ADDlSON'S DISEASE 295 



or evidence of a psychomotor retardation, may be one of the first signs 

 to arouse the suspicion of the patient's friends. In a case observed by 

 the writer, the wife of the patient had noticed for a year previous to the 

 admission of her husband to the hospital, that he had grown increasingly 

 more irritable and quarrelsome, that his memory was greatly impaired, 

 and his handwriting not so good as formerly, that he thought more slowly, 

 and that his speech, although distinct, was slower. The special senses, 

 especially smell, taste, and hearing, may occasionally show impairment. 

 Paresthesias have at times been noted. There appears to be no char- 

 acteristic alteration in the deep reflexes, although in a few instances they 

 have been found to be sluggish. 



As the disease progresses the cerebral manifestations become more 

 pronounced. The mental deterioration may even attain a grade of im- 

 becility, or, in isolated cases, a true dementia. Delirium is common to- 

 wards the end, and choreiform or epileptiform convulsions sometimes 

 occur. In a case reported by Langmead, which ran a rapidly fatal course, 

 convulsions and rigidity, and all the symptoms of a meningitis, were ob- 

 served. In general, marked psychical disturbances are more common 

 in the acute than in the chronic forms of the disease. In the terminal, 

 stages, a violent delirium or maniacal excitement frequently precedes the 

 onset of stupor, coma, and death, the "stormy terminal manifestations," 

 to which Addison drew attention. 



Neuralgic pains in various parts of the body are common in the dis- 

 ease. Pain in the lumbar region (perirenal) may be an early and im- 

 portant symptom. These may also occur in the abdomen (epigastrium, 

 hypocJiondrium) or in the extremities. Occasionally arthralgias, with 

 swelling of the joints, may lead to a diagnosis of arthritis (Ebstein). 



The cardiac muscle shares in the general myasthenia, and the heart 

 beat is usually found to be feeble and slightly accelerated. The heart 

 sounds are faint, and in some advanced cases almost inaudible. The pa- 

 tients are subject to frequent paroxysmal attacks of dyspnea, without ap- 

 parent cause. The slightest exertion may give rise to marked palpitation 

 and dyspnea, often accompanied by stenocardia, as observed by Leva. 

 Anemic murmurs, heard over the heart and blood vessels, have been noted, 

 but are uncommon. There may be forcible pulsation over the abdominal 

 aorta, forming a marked contrast to the feeble radial pulse. Towards the 

 end, more or less cyanosis may be present, with increasing weakness of 

 the cardiac muscle. The patient may die in a syncopal attack. The pulse, 

 as Addison stated, is "small, feeble, or perhaps somewhat large, but ex- 

 ceedingly soft and compressible." In the late stages, the radial pulse may 

 be imperceptible. Arteriosclerosis has not been commonly . observed in 

 Addison' s disease in any marked degree. 



Arterial hypotension is regarded as an important sign of the dis- 

 ease, but reports of the finding of fairly normal blood-pressure readings 



