908 HAKVEY G. BECK 



lips, tongue, mandible, hands and feet) and hypertrophic changes in the 

 bones. Many of these cases should be regarded as states of dyspituitarism. 



(b) In the early stages of dystrophia adiposogenitalis the symptoms 

 are not sufficiently outspoken to make an absolute diagnosis. The condi- 

 tion should be suspected in children with a developing obesity in which 

 growth has become arrested, especially if associated with psychopathic 

 tendencies and frequent headache. 



Attention has already been called to the influence of the various phy- 

 siological epochs, puberty, pregnancy, and menopause. It is usually at 

 these periods when the pituitary undergoes histological changes, associated 

 with alteration of function that the early symptoms manifest themselves, 

 therefore considerable importance should be attached to delayed puberty, 

 obesity and amenorrhea following pregnancy, and obesity, sluggishness, 

 torpor, and headaches following the menopause. 



(c) In the milder forms emphasis should be laid upon the type of fat 

 distribution, which is one of the most characteristic of symptoms ; even if 

 the obesity is slight, the tendency to fat deposition in localized areas is 

 evident. The condition and distribution of the hair and the texture of the 

 skin should always be considered conjointly with the adiposity. A his- 

 tory of sexual abnormalities impotence, absence of libido, amenorrhea 

 and sterility can frequently be elicited, although genital atrophy is not 

 always present. Biedl(c) found it in only 12 out of 32 of his milder cases. 



(d) The pluriglandular varieties are of common occurrence. Only 

 those cases in which the pituitary factor is primary or predominates the 

 clinical picture should be considered in connection with dystrophia adiposo- 

 genitalis ; symptoms referable to the deficiency of the thyroid, goiiads, and 

 adrenals must be differentiated. 



Some of the most valuable data for the purpose of diagnosis are those 

 derived from X-ray studies for abnormality of the sella turcica and the 

 epiphyses. The presence of neighborhood signs and symptoms (optic 

 nerve lesion and visual field defects) and increased sugar tolerance, are 

 also of great diagnostic importance. The existence of any or all of the 

 above findings, in addition to other symptoms enumerated, furnish con- 

 vincing proof of a correct diagnosis. Ophthalmological conditions play 

 an important role in diagnosis, especially for localization of tumors, while 

 other symptoms which result in consequence of local or general pressure, 

 such as headache, nausea, vomiting, epileptiform seizures, stupor, narco- 

 lepsy, trophic disturbances, polyuria, amenorrhea etc., are more of a gen- 

 eral nature. Moreover in slowly growing tumors there is a compensatory 

 reaction to the gradual pressure, so that the general symptoms are in 

 abeyance. In these cases the ocular manifestations are of the greatest 

 significance. 



Thyroid. In thyroid deficiency (myxedema) the obesity is more 

 general ; the skin is thick, infiltrated, non-transparent, wrinkled, dry and 



