222 ADMSON'S DISEASE 



But I must repeat that the endeavor to propound such theories is, for the 

 present, not worth the labor. On account of the uncertainty which still exists 

 regarding the function, not only of the adrenals but also of individual areas of 

 the sympathetic nervous system, there is but little hope of following the 

 complicated pathologico-anatomical changes which produce the symptoms of 

 the disease. I believe it, therefore, to be correct to adhere to this view in the 

 explanation of the pathologic process : That the disease depends upon a patho- 

 logic modification or cessation of the normal relation to the organism of the 

 necessary functions of the adrenals and of the nerve areas which are inti- 

 mately connected with these structures. 



The scant investigations at hand are naturally still open to doubt, and may 

 be modified or rejected after later researches. Whether, in the future, we 

 must be content with an explanation such as has just been given, or whether 

 we shall be able to determine the more minute pathogenetic processes in Addi- 

 son's disease depends upon the results of continued investigations. In my 

 opinion, judging by what has preceded, these researches must be based 

 less upon physiological experiment than upon increased and minute histologic 

 investigation, especially in the areas of the nervous system that are implicated; 

 we also need research in the field of the chemistry of the adrenals, of the blood, 

 and of metabolism. By histological study the question of the constancy of 

 a lesion of the nerves in Addison's disease will be solved ; by chemical research 

 the probable implication of the adrenals in pigmentation of the skin will have 

 to be decided. For histological investigation, the atypical cases without dis- 

 ease of the adrenals will be of the greatest importance. As such eases are 

 particularly rare, these advances in our knowledge will be very gradual, and 

 it will be all the more necessary, therefore, for us minutely to investigate each 

 available case in the future. 



DIAGNOSIS 



A few words regarding the diagnosis of Addison's disease may be added, 

 particularly as the view has lately been expressed that diagnosis is not possible 

 during the life of the patient. Such a view refers of course only to the deter- 

 mination during life of the pathologico-anatomical changes which are ex- 

 pected in the adrenals, or (and this we must emphasize according to our 

 experience) in their surrounding areas, especially in the sympathetic nervous 

 system. The clinical picture of the disease in question, even when it does 

 not present itself in typical form, is usually not difficult to recognize. It has 

 previously been stated that this affection is very similar to many other discol- 

 orations of the skin combined with cachexia, for instance, to certain forms of 

 tuberculosis, carcinosis, malaria, pellagra, vagabond's disease, and the like. 

 These affections, under some circumstances, may show similarity to the Addi- 

 son symptom-complex. But a longer clinical observation of most of them 

 will lead to a correct conclusion, since in these diseases (as has been mentioned 

 above) the pigmentation differs by certain irregularities, and by the absence 

 of implication of the mucous membranes, from true bronzing of the skin, 

 and, further, because the symptoms directly referable to the suprarenal region 



■I'm iM , 



