MULTIGLAKDULAR SYNDROMES 893 



condition, after passing through the preliminary stages, remained in- 

 definitely progressive. It has been impossible, as yet, to observe one case 

 from the beginning to the end of the syndrome a period which varies 

 from ten to twenty years and until this can be done we must fill in the 

 gaps as best we may. 



General Description. This new syndrome, pieced together as de- 

 scribed above, may be generally stated to begin in youth some years before 

 puberty, and go through its varying stages in about twenty years. In 

 its incipiency (first stage) it presents largely the characteristics of the 

 so-called status thymicolymphaticus, or status hypoplasticus of Bartels. 

 There is complaint of muscular fatiguability as a subjective sign with 

 frequent accompaniment of headache. Objectively the case presents 

 usually, though not invariably (for exception see Fig. 5), an insufficient 

 genital development, with perhaps inversion of sex type, with a penis that 

 emerges from scrotal folds of labial type, or cryptorchism, or both. In 

 the female the menses are usually delayed, the uterus and ovaries remain 

 infantile, and there is scarcity of pubic hair. Blood pressure is usually 

 low and blood sugar content low. Enuresis is common. There is usually 

 present the white line of adrenal insufficiency of Sergent. 



In the second stage, that beginning at puberty, we find a continuance 

 of the muscular fatiguability or even an increase. The genitals may re- 

 main backward or inverted in development, the pubic hair is sparse and 

 has the distribution of the opposite sex, the male showing a horizontal 

 demarcation, while the female has the pyramidal type in which the middle 

 line to the umbilicus shows a hairy tendency. Axillary hair is absent and 

 chin and lip show no signs of hair in the boy. Blood sugar is low, usually 

 below 0.07 per cent, and the blood pressure is below the normal. The 

 white adrenal line may be elicited, especially marked after fatiguing 

 exercise. Rontgenograms of the skull usually show a sella turcica which 

 is small or which may apparently be even enclosed by the clinoid processes. 

 This is an important point to determine, for the later progress of the 

 disorder presumably depends upon the capacity of the pituitary gland to 

 become enlarged. The size of the sella turcica, therefore, plays a deter- 

 mining role in the production of the later symptoms. The possible ex- 

 cessive function of the pituitary later on dominates the picture and 

 is conducive to compensatory cure. The thymus gland frequently is seen 

 in the #-ray picture as quite enlarged. In some cases of extreme fatigu- 

 ability there are also seen pineal shadows. During the second stage rapid 

 growth in length begins to become manifest not ordinary normal growth 

 but rapid in the extreme, so that five or six inches increase in height a 

 year is frequent. With this growth fatiguability increases, and it is 

 usually on this account that the patient is first brought to the physician. 



In the third stage we begin to see the results of some of the com- 

 pensatory activities. It is usually ushered in about the twentieth year of 



