40 GENERAL PART 



gland is not satisfactory, there has been upheld by several recent authors a 

 pluriglandular pathogenesis of scleroderma (Dupre and Kahn, Rasch, and 

 others). With regard to this, it is conceivable that sclerotic processes in 

 certain ductless glands in scleroderma do not mean very much. The sclero- 

 derma often spreads to the deeper-lying tissue and may also extend to the 

 bones and muscles; it is therefore not wonderful if now and then the proc- 

 ess should involve individual ductless glands. Moreover, there are found 

 in the majority of cases of scleroderma a great number of manifold symp- 

 toms on the part of the vegetative nervous system, conditions of excitement 

 of manifold nature, such as vasomotor disturbances, tachycardia, shivering, 

 faintings, rush of blood to the head, feeling of anxiety; as Klinger observed, 

 such conditions may occur in attacks. Hess and Kiinigstein saw in one case 

 of diffuse scleroderma, during such attacks, an especial sensitiveness against 

 adrenalin and marked excitement of the heart-action, associated with mani- 

 festations of acroparesthesia and with subsequent outbreaks of sweat. In 

 addition to this are found in the majority of cases a series of trophic distur- 

 bances, such as transitory edema, erythema, urticaria, etc. These make 

 the diagnosis of a coexistent Basedow's disease very much more difficult. 

 On the other hand, I do not doubt that in many of the cases there was 

 actually an increase of function of the thyroid gland, and that it was not 

 at all impossible that the pigmentations had their basis in a disturbance of 

 function of the chromaffin tissue. Nor do I doubt that in certain cases 

 slight symptoms of thyroid insufficiency may occur. When I acknowledge, 

 therefore, the possibility of pluriglandular symptoms in scleroderma, I would 

 regard them as only secondary, in part due to the sclerodermic process ex- 

 tending over the ductless glands, and still more due to functional influenc- 

 ing of the ductless glandular system. There are in addition cases of sclero- 

 derma in which the manifestations on the part of the vegetative nervous 

 system are much less prominent. 



I agree fully with Cassirer in the supposition that in scleroderma the dis- 

 ease process is not primary in the ductless glandular system. 



There has also been an attempt to bring another group of diseases, the 

 trophoneuroses, into relation with the ductless glandular system, diseases 

 such as acute circumscribed edema and symmetrical lipomata. In both 

 are regularly found neurosis symptoms on the part of the vegetative nervous 

 system. Here also is found the possibility of functional disturbances on 

 the part of the individual glands, although the symptoms are here less dis- 

 tinctly prominent. This same thing seems to me to hold good for adipositas 

 dolorosa. This condition will be considered in detail in Chapter XIV; here 

 I wish to dispense with the supposition of ductless glandular etiology. The 

 same is true for xanthelasma, the pathology of which Ckvostek has made 

 the subject of a penetrating study. Ckvostek in consideration of the occur- 

 rence [of xanthelasma] in gradations [schubweise], the kind of distribution, 



