'-S^, 'W!'. i 



226 ADDISON'S DISEASE 



distributed caseation of the glands, a tuberculous nodule in only the right 

 adrenal, while the solar plexus and the semilunar ganglion were embedded in 

 callous connective tissue. 



In the study of such examples the previously mentioned tendency of cer- 

 tain cases of Addison's disease to spontaneous remission with consequent fatal 

 exacerbation is to be remembered. But it must be admitted that here the 

 rapidity and the complete amelioration of the symptoms appears to be out of 

 proportion with what is observed in the spontaneous course of the disease. 

 Particularly, in the second case, the complete recurrence in a few days of the 

 dark bronzing of the skin can only be understood by assuming a preceding 

 artificial modification of the pigment metabolism of the body. It appears 

 that these two eases, and a few similar ones, are sufficient to prove the possi- 

 bility of a favorable influence upon the principal symptoms of Addison's dis- 

 ease by the artificial introduction of suprarenal substance. 



It is true that we have records of quite a number of eases opposed to these — 

 cases in which suprarenal treatment had no influence upon bronzing of the 

 skin, nor upon the general symptoms. And from the reports at hand I believe 

 that the number of these negative cases is at least equal to those in which 

 positive results have been obtained. Sometimes indeed a direct aggravation 

 of the symptoms has been noted from the beginning of this treatment. Nor 

 has it been possible to prove by chemistry that metabolism in the organism 

 is decidedly influenced by the introduction of adrenal substance. For even 

 though one investigator (Pickardt), after a nine days' research in metabo- 

 lism in a case of Addison's disease, during which time suprarenal tablets 

 were administered, found an increase of albumin decomposition, in an analo- 

 gous research by another investigator (Senator), nothing abnormal could be 

 determined. In the case of two dogs who were fed with adrenals (with the 

 raw gland as well as with the glandular extract) similar experiments showed 

 no decided change of the nitrogen balance (Blum). 



Perhaps the form and amount in which the adrenal substance is adminis- 

 tered is important for its supplementary action. Apart from a few unsuc- 

 cessful or disastrous investigations with the implantation of animal adrenals 

 under the skin, the glands have been administered in a natural condition (as 

 fresh as possible), usually chopped up with necessary additions. They have 

 been occasionally given in q, dry condition, as adrenal powder, but in most 

 cases they have been used as extract, which in rare cases has been subcutane- 

 ously injected, but has generally been given internally in the form of adrenal 

 tablets (particularly in England, but also in Germany and other countries). 

 The doses administered varied, according to the reports, with the fresh adrenal 

 gland, from one to two glands daily; with the extracts, an amount corre- 

 sponding to 0.2—4.0 of the dried glandular substance. It will be noted that 

 the best method of introducing the glandular substance has not been definitely 

 determined. Many further observations will be necessary to decide this. 

 The opinion expressed by some authors (for example, by Lewandowsky) that 

 the admmistration of the raw glandular substance is more effective than the 

 exhibition of the extract appears to be confirmed by a number of clinical 

 histories. But it must be pointed out that in the second of the eases men- 



