MULTIGLANDULAR SYNDROMES 889 



Progress. The progress and evolution of the syndrome are usually 

 protracted over a number of years. Frequently an intercurrent disease 

 determines a lethal end ; usually this disease is of infectious character 

 tuberculosis offers the best example. The natural resistance of the 

 organism to such infection is markedly diminished and the course of 

 such intercurrent disease is usually rapid. Unless such interruption 

 occurs, the gradually increasing asthenia finally determines the outcome. 

 Drowsiness becomes more and more prominent, the progressive weakness 

 necessitates complete rest in bed, the bed-ridden patient sinking lower 

 and lower gradually, until finally he dies. There are, however, exceptions 

 to this termination. Occasionally, as described by Cordier et Francillon, 

 remission occurs even to the point of recrudescence of libido. Byrom 

 Bramwell likewise reports improvement in the genital sphere in one of his 

 patients. The disappearance of some symptoms, however, frequently 

 ushers in the appearance of others. Thus Sourdel describes the appear- 

 ance of diminution of vision and hemeralopia with the disappearance of 

 the genital symptoms and the reappearance of hairy growth. In women, 

 a usually prominent accompaniment is a disturbance of the menstruation. 

 Frequently the menopause ushers in the syndrome. As in men, the loss of 

 hair is of note, but is frequently followed by the appearance of a mous- 

 tache. The breasts become atrophied. A subsidiary form of the syndrome 

 presents changes in the pigmentation of the skin combined with symptoms 

 of exophthalmic goiter and eunuchoidism. Such types are reported by 

 Sourdel, Levi et Rothschild, Faure-Beaulieu, Villaret and Sourdel. The 

 secondary type occurs usually in the wake of an infectious disease, be- 

 ginning with headache, dizziness, and loss of hair especially marked in 

 the secondary sex regions. With these tissue changes there occur also 

 changes in the mental level. The patient becomes irritable, depressed, 

 and self -centered. Alternate boulimia andf s anorexia are exhibited. Coin- 

 cidently, the disturbances in the skin become apparent. Brownish patches 

 such as are seen in Addison's disease develop. Patches of vitiligo with 

 sharply demarcated dark brown borders are frequently seen, especially 

 on the abdomen. With the disappearance of the secondary hairy growths, 

 the breasts atrophy, and possibly exophthalmos with a slightly enlarged 

 thyroid makes its appearance. Following closely upon this, tachycardia 

 with cardiac dilatation arises. Vomiting and diarrhea assist in making 

 the patient miserable. Libido vanishes. Asthenia supervenes. There is 

 frilosity with alternate colliquative perspiration. During this develop- 

 ment, the blood pressure goes lower and lower and death at last brings 

 relief. The development is much like the Addisonian, but much slower. 

 Still other sub-types, in which, together with the myxedematous char- 

 acteristics of the above, there are combined disturbances pointing to 

 involvement of the pituitary gland, with genital and gastro-intestinal 

 accompaniments, are described by various observers (Brissaud and 



