MULTIGLANDULAR SYNDROMES 887 



result of various exciting final causes. The basic constitutional predispo- 

 sition can occasionally be recognized even before the actual process has 

 set in. The suspected individuals usually show in adolescence a late devel- 

 opment of their gonadal activity. Women menstruate late ; males have a 

 delayed puberty with little sexual appetite. Both sexes are disposed to be 

 asthenic. The final factor that ushers in the atrophic process may be of 

 quite moderate significance for normal individuals, such as malaria, 

 excessive use of tobacco (Hertoghe), or pregnancy; but usually the final 

 cause is of rather severe nature, namely, the acute infections, influenza, 

 scarlatina, measles, diphtheria, acute articular rheumatism ; or the metallic 

 poisons, lead, arsenic, mercury. Alcoholic and drug habitues are also 

 prone to be affected. Occasionally the syndrome is engrafted upon a 

 previously existing cirrhosis of the liver. Possibly the most frequent 

 causes, however, are syphilis and tuberculosis (Poncet and Lerich^; 

 Faneau de la Cour). Besides chronic malaria, leprosy and pellagra have 

 been cited as causative factors (Agostini). In spite of this comparatively 

 long list of inciting causes, it is only in a surprisingly small number of 

 individuals that the sequel of a pluriglandular insufficiency becomes mani- 

 fest. The probability is great that these diseases are not specific in their 

 selection as far as the ductless glands are concerned, but act simply as 

 final critical determinants upon a system already weak or in unstable 

 equilibrium through inheritance or through lack of compensatory possi- 

 bilities in the system beyond a certain quite limited range. Such an 

 organism might go on seemingly normally for an indefinite time were 

 the limit not transcended. But the "call" or "drag" made especially upon 

 such of the glands as the thyroid or suprarenals by acute infections or 

 intoxications is too much for the small margin of safety allowed by the 

 inefficiently resisting organs and the pluriglandular disturbance then 

 begins its insidious course. Traumatism may also play either a primary 

 or secondary role in the production of the syndrome; primary, if through 

 the trauma one of the endocrin glands is directly injured to such an extent 

 that it cannot meet its physiological requirements, as in traumata of the 

 testicles or the suprarenals; secondary, if general bodily injuries are of 

 such extent and productive of such shock as to require more of the pro- 

 tective and stimulative secretions than can readily be supplied without 

 producing exhaustion of the glands beyond the possibility of their complete 

 restoration to function. 



It can readily be surmised that with so great a latitude of incidence 

 and with such variability of individual glandular reactivity to noxious 

 agents, all conceivable combinations of clinical pictures are possible, once 

 the disease process has begun. And so various groupings, depending upon 

 the particular series of glands most obviously affected, are described by 

 various authors all merging, as before stated, into one another. Such 

 groups are the gonads, thyroid and hypophysis ; gonads, suprarenals, para- 



