220 ADDISON'S DISEASE 



admit their occurrence, they cause great difficulty in explanation; for to 

 assume a functional disturbance of the affected nerve areas, and perhaps also 

 of the adrenals, without any anatomical substratum, would be very unsatis- 

 factory. It may be assumed, however, that cases of this kind will always 

 remain rare exceptions. 



The group of cases in which adrenal disease is present without Addison's 

 symptoms, particularly without bronzing of the skin, does not belong, as has 

 already been stated, to the disease we are considering. ISTor does it offer im- 

 portant reasons to vitiate the views which have been expressed above. In the 

 first place, we usually find in such cases affections of the adrenals which are 

 in marked contrast to typical cases of Addison's disease: The majority of 

 them are tumors of the adrenal glands and the absence of Addison's symptoms 

 is here the rule; thus a recent compilation of 26 cases of primary malignant 

 tumors of the adrenals showed that the clinical picture of Addison's disease 

 was invariably absent. In most of the other cases of this group it remains 

 uncertain whether by tumor formation or other disease of the parenchyma of 

 the adrenals the destruction is as marked as is the rule in most cases of tuber- 

 culosis ; the areas surrounding the glands also appear to remain comparatively 

 free. Finally, in explanation of these cases, an abnormally great development 

 of the accessory adrenals may be thought of. 



I believe the considerations above adduced will suffice to make it obvious 

 that, according to the pathological and clinical material at our disposal, the 

 clinical picture of Addison's disease does not depend exclusively upon a grad- 

 ual destruction of the adrenals, nor exclusively upon a disease of the nervous 

 system (i. e., the abdominal sympathetic and other nerve areas intimately 

 associated with it), but that both these factors are simultaneously active in 

 the development of the symptom-complex — a view in which I coincide with a 

 number of earlier as well as more recent investigators (Fleiner, Neusser and 

 others). How these forms of the disease merge into each other is very difficult 

 to determine, and varies evidently to an extreme degree. A particularly fre- 

 quent connection, according to the views mentioned above, appears to be a 

 kind of ascending disease, which spreads from the adrenals to the neighboring, 

 and, eventually also, to the more distant nerve tracts; that, however, opposite 

 (descending) processes are also at work is at least likely, and has been men- 

 tioned previously. Moreover, there need be no parallelism between these 

 pathologic processes ; on the contrary, in well advanced changes of the adrenals 

 very slight implication of the nerves may be found, and vice versa; in quite 

 a number of cases according to present experience, the disease of one or both 

 parts may be entirely absent. By this variation in the relations of the diseased 

 areas, we may very readily explain the great variation in the intensity of indi- 

 vidual symptoms and in the time of their appearance, so that, for example, 

 the bronzing of the skin may occur years before the general symptoms, or, 

 inversely, the general disturbance may exist for a long time without pigmen- 

 tation. 



If a definition of the pathologico-anatomical basis of Addison's disease is 

 desired it may be given in the following form : The disease depends upon an 

 insidious, partly inflammatory, partly degenerative affection (most frequently 



