| The following is the complete 
              and very lengthy series of Ferret Mailing List posts on adrenal 
              disease. Written by Bob Church.  The e-mail address shown is 
              very likely no longer valid.
 Date: Sun, 1 Feb 1998 03:50:08 -0600From: Bob Church <[email protected]>
 Subject: Bob C: Adrenal Stuff
 Ok. folks, I'm running a bit behind on finishing 
              the adrenal post, mainly because the data conflicts so much with a 
              couple of papers that I've read. I hesitate to post something that 
              may be obviously biased, so I am setting on the stuff and pondering 
              it. I will post the result no later than next weekend, although, like 
              I said, the results were somewhat different than what I expected. That's the problem with being a scientist; the 
              ethics of reporting values which are apparently biased without attempting 
              to explain or correct for the problem. I've just been considering 
              reasons for the difference, that's all. I will report the findings, 
              I'll probably just put a lot of disclaimers into the post. One other problem is the post will be quite long, 
              so I'll probably have to post it directly to Bill (and I know his 
              middle name, naa naa naa) so he can post it as space permits. Its 
              way longer than 125 lines so be prepared for a long read (I can never 
              figure out the 125-lines thing anyway because I use a file size method 
              that doesn't translate in my brain. Sort of like I can use metrics 
              or miles, but I have a hard time translating them. Well, I *know* 
              a pound is .45359237th of a kilogram. Just stuck in my head, like 
              pv=nrt and stuff like that. Just don't ask my phone number...) As for *why* the adrenal reports were so biased? 
              The FML is *not* composed of typical ferret owners, its that simple. 
              Rather I should say, the people who reported the adrenal stuff are 
              not typical ferret owners. A very large part was reported from ferret 
              shelters or people who adopted ferrets that had a history of illness, 
              neglect or malnutrition. That means the sample was not random. What 
              I'm trying to do is see if I can correct for the skew, but it's not 
              looking favorable. As for any correlations, well, if I can't correct 
              for the skew, then any correlations would be as good as "96% of all 
              Americans who die in accidents are wearing clothing, therefore clothing 
              causes accidents." The skew can hide the cause-effect relationship. 
              Everyone knows its nudity that causes accidents. Bob C and 20 MO Accidental Biters. 
               ------------------------------ Date: Tue, 10 Feb 1998 05:13:22 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Adrenal Post, Part Uno.
 Ok, folks, here are the official results and commentary, 
              with a few extra tidbits thrown in regarding sampling and observer 
              biases. Up front, I do not trust much of the data gathered from FML 
              members--not because of the dishonesty of FML readership, but because 
              of how *good* we are (I'll explain later). The post quite long, so 
              I've broken it into several parts for bathroom reading over the next 
              few evenings. I'll say some things some of you will *NOT* want to 
              hear (which included me), but please hold off flames or other comments 
              until the entire series is posted. It will save us all a lot of space 
              and time because what offends you today may be answered tomorrow. What you will be reading is a combination of FML 
              data, compiled with about 20 scientific journal/book sources. Because 
              of the need for brevity, those sources will not be individually cited, 
              but will be added as a bibliography at the end and you can look it 
              up yourselves. Disclaimer: this is *not* a scientific study, and as 
              such, I would never submit it for publication. Do not assume it carries 
              the weight of papers that have undergone rigorous juried review. Also, 
              the FML format limits the length of posts, cannot carry graphics, 
              and is read by people of various educational levels. To write a paper 
              to the level of a scientific journal would require about 8 FMLs dedicated 
              to nothing but the subject, with 5 or 6 graphic attachments to demonstrate 
              the statistics. It is not possible to do such work, and if it were 
              possible to get the space and add the graphics, without being condescending, 
              few readers would have the necessary background to follow the paper 
              properly. Don't be insulted by this; I can fix a car but don't speak 
              "Autoshop," mathematics gives me a headache, and I will never be as 
              smart as the average European because even though I can read in several 
              languages, I can't hardly speak English good. The language of physiology 
              is a difficult one to learn, and no one should be embarrassed because 
              they don't speak or understand it. With that in mind, let me give the bad news first. 1) Treatment of Adrenal Disease. I'm sorry to say, 
              *no* treatment but one has *any* long term effect on the disease, 
              and that one is only really effective if when the adrenal disease 
              starts early in the life of the ferret. Surgery is the only effective 
              treatment. No chemical treatment, such as Lupron, Lysodren, or Prednisone, 
              has been shown to significantly extend the ferret's life after the 
              initial onset of the disease, nor have they been proven to do anything 
              more than mask or slow the progress of the disease. No environmental 
              treatment has withstood vigorous scientific examination and still 
              result in positive results. Homeopathic remedies have not shown *any* 
              ability to extend the ferret's life, nor do they show any more than 
              a moderate lessening of symptoms. In the significant majority of cases, 
              any type of treatment, other than surgery, only offers superficial 
              and limited results. HOLD OFF COMMENTS UNTIL THE SERIES IS DONE, PLEASE! 
              I know these statements are going to cause some disagreement, but 
              I will offer explanations in the next posts that will answer many 
              of your questions. Please wait, and we can hash this out at the end. 
              Ok? The average reported lifespan of ferrets that did 
              not have ANY treatment or surgical intervention was 1 year +/- 6 months. 
              The same times were reported for *ALL* chemical treatments, including 
              Lupron, Lysodren, or Prednisone. If the adrenal disease had an onset 
              when the ferret was under or about 3 years of age, surgery gave the 
              ferret 3 years +/- 6 months. However, if the adrenal disease had an 
              onset after 4-5 years of age, that survivorship dropped down to 1.5 
              +/- 6 months. In all cases, the average length of life was longer 
              if surgery was performed, however, the risk of sudden death was significantly 
              higher in ferrets older than 4-5 years. Chemical treatments were reported to partially 
              or completely return the ferret to working order, with partial or 
              complete return of hair as well as an improvement in other symptoms. 
              This was reported about the same in all age classes of ferrets. The 
              interesting thing about the chemical treatments, or even of homeopathic 
              treatments, was the degree of observed improvement was always higher 
              than the degree of actual improvement. In other words, if a ferret 
              had an improvement in hair growth, it was seen as "the ferret getting 
              better," even though the course of the disease was the same as if 
              nothing was being done and the ferret died within a year or so. This 
              is best illustrated by a comment mailed to me, "The vet said the situation 
              was hopeless, that the ferret could not survive surgery, and it could 
              die as early as in six months....But placed on [homeopathic] medicine, 
              the ferret lived another 14 months!!" 14 months is within the "mortality 
              window" of untreated adrenal disease, so there is no evidence the 
              treatment worked at all. What was seen as the improvement was a return 
              of most of the hair and decrease in aggression, which may have occurred 
              anyway, but such those type of improvements in no way should be taken 
              as evidence that microscopic changes took place within the adrenal 
              gland that altered the disease. Maybe it did, but there is *no* factual 
              evidence. I want to emphasize this. In an extensive search 
              through all ferret-related papers since 1985, not a single published 
              study could demonstrate marked improvement of the ferret by any means 
              other than surgery. That is not so say such studies don't exist, nor 
              am I saying such results are not possible. What I am saying is nothing 
              has been published, other than a few articles with poor sample sizes 
              (or other methodological problems). Surgery resulted in remission of symptoms in most 
              cases, but in those cases where surgery was not going to work, it 
              was immediately seen as a "non-improvement." If the ferret was left 
              untreated, the disease would kill the ferret between 6 months to 1.5 
              years, with the average death being about a year into the disease, 
              so on average (worst-case), the ferret got an extra 6 months or more 
              because of surgery, and in the best case, years of extra life. Personal comments: I am a great believer in "less 
              is better" when it comes to medical care. Personally, I would be dead 
              six times over if not for the surgeries I have placed myself through. 
              Before I took on this self-assignment, I was essentially anti-surgery 
              for the older ferrets, supporting surgery only for those cases with 
              an early onset. For ferrets under 4 years of age, I believe surgery 
              is the only option; do it as soon as possible after blood tests have 
              confirmed the disease. There are a number of risks involved in such 
              surgical procedures, but they only result in a small number of serious 
              complications; the sudden death rate seems to be under 5% from what 
              I can dig up, which is fantastic considering the difficulties of operating 
              on such a small species. From the descriptions of ferrets dying during 
              surgery, they seem to be of two types; either they were extremely 
              ill ferrets with massive tumor involvement, (which suggests a late 
              diagnosis or multiple-organ involvement), or the deaths seem to be 
              anesthetic-related, such as from anesthesia-induced shock (happens 
              even in people). In the former, sudden death should be expected because 
              of the ferret's condition. In the later, such events are unpredictable. 
              In either case, unless some other proof exists of malpractice, these 
              deaths should be considered part of the risks of surgery, and accepted 
              as such without blame being assigned to doctor or owner. For ferrets older than 5 years, there does not 
              seem to be any significant difference between chemical treatment nor 
              non-treatment. Surgery can add about 6 months on average to the lifespan. 
              I question the poor results from late surgery but cannot find any 
              outside stats to contradict them. I suspect the surgical results would 
              be better if the adrenal disease was of a primary onset rather than 
              a secondary manifestation (like when the ferret has already had an 
              adrenal removed). I just don't have enough data to be able to say 
              that ferrets over 5 years of age who get adrenal disease for the first 
              time have better surgical results than those who have already had 
              adrenal surgery. I strongly suspect it is so, but cannot say for sure. 
              Because of that, I recommend that if your ferret is otherwise healthy 
              and this is their first onset of adrenal disease, do the surgery. 
              As for the second onset, discuss all options with your veterinarian 
              and make your decision to best suit the needs of your ferret. You 
              have to weigh the additional 6 months or so with the surgical risks, 
              knowing the end results will not be much different. Now, this is all very clinical and non-emotive, 
              which is what is needed for this type of discussion. If I wanted to 
              push my belief system, I would be arguing *against* surgical procedures. 
              I have been (mostly) convinced by looking at all available data; I 
              have refused to comment on this (or share this) with anyone associated 
              with the problem so no one could question the ethics of the study. 
              In other words; I can into this thinking I could find better options 
              than surgery. I found I was wrong. This is *not* to say existing chemical or homeopathic 
              remedies (or future ones) will not eventually replace surgical treatment 
              in many cases. What I have found is a lot of research is needed in 
              those areas. It is also not to say that, for some, such treatments 
              actually result in improvement of symptoms, or even reversal of the 
              disease, but statistically, they are less than 10%. That means, 90 
              ferrets will take the treatment and will *not* be any better for it, 
              while 10 ferrets will show a reversal or improvement of symptoms. 
              The problem is, are these reversals due to the medicines or because 
              of the animal having a spontaneous remission of the disease? Like 
              I said, rigorous examination of the facts needs to be done, which 
              means, boys and girls, ferrets will die in scientific research. There 
              will be a price to pay for medical advances against this disease. 
              But there *is* something we can all do to help. The problem with any research is getting the samples. 
              I am studying the differences between wild and domesticated forms 
              of the ferret, which could not be done if caring individuals have 
              not donated (and still donate) their ferrets to the cause. I'm not 
              going to kill an animal for its skeleton, so this allows some people 
              to have the satisfaction of helping determine ferret origins, and 
              I get what I need as well. The same is true here. If you choose to 
              treat your ferret with chemical or homeopathic remedies, at the ferret's 
              death donate whatever is needed to a researcher who is willing to 
              compile the medical and histological data. Perhaps Dr. Williams can 
              make some suggestions here. Special handing of specimens *must* be 
              done, but your vet can do it for you. As far as *I* am concerned, 
              if you want to promote any procedure other than surgery, you have 
              an ethical responsibility to provide proof of your claims, which is 
              tied up in the carcass of your dead and beloved pet. Until these types 
              of studies are done, THERE WILL NEVER BE PROOF that chemical or homeopathic 
              remedies (including light treatment) have any substance in the treatment 
              of ferrets suffering adrenal disease. Like it or not the proof is 
              in the pudding, so put up or close the trap. I have myself in enough hot water until the next 
              post, which will cover why some forms of treatment seem to help (when 
              they don't really). Following posts will discuss the treatment of 
              symptoms, the USA-World adrenal difference, some genetic-environmental 
              questions, the question of early neutering, and finally, a summary 
              about everything. They will come every-other day, mostly because they 
              are difficult to write and I have school to think about. As I said, 
              please hold off all questions and flames until the series is finished; 
              write your questions down, but hold off on sending them until I finish 
              this thing, ok? Bob C (C as in Custer) and 20 MO Wild Frettchens 
               ------------------------------ Date: Thu, 12 Feb 1998 17:16:38 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Adrenal Post Nummer Zwei
 I mentioned there seemed to be at least two different 
              things going on in ferrets, resulting in adrenal disease. Mind you, 
              there may actually be more, but from the data collected and the stuff 
              in print, I think right now all you can safely say is more than one 
              factor lurks behind this disease. So what is the implication of "more 
              than one?" Before we answer, let's address the question of 
              what can *cause* adrenal disease. One of the first steps to any scientific 
              investigation is to try and limit the study to the possibilities, 
              rather than the "but what ifs..." So, making the assumption that adrenal 
              disease is initiated by some sort of abnormal growth within or adjacent 
              to the adrenal gland, what basic things could cause it? The list could include genetics, environmental 
              pollutants, diet, body condition, stress, chance, or even that the 
              disease is a species "weakness" (like how specific diseases tend to 
              be more common in certain animals than others). While some people 
              may be convinced that only one of these is the "real" reason, remember 
              I said the disease appeared to have at least two different manifestations. 
              Now do you see the implication? It suggests at least two factors may 
              be responsible. These two factors could be linked, or they could be 
              independent, but only scientific testing will ever prove the relationship--or 
              the reasons--one way or another. I believe there is a genetic component involved; 
              those that kept track of their kits noticed adrenal disease sometimes 
              ran in family lines. The statistics are very poor for this because 
              few breeders care to follow the babies they pump out. This is a shame, 
              because it is quite conceivable that vigorous and healthy hobs and 
              jills may be spreading a recessive trait within the population. This 
              is what all the hoopla about blood lines is all about, as well as 
              the "Marshall Farms Hypothesis," (being that MF ferrets are predisposed 
              to adrenal disease). If you accept the idea that non-American ferrets 
              have a very low incidence of adrenal disease, its quite easy to point 
              the finger at the DNA and blame it, when in fact there may not be 
              any relationship at all and the reason could be because of some other 
              factor within the US and Canadian populations. For a moment, lets assume it is genetics. Do MF 
              ferrets have a higher proportion of adrenal disease than other ferrets? 
              Not if the people who sent data are to be trusted. About half of the 
              ill ferrets did not come from MF at all. Assuming MF supplies about 
              half of the ferrets for the pet market, if they were more prone to 
              adrenal disease, there would have more cases reported in proportion. 
              The reported statistics suggests parity; in other words, it seems 
              as if all "brands" of ferrets are equally susceptible in contracting 
              the disease. (I don't know what the actual percentages regarding how 
              many MF ferrets are produced compared to other breeders, nor do I 
              suspect anyone does because few breeders report their kit placement. 
              If you disagree with my assumption that 50% of ferrets are MF, then 
              by all means provide a substantiated source). One thing that has struck 
              me is the apparent inability of people to look past what the numbers 
              *are*, and see what they *mean*. For example, suppose 100 ferrets 
              are MF and 100 from other sources. 20 ferrets get adrenal disease 
              and about half are MF. That is parity because all populations contract 
              the disease equally. But what if 150 ferrets are MF and only 50 from 
              other sources and out of 20 cases, 15 are MF and 5 are other? Well, 
              that's STILL parity, but it appears MF ferrets get the disease more 
              than others; after all, its 15 to 5 right? The result is many people 
              point out the majority of adrenal cases occur in MF ferrets, but they 
              never correct for the proportionality of breeder demographics. And 
              even if Path Valley, MF, and all the other major breeders opened their 
              books to our inspection, it would still be useless until you figured 
              out how many ferrets were coming from unnamed hobby breeders. The underlying assumption behind the idea that 
              New World ferrets get adrenal disease in higher proportions than other 
              ferrets is that some sort of founder's effect or breeding bottleneck 
              has taken place. In other words, if true, then some breeders have 
              inbred their ferrets so much that a genetic mistake has become visible. 
              This looks good on paper, but I don't buy it for many reasons, especially 
              two major ones. First, look around you; you see albinos, sables, silvers, 
              dark eyed whites, and so forth. Body sizes are small to large, whippet, 
              standard and bulldog. The amount of variation within the USA ferret-line 
              suggests inbreeding is not a problem. Remember the old biological 
              axiom; the older the species, the more variation, the older the genera, 
              the more species, and so forth? Of course the exceptions are lines 
              that are dying out, but that is not a problem in our furry mustelids. 
              We have *LOTS* of variation. If inbreeding is a problem anywhere, 
              it would be minor and essentially isolated. Support for this contention 
              comes from there being absolutely *NO* significant difference in the 
              numbers of one type of coloration or of body type being predisposed 
              towards adrenal problems. Albinos had adrenal problems about as frequently 
              as sables. I only had 87 reports of coloration, so obviously the sample 
              is small and better investigation may find such a link....maybe. I also think the idea is flawed simply because 
              the ferrets in the USA came from Great Britain and Europe, precisely 
              where the ferrets in New Zealand and Australia came from. Those populations 
              tend to follow the basic European lead in lack of adrenal disease. 
              Remember, we are assuming accounts of rare adrenal disease are factual, 
              and without contrary evidence such assumptions are valid. I also have 
              to say that in reading dozens of European ferreting books published 
              during the last 80 years, every medical ailment from blackheads to 
              distemper to swollen prostates to torn nails is discussed, but significantly, 
              no mention of a class of symptoms that could be interpreted as adrenal 
              disease is mentioned. These "ferrets and ferreting" books include 
              three from Germany, one from France and 17 from Britain. I've noticed 
              the same pattern in American ferret books; the mention of adrenal 
              disease only dates back slightly more than a score of years ago. Like 
              I said, interesting. Considering the slow acting nature of the disease, 
              if it was a common problem, it would have been mentioned in one of 
              these books. The same is true in the veterinary literature. 
              I scoured every possible source, from data bases to biological abstracts 
              to the journal indices to books. Nothing in the laboratory papers, 
              nothing in the literature *UNTIL* about a score of years ago, and 
              those reports were almost exclusively American in origin. This lends 
              great support to foreign claims that the disease is largely an phenomenon 
              of the Americas. This is not a claim that should be ignored nor dismissed. 
              Remember this for later. Back to the idea of founder populations in the 
              USA/Canada, Australia and New Zealand. Modern day populations in all 
              three countries had origins in initial founding colonies that date 
              to the turn of the century. In Australia and New Zealand, except for 
              a handful of exceptions, the present populations are essentially direct 
              descendants from those founding ferrets, and adrenal disease is rare. 
              In the USA, because of the ratting industry from the 1880s to the 
              1920s, the initial populations were supplanted several times from 
              fresh European stock. Now, understand, founder effects take place 
              because a breeding restriction took place which shifted *EXISTING* 
              gene frequencies, or introduced a new mutation into the breeding pool; 
              if it isn't in other populations, then it must have been "invented." 
              Now, this begs the following two questions. If the problem preexisted, 
              why hasn't it shown up as much in non-New World ferrets, especially 
              those with similar founding populations? And if it is a New World 
              specific mutation, why is only now showing up and not 40 years ago? This is the trouble. Ever try to introduce a new 
              trait into a population? It takes time; considering the existing range 
              of variation in body types, coloration, color patterns, and sizes, 
              there is virtually no possibility that such a trait could have become 
              established in such a large population is such a short time; if everyone 
              looked about the same or the variation was limited, weeelll maybe. 
              Of course, this is assuming the trait is recessive, which it has to 
              be because more than 70% of you stated the trait does not effect all 
              siblings in a birthing, and if it were dominant, it would. (Of course, 
              the jill could have been bred to more than one male, but that is not 
              common in USA breeding practices, and induced ovulation makes it basically 
              a moot point). So, if adrenal problems are genetic, it must be something 
              brought in with the original founding ferrets that only affected USA 
              populations, or something that started within a few generations of 
              the founding of USA populations. But Bob, didn't you say you thought adrenal disease 
              had a genetic component? Yes I did. The truth is, I'm beginning to 
              wonder if the disease doesn't parallel a similar situation in some 
              forms of human diabetes. In Native Americans, diabetes is quite common, 
              but in earlier populations it was never manifested. So a group of 
              people lived in the Americas for 12,000+ years, and diabetes was rare. 
              Europeans come over, teach the locals how to eat better food, and 
              the locals respond with obesity and diabetes. In this case, there 
              is an demonstrated underlying predisposition for the disease, but 
              without the proper environmental factors, the disease never comes 
              out. Its the old "nature-nurture/genotype-phenotype" 
              debate. And it makes perfect sense. Why is human cancer so difficult 
              to control? Because, in many cancers you don't get cancer unless you 
              have the predisposition AND are exposed to an environmental stimuli. 
              That is why some smokers get lung cancer and others merely die from 
              emphazema or heart disease. Smoking is the environmental component, 
              but some studies have shown that a genetic component is present as 
              well. Remember the last post (and the top of this one) where I said 
              the adrenal problems seem to have more than a single causality? This 
              would go a long way in explaining why more than 60% of you said your 
              adrenal ferret was currently in or came from a shelter. This suggests 
              some sort of commonality that is causing this predisposition to manifest 
              itself. What if the environmental component (if indeed this is the 
              case) was something that was common in the USA/Canada, but rare in 
              Europe, Australia and New Zealand? Could this help explain 1) why adrenal disease 
              is so common in the New World; 2) why, with the introduction of USA 
              practices, adrenal disease seems to have been lately increasing in 
              Britain; 3) why the disease appears to be common in animals exposed--in 
              mass--to similar environments, such as in shelters or mass groups 
              in pet stores; and 4) why the disease responds poorly to non-surgical 
              treatment (because even with the treatment, the ferret is *still* 
              exposed to the triggering factor)? Stay tuned for further details 
              when Bob pulls down his shorts and dares all to light their flamethrowers. Bob C and 20 MO Socksharks 
               ------------------------------ Date: Mon, 16 Feb 1998 00:38:27 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Adrenal Post Numero Trois
 The last post left off with my telling you about 
              a bit of the history of adrenal disease. I want to be clear on this; 
              just because something is not mentioned in a reference or it is not 
              diagnosed by veterinarians, it doesn't mean it isn't there. For example, 
              sometime ago I was interested in canine distemper and was looking 
              through the old literature and found very little. However, when I 
              started looking for the sweats, I found a tremendous amount. Just 
              because I couldn't find old references to adrenal disease doesn't 
              mean some are not there. On the other hand, using old documents for 
              an information search is a tried and true part of archaeology; these 
              old records are called ethnologies, and an archaeological report without 
              some reference to one is hard to come by. I have done a similar thing 
              with ferrets to build an ethographic reference. I've read about every 
              ferret book published (the first dates to 1790), put the data concerning 
              disease, life span, weights, reproductive age, etc., into tables and 
              gandered at the results. What I found is, the ferrets about a hundred years 
              ago are about the same as those today in terms of life spans (6-8 
              years), body weight, diseases, reproductive cycles, and litter size. 
              Knowing that the quality of diet is very important to the reproductive 
              status, I specifically looked to see if the ferrets were breeding 
              at a year old or older. A good, high-quality diet assures the first, 
              but any mustelid that is nutritionally stressed will delay reproduction 
              until the second year, either by not coming into heat/rut, or by absorption 
              of the embryos. Almost all accounts had ferrets breeding at one year 
              of age, with litters averaging 4-8 kits. You can't expect better today, 
              with all our vast knowledge and vet care. In every field I looked, 
              I found the descriptions from the past to fit exactly in with today's 
              data. (I do feel the average age at death was lower, indicating more 
              ferrets died earlier, but the ranges were the same) To me, this means 
              people treated the ferrets quite well and were concerned with diet 
              and health. Therefore, I feel the assumption that adrenal disease 
              was uncommon a hundred years ago is safe to make. If they didn't know 
              that was causing it, they would have at least mentioned the symptoms. I am convinced that the proportional differences 
              in adrenal disease rates between the Old and New Worlds have more 
              to do with environmental factors than genetics. I'm not implying genetics 
              is not important, for I actually feel ferrets as a "group" are prone 
              to them. I just feel various environmental factors are also important, 
              and an understanding of what is different between the two groups is 
              in order. Food: The USA/Canada primarily feed dry kibbled 
              foods; while such foods are being accepted in other countries, pullets, 
              carcass parts and raw meat products are still commonly given. Think 
              about this; as far as I can reconstruct, ferrets in the USA had a 
              low incidence of *reported* adrenal disease until the late 1970s. 
              Now, this might be coincident with better veterinarian diagnoses, 
              more treatment of ill ferrets, or the widespread introduction of dry 
              kibbled foods, which took place at about the same time. A possible 
              problems are a shift from foods having lots of fiber (fur) and roughage 
              to eating something that comes out like paste. I *have* to get off track just a moment here. I 
              just read Fox et al 1997 paper on Helicobacter. 
              A superb paper and one that left me wondering out loud if some of 
              the problems we are recently having with recurrent bowel inflammatory 
              disease, ECE and the like might be tied to expecting our little fursharks 
              to push their intestinal toxins out the back using paste rather than 
              fur and fiber. It is only a recent discovery that human bowel cancers 
              are tied to fiber content. Kibbled foods are essentially a paste made 
              of finely ground foodstuffs; a vole has fur, bone bits, teeth, and 
              non-digested parts pushing the nasties through. Some recent research 
              has shown dogs and cats are generally healthier with fewer down days 
              when fed a more natural diet. Aside over. Feeding: Here we generally feed ad libatium; that 
              is, we leave food in a dish and the dish with the ferrets at all times. 
              This is in part because someone once erroneously equated a high metabolic 
              rate and food requirements to mean they have to eat all the time. 
              This is not only untrue in healthy ferrets, but it would be impossible 
              to do in the wild. What do you think fat is for? Ferrets do just fine 
              if fed twice a day, and will adjust their eating habits accordingly. 
              There are some very nasty little papers that suggest animals eating 
              ad lib have fatter bodies and shorter lives that animals on a bidaily 
              diet, which has been a traditional practice in most other places ferrets 
              are kept. Living Environment: In the USA/Canada, ferrets 
              are house pets and are rarely taken into the out-of-doors. Most other 
              places house ferrets outside and they are rarely taken indoors. Photoperiodism: In the USA/Canada, indoor ferrets 
              are constantly exposed to unnatural light periods. I remain unconvinced 
              that full-spectrum light is any different than the ol' tungsten lamps, 
              since the latter has been used for decades to control photoperiodic 
              cycles in both birds and mammals, but I am concerned about the photoperiod 
              cycle in general in modern environments. This isn't a problem for 
              ferrets housed outside. Trace Nutrients: No one can tell you exactly what 
              trace nutrients human beings need, and we have been spending billions 
              to find out. Very little time or effort has been spend on discovering 
              the essential trace nutrients for ferrets. Remember, ferrets were 
              domesticated from polecats, who evolved as primary carnivores eating 
              fresh meat on a frequent basis. In a cosmic blink of an eye, they 
              have shifted from eating carcasses to eaten dried up bits of preground 
              paste. Exercise: Ever try to work out in closet? Need 
              I say more? Inactivity: Inactivity is mostly due to boredom 
              rather than small cages. I've included boredom because all systems 
              of the ferret are affected, including the endocrine system. Bored 
              animals and people have been shown to have higher disease and death 
              rates. It might take awhile, but you can be bored to death. Continued 
              in the next post. Bob C and 20 MO Furrbutts 
               ------------------------------ Date: Wed, 18 Feb 1998 13:20:20 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Adrenal Post Numerus Quattuor
 Before I get into this next part, I just wanted 
              to thank all those who have helped the flow of this discussion by 
              refraining from posting comments until the series is finished because 
              it allows me to concentrate on getting the stuff out rather than defending 
              statements. Trying to take an in-depth look at a complex disease with 
              little published data regarding causes is not only time consuming 
              and difficult, but to then to spread them out in an attempt to lessen 
              reading (and FML space) burdens makes it all the harder. Thanks for 
              (private) letters of encouragement, and more thanks to those possessing 
              the maturity and insightfulness to withhold comments until the series 
              is finished. Especially after today. So far I have compared basic environmental differences 
              between ferret ownership in the USA/Canada vs. everyplace else. But 
              environmental differences are not just food, housing and lighting. 
              By using the word environment, I am referring to anything not of a 
              genetic nature. In other words, your genes allow the potential of 
              growing to six feet, but outside factors can make you shorter (or 
              taller). American ferrets can be exposed to unique environmental factors 
              that are not typically found in other parts of the world; at least 
              not in the same degree. Paramount among these factors are two which I will 
              discuss; shelter conditions and neutering. I expect to raise some 
              eyebrows in both areas. When I discuss shelter conditions in the USA, 
              I am not discussing filth nor inadequate conditions, so *NO* comments 
              on that. During my travels, I have visited maybe 35 shelters, and 
              not one, even on a bad day, was unsafe for the ferret. In some shelters, 
              the amount of resources spent was outstanding, with ferrets being 
              given wonderful care. I'm thinking of something else; specifically, stress. 
              Ferrets are domesticated polecats, and as such follow a predictable 
              mustelid pattern of behavior (albeit somewhat modified by the constraints 
              of domestication). That means ferrets are territorial and solitary 
              animals, and indeed they are, as feral conditions and lab experiments 
              have shown repeatedly. But most mustelids, including ferrets, will 
              establish a sort of dominance structure when forced to live together. 
              Eventually, they accept each other more as siblings than anything 
              else as the community establishes. With a few exceptions, this never 
              happens in shelters. Ferrets come and go, cages are stacked next to 
              and on top of each other, and the entire room is filled from floor 
              to ceiling with the odors of strangers. If the shelter is full, human 
              contact can be short. Its no wonder that shelter ferrets can be nippy, 
              many show signs of immune suppression, or even blow their coats. I 
              commonly heard shelter operators say, "this little ferret is suffering 
              from stress right now..." Of all the replies, almost 70 percent said their 
              ferret was either adopted from a shelter or lived in shelter conditions 
              for part of their lives (In this category, place getting thrown in 
              a box and stored behind plexiglass in a pet store until sold). Only 
              three out of ten ferrets reported to have adrenal problems came from 
              private breeders. On the surface, this might be seen as evidence that 
              commercial ferret farms are breeding ferrets with compromised genetics, 
              but it could just as easily mean that there may be a common environmental 
              trigger. One other thing; when a privately bred ferret was adopted 
              from a shelter, they also had the same 70% chance of contracting adrenal 
              disease down the line. Hard to believe, isn't it? I have three fairly 
              good papers describing stress-related problems in ranched mink, who 
              show such symptoms as hyper-aggression, hair loss, diarrhea, extreme 
              apathy, neurotic behaviors and self-mutilation. Another paper talks 
              about how mink will form a ranked social grouping when forced to live 
              together, just like ferrets, and once the dominance relationships 
              are set up, rarely fight, just like in ferrets. But when placed into 
              conditions where they are constantly exposed to unknown mink, even 
              the sight of another mink causes quantifiable stress. Now, the papers 
              are really concerned in reducing fur injury, and the mink become coats 
              long before adrenal disease would have a chance to become apparent. 
              The reason I am mentioning the studies is because 1) no such study 
              exists for ferrets, 2) mink and polecats are acceptable analogs for 
              ferrets, and 3) the confinement and close proximity of mink closely 
              parallel that found in ferret shelters. BTW, the fur farmers found placing wood barriers 
              between cages to block visual views was effective in reducing stress, 
              even if the mink could easily smell each other. The only other effective 
              stress-reducing procedure was increasing the space between cages. 
              Could this be a factor in adrenal disease in our little furbutts? 
              I suspect it is at least a part of the problem, but I admit there 
              has been no specific study looking into the issue. More comments later. The other issue is early neutering. This is a monster 
              can-o-worms. Let me define early neutering. Growth patterns vary from 
              species to species; in most, the onset of sexual maturity is prior 
              to the mammal reaching full growth. But not in most mustelids. The 
              ferret reaches 90-95% of its growth in the first six months. By the 
              end of the first year, its bones have stopped growing and are fusing 
              together. This is before or at the onset of the first possible reproductive 
              cycle. I define early neutering as neutering before the growth cycle 
              is complete. Late neutering is after the growth cycle is complete. 
              I assume a growth cycle is complete when the ferret has reached 90% 
              of a typical adult weight, because even though the skeleton has stopped 
              growing, the ferret can still put on weight, especially the males. 
              In an unneutered male ferret, this is muscle mass due to testosterone; 
              in unneutered females, its body fat. Now here is an instance where statistics can fool 
              you. The survey reported early neuters had almost a 80% higher rate 
              of adrenal disease compared to late neuters. Sounds terrible, right? 
              The problem is, what's the percentage of early neuters compared to 
              late neuters? At least 80%? When I normalized the values, I found 
              early neuters and late neuters to have about the same rate of adrenal 
              disease. The stats have other problems as well; the FML is not a typical 
              slice of ferretdom--not even in the USA--and FMLers are far more likely 
              to adopt sickly ferrets than other people, which has a serious impact 
              on the numbers. For both reasons (and more, including a possible bacterial 
              or viral link) I cannot determine if early neutering has a definite 
              negative impact on the ferret in regards to adrenal disease. Size? 
              Absolutely! Adrenal disease? Just can't tell. What is interesting about the survey is it showed 
              females were twice as likely to get adrenal disease as males. This 
              could suggest adrenal disease was sex- or hormone-linked. Breeder 
              females had the lowest incidence of adrenal disease, followed by breeder 
              males. I don't trust the numbers because the reported sample was much 
              too small, but it does suggest a hormone-link. Or does it? Are breeder 
              animals housed or handled differently than neutered ferrets? Do they 
              handle stress differently? See how the question becomes convoluted 
              and difficult to define? We are almost at the end, just a post to tie things 
              together and a post to suggest courses of action. Then feel free to 
              pepper me with any questions you wish; but I'll say right now, I'll 
              only answer those questions asked politely and will ignore any rude 
              question or questioner. This isn't about who is right or wrong, nor 
              is it about me or you. Its about a serious disease attacking our ferrets 
              and a simple exercise attempting to define the questions, because 
              currently, there are no answers. Bob C and 20 MO Sockoholics 
               ------------------------------ Date: Wed, 25 Feb 1998 17:06:21 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Adrenal Post Numero Cinque
 The statistics gathered from the FML are biased 
              at best and unusable at worst because there is no way I can demonstrate 
              the demographics of the FML is similar to ferret owners as a whole, 
              and between you and me, just the fact that every FML person has or 
              uses a computer daily is evidence of that. Even taking into account 
              several previous surveys, the demographics of the FML cannot be fairly 
              compared to any other group. This has important implications regarding 
              the ferret list in general, and one I need to discuss prior to the 
              adrenal summary, because it sheds light on what we see posted here. I'm sure you have all heard the joke, "Those who 
              are against me are liars, and those who use statistics against me 
              are damn liars." You can use statistics to prove almost anything. 
              All you need to find are two things that statistically correlate to 
              each other and you can make a point. The problem is, a statistical 
              correlation does not mean there is a cause and effect correlation. 
              My favorite illustration of this is "Nearly 100% of people with severe 
              hemorrhoids use toilet tissue." Statistically this is probably correct. 
              The trouble is, no cause/effect relationship has been demonstrated. 
              Statistics show mathematical correlations, but only people can take 
              those correlations and look for cause/effect relationships. Scientifically, 
              this requires rigorous controlled testing, which for those of you 
              who are squeamish about such things, usually involves the use of ferrets 
              for medical research and their subsequent sacrifice. The toilet tissue argument is what is happening 
              on the FML regarding adrenal disease. Read carefully; I am *NOT* saying 
              *ANYONE* is wrong or right--all I am saying is not a single person 
              has shown a cause-effect correlation. In addition, each and every 
              one of the supposed solutions are done without scientific rigor nor 
              with controls. By itself, this makes the data essentially useless. 
              Not totally, but pretty much so. For example, and I am talking not just about homeopathic 
              treatments but any treatment, how do you know the change in the ferret 
              is due to a specific treatment and not because of additional handling? 
              Touch therapy is as old as the beginning of human culture and it works; 
              lots of studies have shown touch to increase immune responses and 
              there are a couple of documented cases where touch therapy has been 
              attributed to the remission of cancers in terminally ill people. So 
              what part of treating the ferret is the additional touching, and what 
              part the medicine? You don't have any controls, so you can never be 
              sure. You can believe what you want, even suggest it as a course of 
              action, but you have no proof. Another problem with FML data is we are subject 
              to a constant bombardment of symptoms, treatments, theories, etc. 
              We are not the typical ferret owner. I know; I've met some and you 
              would be extremely surprised to discover how little the average ferret 
              owner actually knows about their carpet monkey. The longer you read 
              the FML, the more you learn about ferrets until you reach the point 
              that there are few medical surprises. This does two things; it makes 
              each of us think we know as much as people who have spent a decade 
              learning the physiology of animals, and it makes us feel hopeless 
              in the face of certain severe illnesses. For example, I have been told canine distemper 
              is 100% fatal, and I believe it. Yet, I know of at least three ferrets 
              that has survived it, albeit with some sort of permanent disability. 
              A similar thing occurs with the constant influx of adrenal posts; 
              we hear it so much that they become paramount in our mind, making 
              the actual severity, demographics or survival rate shift from reality 
              to FMLity, which you cannot assume to be true or real. In other words, 
              because we hear of it so often, we start to grant it far more importance 
              than it actually deserves. I think that false sense of danger taints our perceptions 
              of how we view adrenal disease. While I may know what percentage of 
              FML ferrets display adrenal disease (maybe 10%), MOST of them don't 
              die from it until they are past 6 years of age. That is within the 
              mortality window of the average ferret, even without adrenal disease. 
              Think about this; what do you think *you* will die from when you get 
              near that magical 77 year mark? Humans die of strokes, heart disease 
              and cancers (unless you smoke and its much worse). Our species seems 
              to have a weakness in those areas. The same might be true of ferrets; 
              the "large" number of adrenal problems we see might be an indication 
              that the ferret is actually in its declining years. Don't confuse 
              the early onset type of adrenal disease with the late onset. I personally 
              believe we are looking at two different disease processes here, but 
              more on that in the next--and last--post. So what I seem to be saying is we can come up with 
              all sorts of reasons for the adrenal disease we seem to be seeing, 
              but without proper statistical procedure, known demographics, and 
              careful analysis of the results, we really don't have anything other 
              than rumor and innuendo. Yes, we *know* something is going on, but 
              the relevance and extent of that knowledge is uncertain. What is needed 
              is solid scientific research, the kind that resorts to experimentation 
              on live animals. We need this basic knowledge base in order to accurately 
              assess the true danger that exists to our ferrets. Science is very much like law (except a scientific 
              dream team rarely gets millions of dollars) in that you must have 
              unbroken links between the suspect and the event. Since arguments 
              are similar to a series of links in a chain, break a single link and 
              the entire argument fails. For every one of the possible reasons I 
              could come up with that could cause adrenal disease, I could break 
              one or more links, each the intellectual equivalent of "If the glove 
              don't fit, you must acquit." Does this mean that none of the possibilities I've 
              mentioned are possible? Of course not. I'm convinced more than ever 
              that adrenal disease is an environmentally-triggered genetically-predisposed 
              disease. Which is probably old news to those investigating the issue, 
              but, belief is not evidence, and solid evidence for any cause/effect 
              relationship simply does not exist in the literature. Now, I have a final post after this one and then 
              I'll make myself available to answer questions on any research I've 
              done, the references will be made available, etc. Bear in mind this 
              sort of discussion is necessarily verbose, and with the size of the 
              FMLs lately, when a post goes over 125 lines I have to ship them to 
              Bill who puts them in ASAP. So there is this sort of surreal waiting 
              period until you see stuff. That isn't me back-pedaling or running 
              off finding evidence, but just that I see the question one night, 
              post the answer the next night and you see it the 3rd night (or later 
              depending on various factors). Patience. And keep emotions out of 
              it, ok? For much of this, I could easily do the equivalent of smashing 
              a basketball in your face if I wanted to, but that would detract from 
              the true purpose which is discussing the adrenal issues. It would 
              only force me to use statistical evidence, making me a damn liar instead 
              of just a liar. Bob C and 20 MO Four-Legged Fursnakes 
               ------------------------------ Date: Sat, 28 Feb 1998 04:55:47 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Adrenal Post Number Five
 This is the last of the adrenal posts, to which 
              I am sure some of you will applaud. It has been hard for me as well, 
              well maybe not from a boredom aspect, but hard nonetheless; I had 
              to give the inter-library loan people a box of designer chocolates 
              so they wouldn't complain. The greatest difficulty has been the long-term 
              posting; I think it would have had a lot more impact if they had ran 
              in a week rather than two. That was unintentional and caused by MF 
              debates, the Ohio bite case, and other stuff which is also important. 
              But those issues filled the FML and placed these posts into the category 
              of "I'll drop them in when I find space." Perhaps I should have divided 
              them into more posts, or posted several parts in a row to get around 
              the FML guidelines, but the work seemed to divide itself into five 
              parts, and I was too busy to argue with it. This last post will also 
              be long but hopefully will be posted sooner than the others. With 
              the publication of this post, feel free to pepper me with objects 
              no larger than a soda can, or questions, whichever you prefer. I will 
              not answer rude comments. I will provide specific references to those 
              with a bonafide interest. 250 years ago, the Philosopher David Hume said 
              that you couldn't infer an infinite cause from a finite effect. I 
              have a photocopy of the paper in which that statement was originally 
              written, and I look at it whenever I work on any scientific paper. 
              While the original purpose behind the statement has little place on 
              the FML, the statement itself can sum up the problems of ferret adrenal 
              disease. What can cause it? I came up with more than a dozen really 
              good ideas, but am no closer today at deciding what causes it that 
              I was three months ago when I started to look into the issue. In fact, 
              I think I know *less* now than then. Perhaps the answer has been scotch-taped 
              to my computer terminal all along; you cannot infer an infinite cause 
              from a finite effect. What research I've done suggests adrenal disease 
              in ferrets is a multi-factorial problem resulting from a genetic predisposition 
              and an environmental trigger. Because the genetic heritage of ferrets 
              is little understood--we don't have coat colors worked out yet--that 
              aspect of adrenal problems has no current resolution. In other words, 
              ferrets as a group may be predisposed to adrenal problems, or just 
              USA strains, or just specific breeder strains; no one knows. After 
              working on the genetics of the problem, I'm inclined to believe it 
              is a ferrets-as-a group predisposition. Better statistics and controlled 
              testing could resolve this problem in a few years, provided funding 
              and animals for research be provided. There are a few studies, but 
              they do not answer the question of which type of ferret gets the disease, 
              nor location. Adrenal disease seems to be a geographically isolated 
              disease. Statistically, ferrets in outside of the USA and Canada (or 
              America as in "North") have significantly lower reported rates. Adrenal 
              disease also seems to be a modern disease; that is, after scouring 
              all available records for the last 200 years, I was only able to find 
              a single incidence of what *could* have been adrenal disease, and 
              in that case, my "diagnosis" was based on hair loss and thirst, and 
              could have been something else. Even as soon as thirty years ago, 
              adrenal disease was uncommon enough to not be mentioned in USA publications, 
              including vet-care papers. Some might argue the sudden onset is due 
              to early ferret deaths--they didn't live long enough for the disease 
              to exhibit itself, or that the ferrets were simply killed and no record 
              was made. I reject both arguments because I actually waded through 
              reams of illness reports and cures. The average lifespan of ferrets 
              reported 100 years ago is essentially the same as today, except the 
              average age of death was a little bit lower. Certainly, they lived 
              4-5 years, which in today's American population, would mean adrenal 
              disease would have been noted. Most authors made every attempt to 
              mention illnesses that only had the faintest possibility of occurrence. 
              In an 1860's version of a vet how-to book, the symptoms of Cushing's 
              Disease is mentioned in dogs, and while the aliments of ferrets took 
              up a dozen pages, nothing similar was even remotely mentioned. I don't 
              think you can assume the disease was there but ignored. These guys 
              LOVED to get their names attached to a disease, as if they invented 
              it. I don't think they saw it or it was extremely rare. Since the ferrets in the USA, Canada, Australia, 
              and New Zealand all come from the same basic stock, and those same 
              ferrets show a tremendous amount of variation in body shape, patterns, 
              fur color, and other morphological traits, arguing the American ferrets 
              have some sort of inbred genetic problem is rather pointless. It may 
              be that the supposition is true, and it certainly would explain why 
              so many American ferrets get the disease. But then, it doesn't explain 
              why so many American ferrets do NOT get the disease nor why it is 
              so unpredictable. Like cancer, it seems to run in families, but you 
              cannot predict which ferret will or will not get adrenal disease. 
              Which is exactly why I think an environmental trigger is also necessary 
              for the disease to show itself. I have chosen to assume the genetics are about 
              the same between American ferrets and all others. That is because 
              the initial ferret population in the Americas was so high that a founder's 
              effect or genetic drift becomes improbable. Not impossible, but not 
              very likely either. While I doubt if the America population a century 
              ago rivaled that in Great Britain, it had to equal or exceed those 
              populations in New Zealand and Australia, and guess what? Those ferrets 
              are weaned on environmental conditions similar to those in Britain, 
              and they have similar adrenal disease rates. Assuming the USA has 
              vets better able to diagnose or identify the disease is both nationalistically 
              arrogant and well as unsupported by facts. Did you ever think the 
              reason American vets know more about the disease is because it occurs 
              at rates unnaturally high here? Or that the reason some of reports 
              starting to surface elsewhere might be because American ferret environments 
              are becoming more common? The trouble is, if this is true, (and at best it 
              is only a working hypothesis), what are the environmental triggers? 
              Either the genetics of the American ferrets and all others are different, 
              or they are about the same. You must assume they are the same UNTIL 
              you can prove otherwise. If they are the same, then some environmental 
              factor must be behind the outbreaks. Since there are a number of environmental 
              differences, ranging from photoperiods to diet to a virus to stress 
              to early neutering, and not a single study has looked into THESE issues, 
              then at this point in time the issue is too complex to resolve. Its 
              that simple. Infinite causes and a finite effect. Still, much can be learned if we set aside our 
              prejudices and take a careful look into what is the same between the 
              Americas and Europe, and what is different, because therein lies the 
              answer to the environmental trigger, should one exist. Like links 
              in a chain, it may be possible break a link and prevent the disease 
              from occurring. Sort of like the identical twin smoking study done 
              some time ago. One twin smoked, the other did not. In those cases 
              where the twins had a genetic predisposition towards cancer, the smoker 
              got lung cancer. Smoking was the environmental trigger, and breaking 
              the link--smoking--reduced the chances of lung cancer significantly. 
              Don't buy the comparison? Do you remember what adrenal disease is? 
              A tumorous growth in the adrenal gland? So what is lung cancer? I'm 
              not implying they are the same disease--and in fact they are quite 
              different--but just like comparing a TR-3 to a VW bug, they might 
              be different, but much of the mechanisms is similar. They are inherently 
              comparable. Of all the possible environmental triggers, the 
              most plausible are some sort of biological agent, like a virus or 
              bacteria, stress, early neutering, diet or some combination of these. 
              Photoperiodism might be a contributing case, but since other animals 
              that are as subject to photoperiodism as ferrets, or more, do not 
              exhibit problems, I discount its contribution. An unknown biological 
              agent is certainly a viable option, but little is known of their relative 
              effects in tumor growth. I'm afraid the major environmental differences 
              between American and all other ferrets must lie in diet, stress and 
              early neutering, or some combination. Early neutering does not seem to be a problem with 
              other species, so it loses some of its credibility in the ferret issue. 
              Still, dogs and cats are not typically neutered at the same relative 
              stage of growth as many ferrets, especially those neutered at about 
              a month of age. This is because the growth curves of the various species 
              are different, so one being neutered at 6 weeks might be the physiological 
              equal to another species being neutered at 3 weeks. I know of no research 
              into this issue. Diet can also be an important factor. Adrenal disease 
              really didn't start making headway in the Americas until after kibble 
              became a popular food. It is quite possible that the lack of a micronutrient 
              could be causing a physiological problem resulting in the disease. 
              Convinced kibble is a perfect food? I have three references, none 
              more than 5 years old, that suggest "any kibbled food is an approximation 
              of a natural diet and as such cannot supply the diet the [predator] 
              consumed during its evolution." I have had so many requests that I 
              address the diet issue that I will drop it for now in favor of a future 
              post. Still, as a trigger in adrenal disease? I have some doubts. That leaves stress. Some human research suggests 
              there is "good" stress and there is "bad" stress. Good stress are 
              those events that either strengthen or condition your body towards 
              some event, such as a sporting event or asking someone out on a date. 
              Bad stress is of the type that is not quickly resolved, like school 
              or work stress, and is thought to be a factor in human heart disease. 
              While I was able to find lots of info regarding maternal-separation 
              stress in lots of different animals, little has been done with ferrets, 
              and nothing looking into the possible link between stress and adrenal 
              disease. Stress is a natural suspect, because it is so intimately 
              involved with the adrenal gland itself. It may well be that unresolved 
              stress might be the triggering mechanism, and early maternal separation, 
              close (unresolved) shelter contact with unknown or strange ferrets, 
              or lack of physical contact be factors as important or more than genetics 
              or early neutering. Of course, it could be a combination of those (or 
              others) that is trigging adrenal disease. For example, maybe a MF 
              ferret was early separated, early neutered, then shipped to a pet 
              store having a completely new environment, all full of stress. Feed 
              a kibbled diet which could possible cause some physiological stress, 
              the combinations of all the different stresses trigger the growth 
              of a small tumor in the left adrenal. This is just a story, but it 
              is a testable idea. Complicating the entire argument is the observation 
              that adrenal disease seems to be exhibited in two different manners; 
              one a late onset, and the other is an early onset with often a later 
              recurrence. I cannot distinguish this from being two different diseases, 
              one disease that exhibits differently, or just random happenstance. 
              I know of no study into this issue. As for treatment, surgery is the only treatment 
              that has any long term benefit for the ferret. As already discussed 
              in the 1st post, drug or chemical treatments do not offer a significant 
              difference in life span compared to no treatment at all. They do provide 
              the ferret with perhaps a slightly higher quality of life during that 
              time, but no real increase in lifespan. It is better to be aggressive 
              and remove the tumor as soon as possible, because the disease gradually 
              weakens the ferret and increases the chances of complications. The 
              younger the ferret, the better the prognosis, although the younger 
              the ferret, the more likely a second adrenal tumor will crop up. I don't see an easy resolution to this problem. 
              It requires money, intelligent and dedicated people looking into the 
              issues, and time. Genetic and environmental factors need to be ruled 
              out, ferret *will* die to resolve this, that you can be sure. Can 
              we help? Hell yes! The best way each of us can help is with GOOD records 
              on each and every one of your carpet sharks. As much of the lineage 
              as possible, estimated birth date, diet (including manufacturer of 
              diet), shot record, weekly temperatures and weights, record of treats, 
              social interactions, etc. We can be like Tyco Brahe, who painstakingly 
              measured the distances (time) between stars, knowing there was no 
              real good purpose for the data. Yet, that same data, in the hands 
              of Kepler and Newton, rewrote our history. We can create the data 
              that some smart whipper-snapper down the road can take and solve the 
              problem. I suggest those people who currently are on the adrenal mailing 
              list, work with some quasi-national club to create a scientifically 
              correct adrenal data base, gather info from vets, breeders and owners, 
              and provide it to bonafide researchers. We already have the answers; 
              we just need it in an unbiased and correct form of data. So that's it. I recommend you go back and read 
              the preceding four posts (or just skim them) before firing off a question 
              just to remind yourself of what had been said already. I have tried 
              very hard not to offend anyone position or platform. Not really, I've 
              tried hard to offend them all. I have my asbestos lonhjohns on, my 
              trusty data base in one hand, and Carbone, just starting his first 
              rut, in the other. I'm ready. Bob C and the 20 MO Ferrets just relieved its all 
              over. 
               ------------------------------ Date: Mon, 2 Mar 1998 03:09:31 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Round One: Adrenal Reposts
 Q: "I have had great success with [homeopathic] 
              remedies in adrenal disease. Why did you ignore such a large body 
              of evidence?" A: I didn't. I use homeopathic treatments quite 
              often; when I was on high doses of chemicals, I used several teas 
              and even aroma therapy to get past the nausea. But very little is 
              known about homeopathic treatments and how they work in humans; next 
              to nothing has been done on animals of any sort. That isn't to mean 
              they don't have value; they are useful if nothing more than as a touch 
              therapy, and I think I said that. What I said was there is no proof 
              of their ability to extend life or make any changes in the quality 
              of life in a sick ferret. If such proof exists, and is published in 
              a referred scientific journal, please let me know and I will pass 
              it on with my heartfelt apologies. Q: "I am very interested in the role of diet in 
              ferrets. Can you tell me more?" A: I've had so many requests to discuss this in 
              the last weeks that I'm compiling the references for a nice post on 
              the subject, and will defer until then. Q: "OK, Bob. If you don't think it is genetics, 
              then kindly explain why only [MF] ferrets get adrenal disease. I think 
              they accidentally bred it into them." A: I'm sorry if my explanation wasn't clear. My 
              little survey, as well as others, seem to indicate more actual numbers 
              of MF ferrets get adrenal disease, but when factored to the proportion 
              of MF ferrets, the normalized number drops. I don't know if my numbers 
              are accurate because I don't know how many MF ferrets are sold compared 
              to other breeder's ferrets, and I doubt if such information is possible 
              to obtain. My best guess is the rates are roughly equal. That would 
              make the assumption that MF ferrets have a special flaw rather difficult 
              to support. Besides, if such a "flaw" existed, and adrenal disease 
              was purely a matter of genetics, then the number of adrenal cases 
              could be predictable in large populations, and thus far they are not. 
              While I do believe genetics is a very important factor in the onset 
              of adrenal disease, it simply cannot be the part of what is going 
              on because of the unpredictable nature of the disease. Now, assuming adrenal disease is only a genetic 
              problem, then it should follow some pattern of heritability, which 
              it does not except in the most broad sense. You can say something 
              like 5-10% of ferrets will get adrenal disease in their lifetime, 
              but you can't say who will get the disease. This "random" selection 
              is not actually random; those with the disease must have some sort 
              of shared characteristic(s) which promote the onset, like smoking 
              and lung cancer, and since it is beyond the genetic level, it must 
              be at the environmental level. Because there are so many possible 
              causes, until each one is ruled out, you cannot define a cause-effect 
              relationship. That is why it is so complex an issue, and also why 
              so few treatments seem to work. For example, assume diet is the trigger. 
              You have a ferret with diseased adrenal glands and you start what 
              promises to be a good therapy. However, during the "cure," the ferret 
              continues with the same diet that caused the disease. What are the 
              chances the cure will work? See the complexity now? Infinite causes 
              and finite effect. Q: "Do you really think ferrets in Britain are 
              kept differently than in the USA?" A: Borrow a copy of James McKay's video "Keeping 
              Ferrets." You will not only see some of the fluffiest, largest, most 
              well-behaved ferrets you have ever seen, but you will discover they 
              are housed, fed and treated quite differently make the typical ferret 
              in the Americas. Of course, his ferrets seem to be complete with anal 
              sacs and gonads, so some of what you are seeing is due to hormones. 
              However, nothing McKay has to say is any different than can be found 
              in W. Carnegie's books from the 1910-20s or Ernest's book from the 
              1890s. They are virtually the same, with a few differences due to 
              technology changes. There are more questions which I will answer in 
              the next day's post. Bob C and 20 MO Rasslin' Weasels 
               ------------------------------ Date: Tue, 3 Mar 1998 05:37:56 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Adrenal Responses, Part Two.
 I have a basket of them, so if I don't mention 
              yours. I'll get to it soon. Q: "You really didn't get into deep detail on early 
              neutering. Can you expand it a bit?" A: Its simply a matter of trying to keep the post 
              as short as possible, so lots of stuff I want to say is never mentioned. 
              Sometimes, the effort of minimizing leaves the wrong impression. Sorry. What early neutering is proven to do: 1) Reduces the odor in males. 2) Make males more 
              effeminate. 3) Reduces muscle mass, especially in males. 4) Reduces 
              over-all growth by preventing the hormone-mediated growth spurt near 
              the end of the growth cycle. 5) Prevent unwanted baby ferrets. 6) 
              Prevent female estrogen-related anemia. 7) Reduces aggression. 8) 
              Reduces (to a degree) the territorial desire. What early neutering has never been proven to do: 1) Cause adrenal disease. I have a fairly good understanding of the endocrine 
              system, I know exactly were the to find the hypophysis (and have physically 
              dissected it out in a dozen or more vertebrates, including humans 
              [I've taught human anatomy labs]), and I have read my share of research 
              papers on hormone balance/counterbalance. I even have a copy of a 
              1966 MSc thesis that touches on the interaction of pituitary hormones, 
              anal sac secretions and, yes, the adrenal glands. The problem is twofold. 
              A) No one has published an in-depth study of these interactions in 
              ferrets, and B) No one has published a link (that is, an independently 
              verifiable, reproducible cause/effect correlation) between early neutering 
              and *any* serious disease. I stress "published" because such scientific 
              papers normally undergo a review process which weeds out those experiments 
              that are faulty or containing serious flaws. That doesn't mean such links do or do not exist. 
              It only means nothing has been shown to link the one with the other. 
              If my goal was to remain impartial, or to allow all points to be equally 
              expressed in a fair and open manner, then I had no choice but to draw 
              the line between the proven and the unproven, and only mention the 
              possibilities as such. Since I have heard from both sides of the issue, 
              I suspect I might have met that goal. Personally, I am a strong supporter of late neutering. 
              I won't neuter a male until he ruts, which is usually the first spring 
              after he is born, providing he has had good nutrition. Foster and 
              Chrys are late neuters, Moose and Bear were neutered between 6-8 months, 
              and Apollo, Simon, and Sam are early neuters. Carbone is almost a 
              year old and not yet neutered. I can see a gradient in muscle mass 
              and body size between these males, with the early-neutered guys far 
              more girlish than the middle or late neuters. The difference between 
              the early and middle neuters is not nearly so noticeable as between 
              them and the late neutered guys, who are truly impressive in their 
              size. Chrys is 4.3 lbs. (3 years old), Foster is 3.3 lbs (13 years 
              old) and Carbone is 5.7 lbs (1 year old). My next largest male is 
              Bear, who is 2.8 lbs (4 years old) and was neutered at 8 months. To 
              get larger than this, you would have to have unaltered hobbs. But even though I support late neutering, I also 
              feel it is more important to neuter ferrets BEFORE they are sold, 
              especially those sold through pet stores. The reason is simple; we 
              already have enough ferrets in shelters, and I hate to consider the 
              day when animal shelters are killing as many ferrets as they kill 
              dogs or cats. That will continue to be my position until some link 
              between adrenal disease and early neutering is proven, no matter what 
              I personally may suspect. Q: "Is there a link between adrenal disease and 
              coat color?" A: Not that I could find. If such a link existed, 
              it could be evidence the trait was carried near on of the genes coding 
              for pattern or color. But I could find no link, not even a possibility, 
              between color, pattern or adrenal disease. From a personal perspective, Buddy died of adrenal 
              disease at 10 years old; he was a dark silver mitt. Sandy has suffered 
              from adrenal disease for most of a year; she is thought to be 5 years 
              old and is an albino. Razz died of a stroke, but her necropsy showed 
              she had a massive abdominal cancer that had spread into some of her 
              bones, and which included the adrenal glands. She was a chocolate 
              sable, and died at 8 years of age. I don't see a pattern in my own 
              ferrets, I didn't see one in the published accounts of adrenal disease, 
              and I didn't from the FML survey. More to come.... Bob C and 20 MO Furrbutts 
               ------------------------------ Date: Wed, 4 Mar 1998 18:16:22 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Adrenal Responses part 3
 Q: "Do you think adrenal disease may be more closely 
              related to the type of process than results in breast cancer than 
              the possible reasons you listed?" A: If you mean just another type of tumor or cancer? 
              Maybe so, but keep in mind that many (if not most) human cancers have 
              multiple causes, such as genetics and environmental triggers. Some 
              even have viral triggers. So I can accept the statement in the broad 
              sense, but reserve judgment in the narrow sense. Q: "Do you know....of a type of experiment that 
              could prove one way or another if [MF] ferrets had more adrenal disease 
              than other ferrets? A: Sure. Get 300 unneutered kits from MF and 300 
              from randomly selected private breeders. House each kit identically, 
              feed the same food, allow to socialize with people identically. Early 
              neuter 100 from both groups (4 weeks), middle neuter 100 from both 
              groups (6 months) and late neuter 100 from both groups (1 year). Raise 
              them in identical conditions until they all die; about 8-10 years. 
              Count up the number that had adrenal disease. You would then know 
              just about for sure, but first you need the 600 baby ferrets, the 
              space to care for them, the money to feed them, vets to care for them, 
              and the people to help you do the experiment. I'll run the experiment 
              if someone will get me the grant. Q: "I wasn't lost because of your writing, but 
              the long time between posts hurt my understanding of what you were 
              talking about...." A: Yeah, I've heard this from several people now. 
              In the case of the adrenal posts, they were long, but there was quite 
              a bit of stuff to cover. This type of post is rare, even for my particular 
              style of long-windedness. Also, you have to remember the MF debate 
              and the ferret biting incident took place at the same time--both important 
              issues-- which made Bill's job all the harder. I have no complaints, 
              and suggest you print out those particular posts for ease of bathroom 
              reading. Q: "Have you read anything relating Post-traumatic 
              stress syndrome to adrenal disease?" A: There is a lot of information on this in humans, 
              but I'm not sure of any study done in ferrets. I've read that, in 
              humans, those subjected to long term stress will have elevated stress 
              indicators for a long period of time, even after the stress is removed, 
              including elevated adrenal hormones. However, each species has an 
              unique evolutionary history resulting in a unique physiology, so just 
              because it occurs in one species is not necessarily proof it occurs 
              in other species. Some drugs which have no side effects in animals 
              are dangerous in humans. However, there are more more similarities in physiology 
              than differences, and I would suspect there might be some sort of 
              relatedness between the two. Ferrets are energetic, have metabolisms 
              on afterburner, and have a strong sense territory toward strangers. 
              In essence, they are fairly easy to stress. While suspecting a correlation 
              isn't proof, if I were actively looking into the causes of the disease, 
              this would be one of the first places I would check. Q: "How many references did you consult for this 
              adrenal posts and can you download them for me?" A: I managed to beg, borrow, photocopy, or buy 
              a total of 18 MA/MSc/PhD Theses/Dissertations, 36 books, 6 edited 
              books, and 97 journal articles. In addition, I was able to consult 
              an additional 21 paper abstracts, where the original was in a foreign 
              language or unavailable. The cost to me was in excess of $330 for 
              the mailing costs, photocopies, and purchased books. Quite honestly, 
              if I were to do an experiment or two, I could easily turn this in 
              for a master's degree. Of course, it would even be *longer* and more 
              involved. This represents a tremendous effort on my part 
              to collect, collate, and just type in the references, which I haven't 
              had time to do as of yet. So I will make specific references available, 
              but as for the sum total, they are in a pile beside my desk, which 
              makes them hard to download. Also, in most cases, having the entire list of 
              references is unnecessary unless you want to do academic research 
              in this area. If that is the case, I have two objections. First, researching 
              a subject is part of the learning process which shapes your personal 
              work, and second, I plan on using the references for some work of 
              my own which means you'll just have to wait and cite me. Still a few more, Bob C and 20 MO Poopmeisters 
               ------------------------------ Date: Thu, 5 Mar 1998 08:35:50 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Last Adrenal Questions (for now)
 This is the last I've received so far. Most of 
              the private questions were also mentioned in FML posts, a couple, 
              like the post-stress question, were asked by three or more people. 
              Many questions were adrenal-off topic, or just FML off-topic. But 
              this is basically it (for now). Q: "Can I use your [adrenal] posts in [my local 
              ferret club newsletter]?" A: Its against the law to mail dangerous things, 
              and people have fallen asleep on the seat and almost drowned after 
              reading them! I'm not sure I want to be called the Unabob. Sure. Send me a copy if you have an extra. Q: "If the adrenal issue is so complex...and the 
              ferret is the third most popular pet, why isn't someone researching 
              a cure?" A: That's 3rd most popular carnivore. The problem 
              in the USA is ferrets have a minor economic potential when compared 
              to livestock, horses, dogs, cats and even fish. There are three ways 
              to easily confirm this. First, look at the book section of your local 
              book store. At my favorite store, there were 7 shelves on dogs, 4 
              shelves on cats, 3 on horses, 3 on fish, and 4 on everything else. 
              There were exactly 4 books on ferrets from 3 authors, two were first 
              printed more than 10 years ago (The other two were Modern Mary Shefferman's 
              book "The Ferret," and the rebundled 1996 "Ferrets Today" disguised 
              as a new 1997 book, which it ain't). The second way to tell is to look at the back of 
              pet magazines and see who pays for the slick ads and what they are 
              advertising. Large incomes = large ad budgets = slick ads. Advertisers 
              put their money where they think the profits are. I suspect most of 
              the big players are still waiting to see if ferrets pan out to be 
              more than just a passing fancy. The third way is to see how many graduate students 
              are doing their research on ferret issues. Quite literally, scores 
              of theses (rhymes with feces) are approved each year for livestock, 
              dozens for companion pets, and very few on ferrets themselves; that 
              is, not including those using ferrets as research models for other 
              species. The reason for the disappointing lack of interest 
              in all three categories is nothing but economics. The bottom line 
              is there are not enough bucks being spent by the ferret community 
              to attract the players who typically pay for the research grants that 
              cure this type of stuff. This isn't new; pets weren't really exploited 
              for the big bucks until the last couple of decades. Now, if the disease 
              affected cattle or sheep, it would have been called the "Mad Adrenal" 
              disease and livestock would have been recalled from pet shops and 
              people would have stopped eating hamburger. If it affected dogs or 
              cats, then a serious yet sensitive professor would have been asked 
              to the Today Show to profess his or hers serious yet sensitive views. 
              But stinky attack-ferrets are owned by tattooed weirdo nuts who only 
              spend millions instead of billions on our one-tracked begonia diggers, 
              so there is absolutely no incentive to exploit the market "at the 
              present time." Need I say more? Of course! There are some ways to cure this problem. 1) Start 
              a program to make ferrets MORE popular than dogs or cats, possibly 
              by exploiting the Bud commercials. 2) Convince ferret owners to buy 
              cartons of tacky products with anything even resembling a ferret rubber-stamped 
              on it. 3) Get a couple hundred internet people to boycott, badger, 
              or belittle the players to make more monies available. 4) Get all 
              the little clubs to get over their regional squabbles and ego flailing, 
              band together and form a truly (Inter) National Ferret Club with enough 
              members and money to carry a politically big stick. 5) Form your own 
              little club so you have your own opportunity for regional squabbles 
              and ego flailing. 6) Wait and hope for the best, while bitching about 
              how unfair things are. 7) Write incredibly long posts that incite 
              people to riot, while wearing a t-shirt reading "David Hume and Patrick 
              Henry for President!" This is America, where the currency says "In God 
              We Trust" on one side and "but all others pay cash" on the other. 
              If you want the players to take notice, you have to be noticeable. 
              That means money or political power and usually both. Are we, as ferret 
              owners, capable of such feats? Well, we beat rabies hysteria, have 
              had most anti-ferret laws changed, and just recently saved the life 
              of a "child-attacking ferret." Those times we banded together and 
              chose to ignore our differences, we beat or changed the system. Then 
              we just drift away to resume regional squabbles and ego flailing. 
              Ever wonder why you never see a dozen different Audubon Societies, 
              or a half dozen different Sierra Clubs? Its simply because ten clubs 
              are never as large as one single, giant, powerful "hit bad guys out 
              of the park" club. One voice, pooled resources, political strength. 
              I have been asked why *I* haven't formed a club, and the reason is 
              simple; ferrets DO NOT NEED yet another personality-based club that 
              only divides and fragments our meager resources and unity. What they 
              need is all the existing clubs to become a single strong organization! 
              Its just too bad the clubs won't see the light (or take the hint) 
              and merge themselves into a single national club with enough membership 
              and strength to show the big players we will be still be around in 
              the twenty years it will take their research money to turn the big 
              profits so when they die they can have all kinds of stuff for their 
              children to fight over. Whatever happens, you can etch this in brass and 
              take bets on it. 1) No serious money for ferret research will be made 
              available until big business catches a whiff of profit, 2) No serious 
              advances in ferret diseases such as adrenal disease will be made until 
              serious research funds are made available, and 3) No serious political 
              power will be welded by the ferret community until it speaks with 
              one voice instead of 20. Or 21. Bob C and 20 MO Silly Snapping FurSnakes 
               ------------------------------ Date: Fri, 6 Mar 1998 04:16:19 -0600 From: Bob Church <[email protected]>
 Subject: Bob C: Ok, some more Adrenal Questions
 Q: "Do you really think [kibbled foods] can cause 
              adrenal problems...and is there any type of evidence?" A: Most of my comments will be held off for a future 
              post series on diet. But as for the adrenal-specific part, it is difficult 
              to say. I think without research, ANY discussion is error-prone, so 
              I am reluctant to say anything is certain. But here are some things 
              to consider; bear in mind not a single point has been proven to cause 
              any problem in ferrets. Using pet ads, ferret books and articles as a window 
              to the past, there was virtually *no* mention of adrenal problems 
              until the mid-to-late 1980s. Those articles initially treated adrenal 
              problems as a rarity, but that started to change in the late 1990s-to-early 
              1990s. Now it may be one of the most common reason for surgery in 
              ferrets, rivaling abdominal blockages (and excluding neutering). NOW, 
              either all the ferrets in the Americas since the mid-1980s are cousins 
              and the traits is a genetic defect, or there must be an environmental 
              cause or trigger. Using that same window of history, kibbled foods 
              for ferrets have also become quite popular. Create a graph in your 
              mind. One line the is increase in adrenal disease in the last 20 years. 
              The other line is the increase in the use of kibbled foods (for ferrets) 
              during the same period of time. I have made such a rough chart, and 
              I have to tell you, the lines parallel each other. They are correlated. 
              Add a third line for the popularity of ferrets in the Americas. That 
              line also rises, but it rises at a lower curve than the other two 
              lines. They are not correlated. Adrenal disease is rising at a faster 
              rate than ferrets are becoming pets. Ok, the lines are correlated, but are they cause 
              and effect? That I don't know, and it is definitely an area where 
              research is needed. Maybe ALL kibbled diets are missing something 
              and those ferrets suffering adrenal disease are lacking a specific 
              trace nutrient. Maybe the meat used to make the kibble contains nutrients 
              that *IN EXCESS* causes adrenal disease, and the ferrets are suffering 
              from overnutrition of a specific nutrient. This has happened in people, 
              where hamburger containing excess thyroid hormones seriously--and 
              negatively--impacted growing children. Maybe the kidneys added to 
              the kibble still have some adrenal tissue added, and the hormones 
              are not being destroyed during manufacturing. I can't tell you what 
              is happening, but I do know what a fish smells like when it rots, 
              and this mess has a very strange odor. Q: "Can't inbreeding at [MF] have caused adrenal 
              problems?" A: So why do non-MF ferrets get adrenal disease? 
              I'll let you in on a secret. Ferrets in Britain are often quite inbred, 
              and father X daughter, mother X son crosses are far more common than 
              you might think. The practice is normally done to "set" a characteristic, 
              such as size, temperament or build. They have an adrenal disease rate 
              far lower than our own. Also, IF adrenal disease was the result of 
              a random mutation in American stock, and increased in the population 
              because of inbreeding, why is it so prevailant in both MF and non-MF 
              ferrets? If the trait was dominant, all the offspring of an host parent 
              would have adrenal disease, but they don't. And you would expect at 
              least 25% to have the disease if it were a recessive trait and both 
              parents carried only a single copy of the defective gene, but even 
              that is way too high of a figure. At the very worse, adrenal disease 
              effects 10% of the population (FMLality), and the figure is probably 
              less than 3% (Reality). And it would *never* show at all if it were 
              recessive and only a single parent had the gene. This is not strictly 
              a genetic problem, so inbreeding is probably not much of a factor. 
              The key to the problem has to be something in the environment, and 
              will probably be found in the lifeway differences between American 
              and other ferrets. Genetics might be behind the locked door, but the 
              key is hidden somewhere in the environment. Q: "How has [the adrenal posts] changed your opinions?" A: Before I really looked into the question, I 
              suspected MF breeding practices, photoperiods and diet or some combination. 
              Now I realize the problem is a bit more complicated than that. Perhaps 
              I was secretly hoping I could brilliantly discover some sort of commonality 
              that would let me pontificate a cure. I literally have almost everything written on adrenal 
              disease in ferrets, and lots of stuff on comparable diseases in other 
              animals, yet I cannot definitely say one aspect is more important 
              than another. Its a black box where everything goes in and adrenal 
              disease comes out, and I'm just as much in the dark as the rest of 
              you. But here is where I stick my butt out for all to 
              flame. IF I am right and the key in something in the American ferret 
              lifeway, adrenal disease will begin to increase all over the world 
              as our ferret lifeway practices are exported. IF I am right, then 
              adrenal disease will continue to increase out of proportion to the 
              number of ferrets being produced and yearly totals of adrenal treatments 
              will increase. IF I am wrong, then the status quo will be maintained, 
              those breeders importing foreign blood into their ferret lines will 
              reduce the incidence of adrenal disease in their lineage, and adrenal 
              disease outside of the Americas will remain rare. 
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