ADDISON'S DISEASE 303 



as yet too crude to enable us, except in rare instances, to establish an exact 

 diagnosis intra vitam of the underlying etiological factor, or of the ana- 

 tomical changes present in the suprarenal glands (interrenal and chroma- 

 phil systems). 



Prognosis. The prognosis is always unfavorable, death usually oc- 

 curring within from two to four years following the onset of symptoms. 

 Instances of recovery have, however, been rather commonly reported. 

 In cases that begin insidiously with mild symptoms, the disease may be 

 protracted for ten or fifteen years, especially when associated with an 

 uncomplicated suprarenal tuberculosis, but the prognosis must always 

 be guarded, since death may occur at any time during a syncopal attack, 

 or the disease become transformed into an acute type, leading to a speedy 

 termination, at any stage of its course. According to Eisner the prog- 

 nosis is apt to be better, so far as length of life is concerned, in propor- 

 tion to the extent of the pigment deposit, chronic cases usually showing 

 the greatest pigmentation. Unfavorable symptoms include progressive 

 emaciation, marked hypothermia, persistent hypotension, severe diar- 

 rhea, anemia, large mononuclear lymphocytosis ; hypoglycemia, and a high 

 sugar tolerance ; intermittent hypothermia and pyrexia ; the development 

 of mania or melancholia, The presence of a normal blood pressure and 

 of a normal blood sugar content are regarded as favorable signs. Schles- 

 inger believes that epinephrin injections may prove helpful in making 

 a prognosis. He states that if the blood pressure shows no rise following 

 such injections, death may be expected at an early period. Similarly, 

 Massalongo regards the anemic vasomotor skin reflex (ligne blanche sur- 

 renale of Sergent) as having some prognostic value, since its maximum 

 frequency is met with in casos of serious import. 



In many of the cases of recovery reported in the literature, consider- 

 able doubt has been entertained in regard to the correctness of the diag- 

 nosis. Several of these cases have probably been syphilitic in origin. A 

 number of cases have been reported as cured following suprarenal therapy. 

 It is well established that such treatment may often produce a tempor- 

 ary amelioration of the symptoms, but in all such reports, the possibility 

 of the usual occurrence of remission and intermissions of the symptoms, 

 without such therapy, should be considered. Bittorf(a) has described 

 cures in cases associated with hypernephroma, and Oestreich operative cure 

 of a tuberculous suprarenal with tumor formation. Tieken has recently 

 reported a cure in a case, which was regarded as due to the interference of 

 suprarenal function by an inflammatory exudate extending from the pelvis 

 of the kidneys. It is, perhaps, significant that the great majority of re- 

 ported cures have occurred in cases in which the diagnosis has been open 

 to doubt, or in which some etiological factor, other than the common one, 

 tuberculous caseation of the suprarenals, has been present, Kraus believes 

 that all cases of tubercular origin terminate fatally. Other observers are 



