214 ADDISON'S DISEASE 



leons, frogs, etc.) the dependence of " chromoblasts " upon the nervous system 

 (Eaymond) has been proven. 



Thus the most conspicuous symptom of Addison's disease points with more 

 emphasis than any of the others to an implication of the nervous system. 

 Therefore we are forced to the conclusion that even in the most typical cases 

 a conception of the clinical picture as due to a cessation of suprarenal func- 

 tion is beset with difficulties. 



The perplexities of explanation increase materially when we leave the realm 

 of purely typical cases of Addison's disease, and consider the deviations which 

 the clinical symptoms and pathologico-anatomical findings present under some 

 circumstarlces. Unfortunately, these variations from the normal type of the 

 disease are not very rare. I mean by this, not the many quantitative differ- 

 ences in individual symptoms whereby it often occurs that one symptom, for 

 example, gastro-intestinal phenomena, becomes more marked than all others, 

 or that the bronzing of the skin is very intense in the early stages of the 

 disease, while at other times, toward the termination of the affection, it is 

 only very moderate, that at the autopsy the adrenals, contrary to rule, are 

 found with lesions of fresh degeneration, and in part present well retained 

 parenchyma and the like. All these variations depend upon the duration, 

 course and complications of the disease, and partly upon auxiliary conditions 

 which cannot be controlled. Much more important are the instances of a 

 lack of coincidence between the main clinical symptom, the pigmentation of 

 the skin, and the important factor of the pathologico-anatomical picture — 

 the degeneration of the adrenals. Such exceptions were noted soon after the 

 publication of Addison's fundamental description, and have multiplied in 

 the course of years, so that many modern authors deny wholly the parallelism 

 between the pigmentation of the skin and adrenal disease. 



Two groups of cases are here to be distinguished, and by most observers 

 have been noted separately: The cases in which in well developed Addison's 

 disease with hronzing no affection of the adrenals has been shown, and upon 

 the other hand, advanced changes in the adrenals without discoloration of the 

 skin and even in some cases without any severe symptoms. The frequency 

 of such exceptions naturally cannot be seen in a small group of cases, and 

 full compilations have up to the present time been very rarely made (Aver- 

 beck, Greenhow, G. Lewin). Among the earlier reports of this kind Green- 

 how's statistics are to be referred to, in which among 172 cases of undoubted 

 Addison's disease, disease of the adrenals was absent in 10. The most com- 

 plete compilation at present is that of Lewin, which includes 561 autopsies; 

 according to this, typical Addison's disease with changes in the adrenals is 

 noted in 88 per cent., without lesion in 12 per cent. ; on the other hand there 

 was adrenal disease with bronzing of the skin in 72 per cent, without such in 

 28 per cent, of the cases. Now it must be stated, once for all, that most 

 statistics of this kind which refer to early cases are unreliable on account 

 of the lack of definiteness in the descriptions of the pathologico-anatomical 

 conditions of the adrenals. In some cases disease of the adrenals has doubt- 

 less been overlooked, in others erroneously assumed. Nevertheless the number 



