ADDISON S DISEASE 339 



weeks asthenia, adynamia, pigmentations that were iron-free, and only a 

 slight depression of the blood-pressure. Also psychic disturbances (at first 

 more excitement, then apathy) made their appearance. Autopsy showed 

 a scirrhous carcinoma of the pylorus with metastases into the retroperitoneal 

 tissue, especially at the hilus of the left kidney, into the lungs and pleura, and 

 bilateral thrombosis of the suprarenal. The older of these could very well 

 have occurred simultaneous with the beginning of the Addison's disease. 



Moreover, sometimes in the subacute cases there is observed graded 

 [schubweises] occurrence of the stormy manifestations. Chronic Addi- 

 son's disease mostly shows remissions, in which also the pigmentation may 

 retrogress. Cases that have lasted ten years are on record. As the remis- 

 sions may have lasted for years, we must be cautious as to our assertions 

 that an individual case has been cured. 



Such individuals with chronic Addison's disease are for the most part 

 very labile; physical exertion, excitements or slight complicating affections 

 may lead to a fatal collapse. 



As an example of the chronic course, I cite the following case: 



Observation XLVI. H. K., forty-two years. Entered the clinic Nov., 1911. No 

 tuberculous taint; the family, however, shows the presence of gout. The illness began 

 ten years ago, when a gradually increasing brown coloration of the skin became ap- 

 parent; during the first years the coloration was extraordinarily intense, the greater part 

 of the skin, but especially that of the face, the neck, hands and forearms being deep 

 brown a bronze color. Since that time the brown coloration has persisted in varying 

 intensity. At that time the patient spent a year at Davos, as the lungs had become 

 affected. Ten years ago an attack of articular rheumatism that affected especially the 

 joints of the feet and toes. Since that time several attacks, two or three times a year, 

 in which the most different joints are involved. At present such an attack is in prog- 

 ress after an interval of some years. Loss of 12 kg. weight during the last half year. 



On examination, it was found that the skin of the whole body shows a brown colora- 

 tion, which is especially intense on the extensor surface of the forearm, on the backs of 

 the hands, on the face and neck, and on the genitalia and inguinal region. The brown 

 coloration is partly diffuse, partly more circumscribed in spots, the individual spots at- 

 taining the size of a lentil. Mucous membranes of the lips, mouth, and throat show 

 numerous mustard-seed-sized, irregularly limited brownish-black spots, which are espe- 

 cially distinct on the mucous membrane of the cheeks. The mucous membranes are 

 pale, the skin is dry, the percussion sound over the left pulmonary apex is shortened, the 

 vesicular murmur weakened; no rales. The cardiac dulness is rather small, the heart- 

 sounds are clear, the blood-pressure, according to Gartner, 60, liver and spleen not enlarged. 



Several joints are reddened, swollen and painful, especially both knee-joints, right 

 great toe-joint, left ankle-joint, left shoulder-joint, right elbow-joint and left hand-joint. 



No uric acid demonstrable in blood. 



Traces only of albumin in the urine. 



Temperature up to over 38. 



Estimation of sugar in the blood (Bernstein} 0.067 per cent. 



Leucocyte count normal (8 per cent, eosinophiles). We are here dealing with the 

 chronic Addison's disease, that has existed for ten years and that shows long remissions. 

 During the last years the condition is apparently rather stationary, lately a new exacer- 



