THERAPY 223 



are absent. Above all, the correct etiology may usually be recognized in the 

 other clinical conditions. If, however, these pseudo- Addisonian affections can 

 be excluded, and if the true Addison symptom-complex is present, we must 

 remember the presence of changes which, according to experience, are fre- 

 quently present; viz., caseation of the adrenals, a presumption which may be 

 confirmed by the determination of tuberculous disease in other organs, par- 

 ticularly a moderately advanced pulmonary tuberculosis. In a similar man- 

 ner, in a small number of cases, secondary symptoms which favor carcinosis 

 or kindred affections may, perhaps, be combined with a palpable tumor in the 

 adrenal region, this directing the diagnosis to a malignant growth of the 

 adrenals. Only where both these forms of adrenal disease are unlikely will 

 the assumption of any other and rarer form of adrenal disturbance be justi- 

 fied. In all cases it must be remembered that, besides disease of the adrenals, 

 an affection of the surrounding nerve areas, particularly of the abdominal 

 sympathetic plexus, with a greater or less distribution to the central nervous 

 system, may be present; that moreover under some circumstances, these dis- 

 eases of the nervous system may take the place of the affection of the adrenals ; 

 and that, finally, in rare exceptional cases, both may be absent. That the 

 finding of the latter cases, however, is not opposed to the clinical diagnosis, 

 " Addison's disease," I need not reiterate. 



On the other hand, the cases of profound adrenal degeneration without 

 the symptoms of Addison's disease, particularly without bronzing of the skin 

 (which are not very rare), will generally be impossible of diagnosis. That 

 these do not belong to Addison's disease, in the strict sense of the term, I 

 have already stated. Lately it has been proposed to differentiate them by 

 the term " adrenal insufficiency." Only in instances in which the disturb- 

 ances point definitely to the adrenal region, and particularly where palpation 

 shows a tumor or other abnormal condition in this area, can this type of 

 disease of the adrenals be suspected. Where this is not the case, the picture 

 of a general cachexia is present, a picture which, as a rule, is not characteristic 

 enough to separate it from other constitutional disturbances. 



THERAPY 



The doubts which envelop the pathogenesis of Addison's disease will natu- 

 rally also appear in the views which dominate the treatment of this affection. 

 Accordingly we note from the time at which the clinical picture became known 

 up to within the last few years but few endeavors to adopt a specific or method- 

 ' ical treatment of the affection, and these few have not been further developed. 

 Thus, by some observers, remedies such as faradization, hydrotherapy, amyl 

 nitrite, nitroglycerin (on account of its action in raising blood-pressure) 

 and transfusion have been employed and advised without having obtained 

 general recognition. In some of these instances, and by these methods of 

 treatment, a decided improvement is said to have resulted, and some cases 

 have been reported even as " almost cured," and to have died only during a 

 relapse. There are intercurrent improvements to which I have already re- 

 ferred when discussing the spontaneous tendency of the disease to a fluctuat- 



