ADDISON'S DISEASE 291 



ing disinclination for physical or mental effort. His friends may notice 

 that his complexion is becoming darker. Sooner or later, gastric disorders, 

 with loss of appetite, nausea, epigastric discomfort, constipation or diar- 

 rhea, occur with increasing frequency, and may lead him to consult a phy- 

 sician. Gradually these initial symptoms, mild at first, and without uni- 

 formity in the order of their appearance or progress, in different indi- 

 viduals, become sufficiently marked in degree to enable the clinician to 

 correlate them with the clinical entity of Addison's disease. 



Addison's admirable portrayal of the initial stages of the disease 

 merits quotation in this connection: "The patient, in most of the cases 

 I have seen, has been observed gradually to fall off in general health ; he be- 

 comes languid and weak, indisposed to either bodily or mental exertion; 

 the appetite is impaired or entirely lost; the whites of the eyes become 

 pearly; the pulse small and feeble, or perhaps somewhat large, but ex- 

 cessively soft and compressible; the body wastes, without, however, pre- 

 senting the dry and shrivelled skin and extreme emaciation usually at- 

 tendant on protracted malignant disease; slight pain or uneasiness is 

 from time to time referred to the region of the stomach, and there is 

 occasional actual vomiting, which in one instance was both urgent and 

 distressing ; and it is by no means uncommon for the patient to manifest 

 indications of disturbed cerebral circulation. We may, indeed, suspect 

 some malignant or strumous disease we may be led to inquire into 

 the condition of the so-called blood-making organs but we discover no 

 proof of organic changes anywhere ; no enlargement of the spleen, thyroid, 

 thymus or lymphatic glands; no evidence of renal disease, of purpura, 

 or previous exhausting diarrhea, or ague, or any long-continued exposure 

 to miasmatic influences; but with a more or less manifestation of the 

 symptoms already enumerated, we discover a most remarkable and, so 

 far as I know, characteristic discoloration taking place in the skin suffi- 

 ciently marked, indeed, as generally to have attracted the attention of the 

 patient himself, or of the patient's friends." 



The appearance of the cardinal symptoms may be accompanied, or pre- 

 ceded by, certain nervous and mental manifestations. The p&tient, as a 

 rule, becomes markedly apathetic and listless, and may exhibit mental 

 depression or increased irritability. The mental processes are retarded 

 and the memory shows signs of impairment. Occasionally neuralgic 

 pains in the lumbar region, or in the epigastrium, or extremities, occur; 

 cr, at times, headaches, fainting spells, tinnitus, vertigo and a more or 

 less stubborn insomnia. There is no fixed order in the sequence of symp- 

 toms. As a rule, however, the asthenia precedes the melanoderma but 

 not invariably. Occasionally the discoloration of the skin may be pres- 

 ent for months before the appearance of the other symptoms. In other 

 instances, the asthenia, gastro-intestinal disturbances and melanoderma 

 develop together. In the majority of cases, the symptoms progress slowly 



