growths, lipomatose diffuse generale; this is the 

 most frequent form, and in it the fat is not uniformly distributed as in ordi- 

 nary adiposity, the skin shows much more an uneven texture. The fat 

 masses feel lump-like, like a bundle of worms (Dercum), and at those places 

 especially where a pressure is exerted, for instance in the waist, or where the 

 garters press, they are separated from each other by deep furrows. 



In lipomatose diffuse localisee the accumulations of fat are mostly found 

 only on the trunk and on the proximal third of the extremities. In such 

 cases the fat deposits may be quite excessive and hang down like an apron, 

 as for instance in a case of Dercum and McCarthy's, in which the fat masses 

 hung laterally over the hips and backward over the buttocks in thick folds, 

 or in a case oiLdning and Fuss's in which the fat masses hung from the abdo- 

 men and the inguinal region almost to the lower third of the thigh. 



In the nodular form the throat and face, as well as hands and feet, eventu- 

 ally also the forearms and [lower] legs are entirely free; the latter are 

 often very thin. In a case of Debove's there was found, especially on the 

 outer side of the upper arm, symmetrically disposed masses up to the size 

 of a pigeon's egg. The hands were entirely free. These fat nodules may 

 be arranged in a multiple manner, or symmetrically. 



On careful observation of the reported cases we may see that all transi- 

 tions between these three types occur. This was already observed by 

 Weiss; the classification has but little value. I refer to the case detailed 

 above, which constitutes a combination of lipomatosis nodulaire and lipo- 

 matosis diffuse localisee. 



The second cardinal symptom consists in the painfulness of the fat. 

 In many cases there is a sensation of violent burning " as if a dog were tear- 

 ing the flesh from the body" (HaSkovec); in other cases the pains occur in 

 attacks, under circumstances before the fat infiltrates become visible. In 

 other cases vesicles appear during the attacks of pain. In other cases spon- 

 taneous pains are absent, the fat infiltrates are painful only on pressure; in 

 my case the painfulness of the fat infiltrate was bound chiefly to the vicinity 

 of the dilated veins. There are also cases described, otherwise typical, 

 in which the tenderness to pressure was but very slight. 



In all cases the asthenia is more or less distinctly pronounced. In the case 



