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Duration of the Disease - Addisons Disease and Other

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DURATION OF THE DISEASE - ADDISON'S DISEASE AND OTHER No definite or uniform course has been observed. It is always difficult to determine the exact date of the on set of the malady, because the early symptoms may be slight and un noticed. The fact that exacerbations of the symptoms occur, with remissions leading to renewal of vital powers, has been already noted. There are acute and chronic varieties of the disorder. Many eases end fatally iu about eighteen months, others have been oh served to last for some years, and in one instance the disorder ran a course of seven years, no doubt illustrating the paroxysmal character from time to time.

Oita/Rion of the Urine.—There is nothing specially noteworthy to he recorded respecting the urine in Addison's disease. Careful anal yses have been made, and deficiency in the output of uric acid and urea has been generally observed. This is probably the result of di minished waste of tissue, which is the rule in this disorder. An ex cess of iudican (urohminatoporphyrin) has been rather frequently noted, but it is characteristic generally of some digestive disturbance, or of nervous exhaustion. It may be significant of adrenal disease owing to failure in blood-metabolism, and Dr. MacMunn is strongly of this opinion.

afialition. V Other Organs of the Body.—Tuberculosis is probably the most commonly associated morbid state, and nodules of cheesy or cretaceous matter, and groups of tubercles, may be found in the lungs or widely spread throughout the body. Tubercular disease of the spinal column, leading to abscess, is far from infrequent, and stands in definite relation to disease of the adrenals by reason of con tiguity. Injuries to the spine have often been noted as the first link in the chain of events leading up to Addison's disease. 'Spinal caries appears somewhat frequently to precede the disease.

The order of events in this ease may not improbably be as follows: As a result of injury, the spinal column is wrenched or damaged. Such mischief is more or less readily repaired and recovered from in healthy subjects. In so-called strumons persons, to whom a special vulnerability attaches, a low form of inflammatory process is set up, more particularly in the bodies of one or more vertebrae, leading to abscess. Bruising of vulnerable parts is now recognized as a condi tion which renders them liable to infection by such germs or bacilli as may find access to them. In this way a tubercular process may con ceivably be established, and this tends to spread, involving in due course the adrenal bodies.

of the stomach has been noted with some frequency, also ccchymoses and small ulcers. The former are due to overgrowths of lymphoid tissue around the gastric tubules. These probably soften and lead to the formation of small ulcerations. Enlargement of the solitary and agniluated glands of the small, and of the solitary glands of the large intestines has been not infrequently noticed. Addison noted this lesion.

The lympharia adjacent to the adrenals have been often found en larged, and imbedded in overgrowth of fibrous tissue. The mesen teric and retro-peritoneal glands are frequently enlarged, and some times caseous or firm, from overgrowth of Aroma and atrophy of glandular structure.

The spleen has been found enlarged, sometimes greatly so, dark, and softened, but with no great frequency. Clinically, splenic en largement is not commonly detected. Nothing has been noted re specting the condition of the thyroid body. Cerebral softening and sub-arachnoid effusion have been met with, also pericarditis with effusion. These are, however, only occasional and secondary changes, and form no part of the malady as commonly understood.

The liver presents no specially noteworthy changes, and the same may be affirmed in respect of the kidneys.

Without doubt, some of the most important associated morbid changes relate to the condition of the great abdominal nervous plex uses, and we must next direct careful attention to this. We have al ready seen how direct and intimate are the relations between the ad renals and this part of the nervous system. Careful dissections have repeatedly shown that the ganglia and branches of the abdominal sympathetic nerve are involved in the inflammatory processes which have taken place either primarily in the adrenals themselves, or have reached them by extension from other inflamed (and probably in fected) contiguous structures. Such dissections are extremely diffi cult to execute, requiring, as only those who have attempted them can know, great patience and anatomical knowledge. The semilunar ganglia have been found altered in structure, enlarged and redder than natural. Dense meshes of fibroid tissue have been observed enveloping them and the nerve-branches connected with them. This new growth proceeds from the connective-tissue capsular investment of the adrenals, and gradually invests and mats together the ganglia and delicate nerve-fibrils. The growth is generally very dense and hard, and the difficulty is to determine accurately what is nerve-matter and what is mere fibrous tissue. The supra-renal and solar plexuses thus become fused, as it were, into a matted felt of encroaching and enveloping fibrous overgrowth. The nerve-cells of the semilunar ganglia have been found opaque and granular, with traces of former hemorrhages into their structure. Branches of nerves proceeding to the adrenals from these ganglia have been seen enlarged, and in one instance Dr. Cayley found a branch of the great splanchnic nerve at least twice the size of a healthy nerve. This enlargement was due to increased fibrous growth in the nerve-sheath. In Dr. Tuckwell's dis section, which is now in the Museum of St. Bartholomew's Hospital,' it is seen that fibrous overgrowth caused matting of all the nervous plexuses, and this extended up the splanchnic and pneumogastric nerves, and became continuous with firm old adhesions which sur rounded the liver and spleen, and bound the upper half of the omen tum to the anterior abdominal wall. No change was found microscopi cally in the nerve-fibres proper, but the nerves have been noted as small in one case (Professor Tigri). We are thus in face of a pro liferating connective-tissue fibrosis, spreading over parts immediately contiguous to the adrenals, and part of this process must be regarded as entailing greater or lesser degrees of both neuritis and perineuritis.

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