200 ADDISON'S DISEASE 



survey of the present status of our knowledge of the patholog}'^ of the affection, 

 this problem is our chief interest. We hope clearly to demonstrate what the 

 investigations of the last half century have contributed in explanation of 

 the disease, and what is left for future studies to elucidate. 



A brief description of the clinical picture must precede the rest of my 

 discussion. 



CLINICAL PICTURE OF ADDISON'S DISEASE 



The description need be but very brief for, in the portrayal of the clinical 

 symptoms, the first description given by Addison in 1855 is practically ex- 

 haustive, and many of the later observations have but supplemented this in 

 certain respects. 



All typical cases of the disease show (simultaneously or serially) the fol- 

 lowing four groups of symptoms : 



1. General adynamia; 2. gastric and intestinal disturbances; 3. general 

 nervous symptoms ; 4. abnormal pigmentation of 'the surface of the tody. 



I here emphasize the conception of " typical cases," and do not believe it 

 advisable in describing the nature of the disease to deviate too far from this 

 conception. In particular, I do not believe that we ought to inchide as cases 

 of Addison's disease (as has often been done of late) those in which the most 

 conspicuous symptom, the abnormal pigmentation of the skin, is absent, even 

 though examples of this kind (of which more will be mentioned later on) 

 may be important in sthe explanation of the nature and the pathogenesis of 

 the disease. The differentiation of characteristic sjrmptom-pictures can 

 advance our clinical knowledge only when it is carried out with the neces- 

 sary consistency. 



The signs of adynamia as a rule develop very insidiously, showiug them- 

 selves in general malaise with exhaustion upon slight exertion, gradually 

 increasing to extreme muscular weakness, particularly of the lower extrem- 

 ities, so that walking may become very difficult. These symptoms cannot well 

 be referred to a profound disturbance of nutrition of the muscles, for, as a 

 rule, neither very marked emaciation nor muscular atrophy is present, at least 

 in the early stages of the disease. A weakened condition of the heart muscle 

 is also apparent, particularly in advanced stages of the disease. The pulse 

 is often very small, and, at least in the earlier stages, more often slowed than 

 accelerated. Subnormal temperature (95° P. or a little above this) has been 

 repeatedly observed, particularly in the terminal stages of the disease. 



The muscular weakness cannot be attributed to a marked anemia, for the 

 microscopic examination of the blood (which will be referred to more in 

 detail later) has generally indicated even in a late stage of the disease only 

 a moderate diminution of the red blood-corpuscles and leukocytosis while 

 some recent observations have shown a conspicuously large number of eryth- 

 rocytes. 



The disturbances referred to the digestive canal show themselves in the 

 earlier stages of the affection by general dyspeptic complaints : Loss of appe- 

 tite (often extreme), occasionally bulimia; tendency to nausea and vomiting, 

 sense of pressure in the epigastrium; also disturbance of intestinal activity 



