physician, to hyperacidity. The attack yielded somewhat to sodium bicarbonate, magnesium oxid and bismuth so that he was again able to return to his work. However, the weakness persisted and he was placed on digitalis. Subsequent to January 25, the salivary secretion was deficient, and he lacked appetite and could not relish food. He continued on suprarenal treatment; epinephrin solution 1: 1,000, 3 minims, twice a day hypodermically; rectal injections of %oo grain of the whole gland, and two capsules, 10 grains each, of whole gland, by mouth, at night. In February, the weaknesj and shortness of breath became more pronounced. He suffered from pain in the left upper portion of the chest which Dr. Sachs called "low pressure angina." The pain was relieved by heat, exertion, food and nitroglycerin.In March, 1921, Dr. Muirhead returned to the clinic, complaining of extreme weakness which confined him to bed, and of pain in the left shoulder. The pigmentation was marked. He was extremely asthenic, and suffered almost constantly from gastro-intestinal symptoms, especially burning in the stomach. The heart was slightly enlarged and the sounds were of poor quality. An electrocardiogram disclosed a rate of 92, sinus tachycardia, notched QRS complex in all leads, arborization block, and slight right ventricular preponderance. The blood pressure was 86 systolic and 54 diastolic; the blood urea was 56 mg. for each hundred cubic centimeters, and the uric acid 2.8 mg. The hemoglobin was 68 per cent., and the erythrocytes numbered 3,820,000. The patient ate very sparingly, and toward the end of his stay developed a mild acidosis. He left the clinic, March 23, unimproved. The subsequent course of the disease is submitted in Dr. Sachs' report:"The blood pressure just prior to his death was 84 systolic and 60 diastolic. Dr. Muirhead had a mild acidosis from time to time, for which he was given alkalis. Alkalis during the latter part of his illness distressed him greatly and were discontinued. His gastric acidity changed from a hyperacidity to a hypo-acidity. He progressively became more asthenic until it became difficult for him to swallow. He gradually lapsed into coma, and died, April 26, 1921."
REVIEW OF CASEClinically, Dr. Muirhead presented a typical, slowly progressing case of chronic. Addison's disease with pigmentation, marked asthenia, intestinal discomfort, and low blood pressure. He gave a questionable history of renal tuberculosis; but tuberculosis was not borne out at operation, a right side nephrectomy being performed in 1918. Subsequent to the nephrectomy, gout developed; the patient suffered from typical attacks of great severity, involving the metatarsophalangeal joints associated with high level of uric acid in the blood. Both the gout and blood uric acid responded promptly and permanently to a low purin diet. It is of interest to speculate on whether or not the removal of the kidney was a factor in the increase of the blood uric acid and in the development of gout.The patient's improvement under . treatment wit...
