338 THE DISEASES OF THE SUPRARENAL APPARATUS 



assume a bronze tint. Pigment displacements are less frequent. The pig- 

 mentations of the mucous membranes are almost always spot-like and 

 blackish-blue. They are found on the borders of the lips, on the mucous 

 membranes of the cheeks, on the soft palate and on the border of the tongue. 

 Pigmentations of the vaginal and rectal mucous membranes are also observed. 

 The skin pigment lies in the deeper layers of the rete Malpighii and is iron- 

 free. In rare cases there is observed also a combination of Addison's disease 

 with hemochromatosis (Fod, Bittorf, and others). The pigmentation is ex- 

 traordinarily frequent. In the statistics of Lewin, based on five hundred 

 sixty-one autopsied cases, it was found in 72 per cent., and Bittorf believes 

 that these figures are too low. 



The course of Addison's disease is very manifold. There are peracute 

 cases in which destruction of suprarenal is brought about by hemorrhages, 

 thrombosis, etc.; in these cases death may occur in a few days with stormy 

 cerebral and intestinal manifestations. Pigmentation is absent. 



A short time ago Brodnitz reported an interesting case which I shall repeat 

 in detail. It was that of a thirty-six-year-old, strongly built, markedly fat 

 man, previously healthy. Two and four years ago there suddenly occurred 

 violent intestinal colics, which ceased after a few hours, and were followed 

 only by a marked loss of strength. Also at present such a colic has come on 

 quite suddenly. The facial expression is anxious, the pulse hard and full, 

 50-60 beats per minute, the temperature normal or slightly subnormal. No 

 improvement on injection of morphine. This condition lasted two days and 

 was then followed by an operation. On the jejunum and ileum were found 

 columnar contractions of 10-20 cm. of the intestine at three places. Other- 

 wise conditions were normal. In the course of the fourth day manifestations 

 of peritonitis made their appearance. Tympanites appeared, the pulse was 

 soft, thread-like, very rapid. Vomiting, temperature increased to 39C. 

 Death on the fifth day. At autopsy was found marked inflation of the 

 stomach and duodenum, the small intestines, and the colon. No peritonitis. 

 Complete destruction of the right suprarenal, partial destruction of the left. 

 On microscopical examination the left suprarenal at one place showed marked 

 development of the connective tissue, with hemorrhagic pigment, in brief 

 signs of a previous hemorrhage. 



As a further example I cite the case of Karakaschejf. A young man of 

 eighteen years became sick suddenly with pains in the head and abdomen 

 and felt very ill, but nevertheless went about. The manifestations became 

 stronger only after three days, when vomiting ensued, and finally loss of con- 

 sciousness. Autopsy showed old total destruction of the right suprarenal, 

 apparently through thrombosis and a quite fresh infarction of the left supra- 

 renal. Death had occurred five days after the beginning of the illness. 



In other cases the affection lasts for weeks. Here the adynamia comes 

 more in the foreground. In the case of Straub there developed within two 



