ADDISON'S DISEASE 297 



ingeal or miliary) may entirely dominate the clinical picture, and ob- 

 scure the essential features of the symptom-complex. 



The Blood. Although Addison first regarded this disease as an idio- 

 pathic anemia, the blood examination in the majority of patients shows 

 the erythrocytes to be within fairly normal limits, or only slightly reduced. 

 In some patients, a pallor of the skin, associated with the characteristic 

 bronzing, simulates the appearance of a primary anemia. According to 

 Nothnagel(&) anemia is not an integral part of Addison's disease. In the 

 advanced cases, however, complicated with tuberculous or cancerous 

 lesions, or severe gastro-intestinal disorders, a marked secondary anemia 

 may be found. In the average patient the erythrocytes rarely fall below 

 3,000,000, and in some rare instances a polycythemia has been reported 

 with red counts of over 6,000,000. From a series of hospital records, 

 an average erythrocyte count of 4,500,000 was determined. The hemo- 

 globin content was found to average 84 per cent (Sahli), and the leucocyte 

 count 10,000. Several observers have remarked that the hemoglobin 

 content is relatively low in the greater number of cases. The abnormally 

 high erythrocyte count observed by some writers is probably due to the 

 concentration of the blood, subsequent to a profuse diarrhea. 



The leucocyte formula has shown, in some instances, interesting de>- 

 viations from the normal. Neusser has called attention to the relative 

 frequency of a lymphocytosis, an observation that has been confirmed by 

 a number of writers. Another important observation is the somewhat 

 common finding of an unexplained eosinophilia. In Wolf and Thacher's 

 case an eosinophilia of 20.5 per cent was determined. The polymor- 

 phonuclear cells are frequently found decreased, in some cases falling 

 below the total lymphocyte count. In one case reported the polynuclear 

 cells were found to be as low as 36 per cent. Mararion, in a study of the 

 leucocytes in Addison's disease, observed, in his series, a mononucleosis 

 of from 35-60 per cent. Neusser regards the presence of a lymphocytosis 

 as an unfavorable sign. The possible relation of these changes in the 

 leucocyte formula (lymphocytosis, eo<sinophilia, neutrophilopenia) to 

 status thymicolymphaticus in Addison's disease, merits further study. 



Urine. The urine, as a rule, shows few important changes. The 

 total quantity is usually decreased, although polyuria, sometimes asso- 

 ciated with polydipsia and polyphagia, has been noted in a few examples. 

 The specific gravity may be somewhat low. The coloring matter is not 

 present in excess in most cases ; indeed, some writers state that the urin- 

 ary pigments are actually diminished. An excess of indican is commonly 

 observed. A large number of reports would seem to indicate that the 

 principal urinary constituents are present, in the majority of cases, in 

 normal proportions. There are in the literature, however, isolated obser- 

 vations of the finding of abnormal bodies. McMunn described an increase 

 in urinary pigments, and in one case, the presence of an abnormal color- 



