If this view be accepted, we must necessarily drop the belief that Addison's disease is uniformly the result of a specific lesion in the adrenals, as has been long taught in the Guy's Hospital School, and we must enlarge our conception of the etiology of the disease.
Our present knowledge forbids the acceptance of the simple unity of Addison's disease, and the fact that gross changes in the abdomi nal sympathetic system, without implication of the adrenals, have been observed lends additional support to the larger and more com prehensive view of the pathology of this condition.
A case reported by Dr. Hadden 8 is noteworthy in this connection. He found the adrenals destroyed by a fibroid proce6 or cirrhosis in one example of Addison's disease, and the semilunar ganglion in filtrated with similar fibro-nuclear growths. He believed that the sympathetic fibres were necessarily much involved in the process.
It has been sought to explain the occurrence of atrophy of one or both of the adrenals by supposing that the wasting is the ultimate stage of the more commonly recognized enlarged condition. I am not prepared to accept this view. If we regard the most frequent lesion of the adrenals in Addison's disease as one of a tubercular na ture, we are hardly warranted in expecting atrophy as the ultimate outcome of such a process iu any case. This is not the experience of the dead-house in other examples of tubercular processes. They are apt to leave readily recognizable changes behind them, gross indeed, even if obsoloseent.
Dr. Saundby, of Birmingham, has recently suggested, as did Dr. Duclos, of Tours, that the general symptoms of Addison's disease are explicable on the view that some poison is generated in the blood, possibly the result of some imperfect pigmentary metamorphosis. At the present time, we can only state that if this be the case we have no certain knowledge of such peccant material, and it must remain for future researches to bring it to light.
The question of any microbic elements capable of generating a specific poison must not be left out of consideration, although there are no facts to justify any opinions on the matter. The existence of the tubercular bacillus is sufficiently proved as the most certain and frequent exciting cause of the primary lesion of the adrenals in Addi son's disease. The remarkable fact remains that in cases of general tuberculosis these organs appear to be little if at all involved, and are certainly not to be reckoned amongst the most vulnerable tissues for invasion by the bacilli of tubercle.
The fact that the symptomatology of Addison's disease may vary materially in different cases in respect of nervous symptoms and of the presence or absence of melasma has been pointed out, sugges-: tively, by Dr. Bedford Fenwick, and will again be alluded to. He is of opinion that cortical disease primarily and mainly involving the adrenal bodies entails melasma, while medullary disease gives rise to graver and more prominent nervous symptoms. The anatomical and physiological relations of the two parts of these organs appear to warrant this conception.
It is certain that, as has been already indicated, acute cases, of rapidly fatal ending, are often devoid of pigmentary symptoms.
Further investigations in this direction appear to be necessary, but we may believe that this distinction is rather too fine, and that gross disease in the cortical portion will very soon involve the medul lary district, and vice versa.
There can be little doubt that a large part of the symptom atology of Addison's disease depends upon the morbid condition of the ab dominal nerve-centres. Many well-known facts come in to support this belief. The occurrence of nausea, gastric crises, vomiting, de pressed circulation, collapse, and sinking sensations are all consonant with the idea that these sympathetic centres and nerve-fibres are gravely involved. We have already enumerated their wide-spread connections, and shown how far-reaching may be the morbid radia tions from them. We have further noted the occurrence of pigmen tary changes in connection with chronic irritation of various abdomi nal organs innervated from the same source, and we have also seen that there is strong reason for believing that the adrenals in particu lar have to do with a very special variety of pigmentary metabolism in the system. We have also to bear in mind not only the proximity of these great vital nerve-centres to the adrenals, but the fact that these organs have an inordinate nervous supply among their inti mate tissues far exceeding that of any other viscera in the body. If many of the symptoms are due to what Dr. Goodhart terms "stran gling of the abdominal sympathetic," we not seldom find causes at work 'to induce this both in Addison's disease and iu some other morbid conditions, such as Hodgkin's disease, chronic inflammation of lymph-glands, and scirrhous cancer, and such examples have been sometimes recognized clinically, and determined after death.