202 ADDISON'S DISEASE 



average duration of the disease, as determined from a large collection of 

 cases. The termination is always fatal; in the few cases which have been 

 described as cured the diagnosis is doubtful. 



To complete the description it may be stated that Addison's disease (par- 

 ticularly in North Germany) is quite rare, that with the exception of earliest 

 childhood and extreme old age it attacks all periods of life quite uniformly, 

 and is more frequent in men (60 to 70 per cent.) than in women. Important 

 etiologic factors cannot be determined ; in a number of eases prolonged psychi- 

 cal depression (care and sorrow) appear to play a role. 



Besides those diseases with which the malady is often associated (tubercu- 

 losis, and, to a lesser extent, carcinosis) I must mention certain cutaneous 

 complications which have become known by experience, among which are 

 especially scleroderma, and in rarer cases prurigo, mycosis fungoides, etc. 



GROSSER PATHOLOGICO-ANATOMICAL LESIONS IN ADDISON'S 



DISEASE 



As regards the pathological anatomy of the disease numerous investigations 

 in the last few decades have confirmed the findings emphasized by Addison, 

 i. e., the coincidence of the symptom-complex just described, with disease of 

 the suprarenal bodies. In the overwhelming majority of the recorded cases, 

 a profound change in these organs with destruction of the greater part of the 

 normal parenchyma has been observed. Furthermore, experience has shown 

 that Addison's disease is not produced by any and all the pathological changes 

 of the adrenals but that a definite form of disease of the organ is usually 

 present, particularly a form of chronic tuberculosis, in which the parenchyma 

 is rapidly destroyed, partly by caseous degeneration, partly by fibrinous con- 

 traction. The macroscopic changes according to age and distribution : In the 

 majority of cases the adrenals are enlarged (occasionally to several times the 

 normal) ; upon section the tissue in part shows inflammatory swelling with 

 foci of caseous softening; in other areas, contraction and induration with 

 hard, cheesy, or calcified deposits. In a small number of cases processes of 

 contraction are predominant, so that the organ is smaller, occasionally so 

 small that it can only be found with difficulty. The disease of the suprarenal 

 bodies in the majority of cases is bilateral but, as a rule, not equally developed 

 on the two sides. In the interior of the individual organ the cortical and 

 the medullary substance are as a rule uniformly implicated, so far as can be 

 noted at the autopsy. Tubercle bacilli have lately been found by many 

 observers in the foci of disease. 



In a small number of cases the adrenals show other forms of disease. 

 Among these, according to the latest investigations and reports, comparativelv 

 the most frequent seems to be simple atrophy of the organ, a change which 

 in some instances is so extreme that the adrenal appears to be absent. But 

 it is very likely that some of these atrophic cases represent only the remains of 

 inflammatory processes after the absorption of softened foci. In a still smaller 

 number of cases malignant neoplasms (carcinoma and sarcoma) have been 

 found in the parenchyma of the organ. Still more rarely other diseases, such 



