ADDISON'S DISEASE This disease has been brought by its discoverer into casual relation with changes in the suprarenals. In its essential parts his original description is probably still perfectly valid. Neusser, to-day probably the best authority on the subject, characterizes the disease as follows:— " There is idiopathic anamiia, accompanied by groat adynamia and apathy, disturbances on the part of the digestive tract and the nervous system, and accompanied by a bronze discoloration of the skin. The disease has a chronic course, with progressive caehexia, but often shows turbulent symptoms, such as intractible diarrhcea, coma, or convulsions, and terminates inevitably in death." The disease is rare in infancy. Monti has found among 290 cases, 11 in children. Family tendency has not been established.
Symptomatology and Diagnosis.—In children there is emaciation, pallor, and asthenia, but the asthenia is greater than would be expected from the degree of wasting. Gastro-intestinal disturbances gradually appear which may vary from the mildest indigestion to the most in tractible vomiting and profuse diarrhcea. Pigmentation, which in most cases determines the diagnosis, often appears quite late. The pigmentation varies widely in degree. Sometimes there are only a few pigmented spots upon the surface of the palate, which may be only too easily overlooked, so that, wherever Addison's Disease is suspected this region should receive the closest scrutiny. In othcr cases the pigmentation is so pronounced that almost the entire cutaneous surface is bronze-colored.
The temperature may be subnormal, but febrile paroxysms have also been described. Nervous symptoms, headache, vertigo, convulsions, —are part of the clinical history. According to Gerhardt, convulsions are seen in two-fif ths of the cases in childhood. Acute paralyses (pero neus palsy) also occur.
The duration of the disease is variable. Generally it lasts months, less frequently years. In one case, described by Netter, the process was very acute. The child was four years old, perfectly healthy, and was suddenly taken ill with vomiting, diarrhcea, apathy, and depres sion. A diagnosis of peritonitis was made, and the child died after three days, when the autopsy revealed tuberculous foci in the supra renal glands. This case illustrates the great difficulty of establishing the exact diagnosis in diseases of the suprarenals, for the very reason that their symptoms are so extraordinarily ambiguous.
Leube, in his well-known "diagnosis" remarks in regard to the suprarenals that their diseases are not as yet subjects for diagnosis.
Pathological Anatomy and almost all eases of Addison's Disease the suprarenals have been found to be affected by tuberculosis. The tuberculous infection was either total in both glands so that there was no normal tissue to be found, or else small foci existed in one or both organs.
Tuberculosis of the suprarenal glands is distinguished by abundant formation of granulation and scar tissue. The process may be emi nently chronic, until finally the entire suprarenal gland may be changed into scar tissue, in which only sparse cascous portions may still be discovered, or the scar formation may extend through the capsule of the suprarenal, and affect the cadiac axis as well, a fact which may have an important bearing upon pathogenesis.
Other pathological processes of the suprarenals (tumors, atrophy, etc.) were found in a small number of crises.
The fact that there do undoubtedly occur typical cases of this dis ease in which the suprarenal glands are sound, made it necessary to seek the cause of Addison's Disease not only in disturbance in the functions of the suprarenals, but also in those of the sympathetic ner vous system. From a careful analysis of heretofore observed cases, and on the ground of the results obtained by experhnentrd pathological research, and by physiological chemistry, Neusser arrives at the follow ing opinion as to the character of Addison's Discase:—"The supra renal gland is one which produces an internal secretion, whose func tion is to counteract the toxic products of the metabolic activity of other organs, and to produce a substance which is indispensable above all to the preservation of the normal tone and to the nourishment of the sympathetic system. Addison's complex of symptoms is in every case dependent upon injury to, and finally entire suspension of the function of the suprarenal glands. This may result either from an ana tomical disease of the glands themselves, or else their secreting and antitoxic action may be hindered and finally paralysed by disturbance of the conducting tract which controls their function. This tract runs from the spinal marrow through the splanchnic and cceliac ganglion. In this manner the result will be on the one hand a nutritive and func tional disturbance of the sympathetic system, and on the other, a gen era] auto-intoxication. Besides these two principal factors, a local damage to the abdominal sympathetic, by extension of the pathologi cal process to it, plays in many cases a part in the production of sundry Addisonian symptoms. Pigmentation of the skin and mucous mem branes is not an integral part of Addison's complex; it may have diag nostic, but it does not have absolute importance. Pigmentation is not a direct, but an indirect symptom of suprarenal disease. It is caused only through the medium of the sympathetic, damaged gener ally or locally." As to the pathogenesis of Addison's Disease, even at this day, opinions arc widely at variance. Wiese] from the examination of five cases, sees the essential factor in the complete destruction of the cells of the chromatin system. Karakascheff, who had worked out the problem in Marchand's Institute, awards to the cortex of the supra renals the whole importance in the origin of the disease. He infers this front the observation lie made upon a five-year-old child who died of atrophy, independent of any disease of the suprarenal gland, whose autopsy revealed extensive haemorrhage, which had existed since birth, in the medullary substance, which was thereby completely destroyed. The cortical substance was intact. According to this, it would seem that the lowering of blood pressure which can always be proven clini cally, might explain the relation of the medullary substance to Addi son's Disease.
Therapeutics.—Up to this time there is no record of recovery from this condition. Organotherapy with the numerous commercial preparations on the market has signally failed. The gastro-intestinal and nervous manifestations must be treated symptomatically.