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become pigmented first, then any site of compression and the flexures of the joints. The mucous membrane of the mouth, conjunctivæ, and vagina show evidence of pigmentation. The sclera and the roots of the nails do not become pigmented, the soles of the feet and palms of the hands are not discolored until late in the disease.
Gastric irritability, nausea, and sometimes an obstinate diarrhea (apparently causeless) occur early. Dizziness and severe fainting spells are frequent and may terminate life. Asthenia is usually marked and apparently out of all proportion to the general condition (Osler). About one third of the cases complain of pain and tenderness in the epigastric and lumbar regions. The muscles become flabby but emaciation is very slight. The temperature is usually subnormal, the pulse weak and the extremities cold. The blood not uncommonly contains free pigment granules, and the red blood-corpuscles may be diminished in size and decreased in amount.
Diagnosis. The disease is not likely to be confounded with any other after pigmentation occurs. Bronzing from the sun's rays, discoloration from nitrate of silver, icterus, the patchy discoloration of pregnancy, and the ashen tint of certain hepatic and pancreatic disorders are only to be borne in mind to be differentiated. Pityriasis nigra is accompanied by itching and desquamation which does not occur in melasma suprarenale.
Prognosis. The disease varies in duration from a few months to ten years. It has been classed as always fatal ; death results from asthenia, diarrhea, convulsions, and coma.
The following case has been under observation for about eight months. Mr. C., aged fifty-five years; occupation, teamster; family history good, saving an epileptic son. Physical examination showed, upon inspection, skin of body and limbs a lemon-yellow; face and hands dark bronze; mucous membrane of mouth and conjunctiva brownish red; hair black (so from childhood), also epigastric pulsation. Palpation, percussion, and auscultation revealed tenderness in epigastric and lumbar regions; both kidneys elongated and tender; also a cylindrical aneurism of the abdominal aorta. A history of continuous epigastric and lumbar pain, frequent faint spells without loss of consciousness, and loss of strength with feeling of weariness. Diarrhea without any assignable cause would occur, and was very persistent; nausea was variable and the mouth constantly filled with slime. The joints ached at times; and the epigastric pains are now continuous downward
over both iliac regions and upward and especially toward left arm. (It is presumed these pains are aneurismal in origin.)
Attacks amounting almost to syncope, with cold, clammy sweats and muscular twitching followed by slight fever and bounding pulse, averaging about ninety beats per minute, has occurred at various intervals. (Twice when the treatment, consisting of the extract of the suprarenal gland, had been withheld ten and fourteen days respectively these attacks occurred.) The urinary symptoms are frequent passing of bright red, acid urine, containing uric acid in the proportion of 1.43 to urea; also uroerthryn, melanin, biliary coloring matters, and indican in excess.
The eatment has been the iodide of potassium and the extract of suprarenal gland. The iodide was exhibited two weeks before the extract and seemed to ameliorate the epigastric and lumbar pains, which probably depended upon the aneurism. The discoloration and dizziness remained. The extract was then prescribed in doses representing one twelfth of the suprarenal gland of a sheep, to be taken three times daily; the discoloration rapidly disappeared from the body and slowly from the face and hands; after about three weeks exhibition of the drug the dizziness became milder and was less frequent in occurrence.
The pathology of morbus Addisonii is very uncertain, since cases are reported where the solar plexus was alone involved, where the suprarenal bodies only were diseased, where a single suprarenal gland was affected (Sajous' Annual, '94), and finally cases where marked changes in the suprarenal bodies have been found upon post-mortem exainination, where clinically no symptoms of the disease have been observed (Adami). Since either the sympathetic or adrenals are always found affected, and since the sympathetic controls the physiologic action of the gland (?), it appears probable that the symptoms of the disease are produced by either a real or a relative “glandular inadequacy."
The sympathetic excites a tonic action upon the walls of the bloodvessels, causing rhythmical contractions; if, however, the nerve be divided dilatation of the vessels with consequent congestion follows. In the case of this patient the aneurism has been recognized for the remarkable period of thirty-four years.*
At the age of fourteen the patient felt something give way in the abdomen while straining to save his father from being crushed by a
* Dr. Kalfus, now deceased, diagnosed aneurism in 1864.
log. In addition to the aneurism there is a history of traumatic injury having occurred, about twenty-six or twenty-seven years ago, that caused depression of the sternum just above the xiphoid cartilage. It seems possible in this case interference with the sympathetic resulted either from traumatism or from pressure from aneurism, causing both functional and morbid changes in the suprarenal glands; or the aneurism may have caused the changes from direct pressure, at least upon the left suprarenal gland.
In those cases where the sympathetic has been found involved and the suprarenal remained intact, it would seem possible the symptoms resulted from simply a lessened production of the suprarenal principle analogous to functional dyspepsia. In those cases where even extensive changes have occurred in the suprarenal gland no symptoms of the disease were recognized, it must be supposed a sufficient functional activity existed to meet the demands of the system. Many cases analogous to this may be cited; for instance, myxedema results from enucleation of the thyroid glands, yet engrafting even small portions of a gland anywhere within the system causes the symptoms to subside; ovariotomy may be followed by amenorrhea, but if a portion of an ovary be left, menstruation continues; likewise complete castration causes atrophy and loss of function in the glans penis, but if the castration be incomplete, the penis remains normal and functionates. Believing, therefore, that either primarily or secondarily the actual cause of Addison's disease is the absence of adequate suprarenal principle in the system, it is expected an artificial supply of this principle will mitigate the symptoms at least in those cases where the primary cause is not itself fatal; that is, when pressure is the exciting cause and there is an absence of tuberculosis or carcinoma.
A DEATH FROM CHRONIC STRYCHNIA POISONING.*
BY A. H. FALCONER, M. D. Patient, female, aged thirty-five, married, three children. I saw her first on May 1, 1898. Symptoms were as follows: She was very weak, ached all over, especially on top of the head; a large, coated tongue with indentations on sides; vertigo; weak pulse but regular; temperature 99°, pulse 112; chilly sensations, constipation and every other
*Reported at the Louisville Society of Medicine, June 6, 1898.
symptom of malaria. So, thinking that was what I had to deal with, I put her on a malarial treatment. She began having these symptoms about three or four weeks ago and gradually grew weaker. She said when she took a short walk, just around the square, her husband would have to support her before they got back to the house, especially when she got to the steps; then afterward she seemed to have something in front of her eyes. She could not see well for a few minutes.
May 2d I saw lier, and still continued my malarial treatment; and on the afternoon of the 2d she began to complain of some cramps in limbs, but not severe. So, thinking that they would soon disappear, I paid but little attention to them. On May 3d saw her about 9 A. M. She was then complaining of about the same symptoms as before, except a little nauseated. I at once discontinued the use of the iron she was on, thinking that had nauseated her a little. I saw her again that afternoon, and she was very much nauseated, could not even retain water on her stomach. I then discontinued all of my present treatment, and tried hot water to quiet her stomach without any results, so then put her on sodii bicarbonatis and aquæ menthæ pip. àā 2 ounces, teaspoonful every five minutes, and succeeded in quieting her nausea by bedtime that night; and after this she had nothing until I saw her the next morning (May 4th) when I received a message about 4 o'clock A. M. to call at once, that she was worse. I responded at once, and upon my arrival found her eyes fixed, mouth a little open, teeth showing, stiffness in the back of neck, and the fingers of both hands were contracted very firmly down in the palms of the hands, so much so that they could not be removed. These contractions were clonic; at times she could straighten the fingers out almost full length. All during these contractions the patient was thoroughly conscious. Her tongue was swollen and a little protruded, which interfered with her talking to some extent. All these symptoms came on gradually. So then I decided that I had something more serious than malaria. Dr. J. W. Guest was called in consultation at this time, and we together proceeded to make a thorough examination of every organ, and to inquire more fully into the previous history of the case. We found the lungs, heart, liver, and every organ in a good condition, except the heart was still weak. But upon examining further into the previous history of the case we learned that she had been on strychnia in tablet form, one thirtieth grain each, for eight months four times a day. She said they were prescribed for her for nervousness. So, after hearing this,
and knowing that every other organ of the body was in good condition, and the symptoms we had while they indicated strychnia poisoning they were not that of acute poisoning. We then decided that we had a case of chronic strychnia poisoning, caused by an overaccumulation of the drug, with a gradual outburst. We then gave her hypodermatically one eighth grain pilocarpine mur. at 11 o'clock A. M., and ordered soapsuds enemas every two hours, and in about an hour she was perspiring profusely. At 12 o'clock she was removed to the Norton Infirmary. Upon her arrival there pulse was 122, temperature 100.2°; by evening temperature fell to 99.2°, and pulse was 114. Kept up the enemas all day, each returning well colored, and particles of fecal matter in them. Profuse perspiration continued from the one dose of pilocarpine until 9 P. M. Hare states the sweating period is from three to five hours, but this lasted ten hours.
Kidneys acted normally, about four or five times a day. Night of the 4th slept very little; in no pain, but could not go to sleep. She never did complain of a single pain from this on. Morning of the 5th, very restless, still very weak. Ordered nourishment and whisky by the mouth every two hours, also .on grain nitroglycerine hypodermatically every four hours and enemas stopped. Very nervous all day, but became quiet about bedtime. Temperature ranging from 98° to 99.6°; pulse 110 to 120. Night 5th slept fairly well. I saw her early on 6th, she was feeling very well. Contractions in hands all disappeared, eyes about natural, but teeth still showing some, and tongue swollen still; pulse very weak; patient delirious. Ordered nourishment and whisky same, and gave nitroglycerine every two hours. At 1:30 urinated involuntarily; constipated very badly, given five grains of calomel, followed by Sedlitz powder every two hours, until moved. Three powders were taken before calomel acted. Had four large, dark, thin stools, last one only partly formed. On 6th pulse range 108 to 120, teinperature 98° to 98.2° in axilla, respiration 20 to 28. Slept ten to twenty minutes at a time during the day, and fairly well that night. On morning of the 7th very restless, and complaining of being tired, and some headache. Continued whisky with my nitroglycerine and nourishment the same. Patient very restless up to i P.M., then slept a great deal during the afternoon, but only a few minutes at a time. The case was seen by Dr. J. W. Guest once a day in consultation, and each time she was examined thoroughly for complications and to see if another diagnosis could be made, but without any