322 CLINICAL CONSIDERATIONS 



than to the comparatively lesser changes demonstrable in the 

 adrenal. Wiesel 678 attributed Addison's disease to destruction 

 of the medulla rather than to the cortex. 



In view of recent developments in our knowledge of the 

 relative functions of the cortex and medulla, we must accept 

 the view that the cortex is responsible for most of the symptoms 

 and for the fatal outcome of Addison's disease. As we have 

 already seen, it is doubtful if the medulla is even responsible 

 for the pigmentation. The symptoms of the disease are identi- 

 cal to those observed in experimental cortical insufficiency. 

 We may, therefore, consider damage to the cortex or to its 

 secretion as the sole responsible agent for the disease. It is 

 possible, however, that a diseased medulla may cause destruc- 

 tion of the cortical hormone; for, as we have seen (Chapter II), 

 the blood from the cortex which presumably carries the hor- 

 mone is drained into the medulla. Wide involvement of the 

 medulla might easily cause destruction of the hormone as it 

 passes through the diseased tissue. This would explain the 

 existence of cases of Addison's disease in which the adrenal 

 defect was limited to the chromaphil tissue, but the evidence 

 for the existence of such cases is very meager. It is more likely 

 that the clinical diagnoses were in error in these cases. 



DIAGNOSIS 



It may appear from the preceding sections that diagnosis in 

 Addison's disease is a comparatively simple matter. The pig- 

 mentation, asthenia, hypotension, gastric disturbances, etc. 

 define a clinical picture to which many cases closely conform. 

 However, in a certain group of cases an error in diagnosis may 

 easily result. Pigmentation closely resembling that of Addi- 

 son's disease, as has already been noted, is frequent in other 

 conditions. Asthenia is common in protracted debilitating 

 illnesses as are also hypotension and digestive disturbances. 

 Hence the occurrence of this group of symptoms may often, 



