39 



ing to this, those which point to an alteration in the metabolism and in 

 general to a functional influencing of the ductless glandular system. It 

 seems to me that there is wanting in this case any secure foundation for 

 bringing a primary alteration of the ductless glandular system into an etio- 

 logical relationship. 



Of the vasomotor neuroses, scleroderma seems to merit a more exact con- 

 sideration. In this affection there are a series of findings that point to a 

 marked involvement of the ductless glandular system, v. Strumpell has 

 pointed out a certain opposition in the symptom picture of scleroderma and 

 acromegaly. In the latter the bones and skin are hyperplastic, while in the 

 former there are processes of shrinkage in both organs. The opinion that 

 the basis of scleroderma is a functional disturbance of the hypophysis finds, 

 according to Roux, corroboration through the fact that in this case apparent 

 sclerotic processes are found in the hypophysis. Until the present, however, 

 this case has remained isolated; the opinion is often expressed that sclero- 

 derma depends on an alteration of function of the thyroid gland. After 

 v. Leube first pointed out the coexistence of scleroderma with Basedow's 

 disease, numerous pertinent cases were found in the literature, which have 

 been compiled by Saltier. Cassirer mentions, however, that in these cases 

 the diagnosis Basedow's disease is to be accepted with caution, as im- 

 portant symptoms of Basedow's disease, such as pigment displacements, 

 changes in the thyroid gland, irritability of the heart, also belong to sclero- 

 derma in itself. Even the exophthalmus may be stimulated by the sclero- 

 dermic mask. Cassirer himself calls attention to the fact that these symp- 

 toms similar to Basedow's do not always follow in their intensity the course 

 of sclerodermic process. The occasional appearance of myxedemic symptoms 

 (Grasset, Osier, Dehu, et al.} and the not rare finding of sclerotic changes in the 

 thyroid glands of those sick with scleroderma have permitted Jeanselme, 

 Singer, Hectoen, v. Notthajjt, Leredde and Thomas, and others to regard the 

 cause of the scleroderma as an insufficiency of the thyroid gland, the more 

 probably for the reason that in many cases good results are obtained by 

 thyroid medication. The common occurrence of pigmentations in sclero- 

 derma seems to indicate the associated involvement of the chromarfin tissue. 

 The pigmentations may simulate those of Addison's disease. In not rare 

 cases there are also observed typical smoke-gray discolorations of the mucous 

 membrane of the mouth. In a large number of cases the combination of 

 scleroderma with Addison's disease has also been assumed, although there are 

 numerous observations (Lichtwitz, Kren, and others} of scleroderma with 

 typical Addisonoid pigmentations of the skin and mucous membranes that 

 showed no alterations in the suprarenal glands at autopsy. Finally the 

 combination of scleroderma with tetany has been described in a case of 

 Dupre and Guillain's. In this case it seems as though a pronounced Addison's 

 disease were also present. As the supposition of change in one ductless 



