of vision. Swelling and pain occurred in the legs and the dorsum of the feet. Thyroid therapy appeared to improve him.
Dr. E. A. Carmichael kindly asked me to see a fourth case, which was shown to the Section of Neurology of the Royal Society of Medicine on November 2, 1950. The patient was a young man in whom severe exophthalmos and clubbing had occurred without definite evidence of preceding thyrotoxicosis. X-rays did not, in this instance, show subperiosteal new bone formation on the phalanges and metacarpals.
The five cases are alike in that all occurred in males and all were associated with severe exophthalmos and with hypothyroidism. In the three cases first described a severe hypo- thyroidism supervened on a previous severe hyperthyroidism. There is some room for doubt as to whether this was so in Dr. Carmichael’s or in the present case. The evidence for a previous hyperthyroidism is incomplete. Thomas’s suggestion that the bone change is brought about by a sudden change in blood flow is hardly compatible with the fact that in Cushing’s case the changes set in seven years after operation. In the present case clubbing was already present when the diagnosis of thyrotoxicosis was made in 1932, but it only became severe (if relations are to be believed) seventeen years later. Moreover no such sudden change in blood flow is likely to have occurred, for the cardiovascular signs seem to have changed little during this period of time.
REFERENCES
CUSHING, E. H. (1937) Internat. Clin., 2, 200.
RYNEARSON, E. H., and SACASA, C. F. (1941) Proc. Staff Meet. Mayo Clin., 16, 353.
THOMAS, H. W. (1933) Arch. int. Med., 51, 571.
Mixed Type of Cushing’s Syndrome and Adrenogenital Syndrome due to Adrenal Cortical Carcinoma .- A. W. SPENCE, M.D.
A married woman, aged 47, with a five years’ history of profuse menstrual periods lasting for seven to ten days; fifteen months before admission to hospital her face began to become florid; six months later she developed dull aching substernal pain on exertion, menses became irregular and scanty, she began to gain in weight and observed excessive growth of hair on the face and body. Amenorrhea for seven months before admission.
On examination, plethoric, fat face with beard and moustache (shaved); Cushing type of obesity; petechial eruption over upper chest, neck and arms; hirsuties of body, forearms and legs and male type of pubic hair; B.P. 240/130; no purpuric striæ; no glycosuria; weight 12 st. 12 1b.
Investigations .- Blood count: R.B.C. 5,500,000, Hb 110%; colour-index 1.0; W.B.C. 10,000 (Differential normal).
Glucose tolerance: Fasting blood sugar 88 mg. %; blood sugar at half-hourly intervals after ingestion of 50 g. glucose-157 mg., 230 mg., 229 mg., 157 mg. %.
Basal metabolic rate: plus 43%. Serum phosphorus 3.2 mg. %. Serum chlorides 603 mg. % (as NaCl).
Urinary 17-ketosteroids: 42.5 mg. in twenty- four hours : it is of interest that dehydroiso- Serum sodium 356 mg. %. androsterone was not found. Serum potassium 21 .- 4 mg. %.
Urinary corticosteroids: 1.3 mg. in twenty- four hours.
Alkali reserve: 61.4 vols. CO2 per 100 c.c. serum.
Serum calcium 9.5 mg. %.
X-ray pituitary fossa normal.
X-ray dorsal and lumbar spine: no osteoporosis.
I.V.P .: right kidney appears rather ptosed; excretion normal.
X-ray after perirenal insufflation showed a circular shadow 5 cm. in diameter in the region of the right adrenal gland, suggestive of an adrenal tumour.
29.11.49: Left adrenal gland explored by Mr. Ellison Nash and found to be normal.
13.12.49: Removal of a tumour of the right adrenal gland, which histologically was a carcinoma. Fuchsinophil reaction negative.
18.12.49: Urinary 17-ketosteroids 6 mg. in twenty-four hours. B.M.R. plus 30%. Glucose tolerance: 110 mg. (fasting), 190, 215, 210, 130 mg. %
8.1.50: Discharged from hospital; plethora less and shedding hairs on the legs. Weight 11 st. 3 1b.
7.2.50: Period started and lasted seven days; B.P. 200/115. From this date periods regular. Glucose tolerance 108 (fasting), 210, 140, 102, 102 mg. %
12.6.50: 17-ketosteroids 2.1 mg./day.
26.10.50: 17-ketosteroids 5.0 mg./day. B.P. 180/85. Wt. 12 st. 9 1b. During the six months after adrenalectomy gradual loss of hair on arms, legs, back, chest and abdomen; hair on face not falling out, but comes out with tweezers; still shaves.
FEB .- ENDOCRIN. 2