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 "^, y --''vv y ' ' '!>'> ' ";■ '■ 
 
 TYPICAL CASE 
 
 ,<•'■■ 
 
 OF 
 
 ADDISON'S DISEASl 
 
 WITH REMARKS. 
 
 BY 
 
 GEORGE ROSS, A.M., M.D, 
 
 Professor CUnioftlMedicinp, McOill Univer.Mty, AttonriiDg rhvMciaii Mniitroal Gtiieml 
 Hospital. Reported by Mr. H. K. ViiU!U;ig, Clinical Clerk. 
 
 I 
 
 PRINTED BY/LOY^LL^lmm»(i Ai^D VVOklSHlNG COMPANY, 
 
-rft 
 
't"-A 
 
 TYPICAL CASE 
 
 OP 
 
 ADDISON'S DISEASE 
 
 5 
 
 WITH REMARKS 
 
 i 
 
 From the Transactions of the Canada Medical 
 Association, 1877. 
 
 BY 
 
 GEORGE ROSS, A.M., M.D., 
 
 Professor Clinical Medicine, McCrill University, A1;teniUng Physician Montreal Greiieral 
 Hospital. Eeportcd by Mr. H. N. Vineberg, Clinical Clerk. 
 
 PRINTED BY LOVELL PRINTING AND PUBLISHING COMPANY. 
 
 1877. 
 
■ 
 
 
TYPICAL CASE OF ADDISON'S DISEASE. 
 
 WITH HEMAHK8. 
 
 BY GEORGE ROSS, A.M., M.D. 
 
 I'rofefi<or of Clinical Medicine, McGillUnlveraity, Attending Physician Montreal Genera, 
 Hospifal. Koijortod by Mr. H. J^. Vineberg, Clinical Clerk. 
 
 J. F., rot. 23, coal carter, was admitted into the Montreal Gen- 
 eral Hospital, on the 9th June, 1877, under the care of Dr. Ross, 
 sufferinuf from discolouration of the skin, pain in the stomach, 
 vomiting and weakness. 
 
 Nothing can be learned concerning his previous family history 
 except that his father and mother ai-o both living, and no account 
 of tuberculous disorders can be hoard of amongst any other mem- 
 bers of the family. 
 
 He himself it seems took very early to drinking habitually, 
 getting very drunk quite frequently. He was, in consequence, 
 necessarily exposed to much hai'dship, sometimes even lying out 
 in the cold and rain. Ho cotitinuod thus intemperate utitil about 
 two years ago, when his pi-cscnt ill-health began. Up to this time 
 he says he never knew what it was to be sick. He then began to 
 complain of being weak, and sutfered from giddiness a good deal, 
 and sometimes from pain in the front part of the head. He con- 
 tinued, however, lo work until last fall, but often feeling that he 
 was not strong enough for it. The giddiness also kept increasing, 
 so much so that he many times when stooping down, rolled over 
 quite helpless, and he was often suspected of being drunk. Is not 
 aware of having ever strained himself, but, of course, did very 
 labourious work. His appetite had been failing and he was becom- 
 ing very singular in his selection of food. For instance, he could 
 not eat butter, but insisted upon having lard, and he had a strong 
 craving for acids, especiallj' pickles and vinegar, which latter (if 
 his father can bo believed) he would drink pure by the pint at a 
 time. He also had attacks of vomiting not unfrequently, even 
 whilst at work, and often sutlered from pains in various parts of 
 the body — " all over him " as he says. Besides these, the follow- 
 ing symptoms have also been observed, and have been growing 
 KSteadily more marked since last winter. Breathlessness upon the 
 least exertion. Drowsiness, tending at once to fall asleep if left to 
 himself, and such intense feeMeness that he could oot possibly 
 
120 
 
 CANADA MEDICAL ASSOCIATION. 
 
 walk' 8h-ni,i;l.t Tho latter bo 
 
 gottinirui) in tho mornings "'lion ho rools and 
 iKli'unlcon man. Cold extremifi 
 remarked him woariiiif mil 
 stove 
 
 in<!; moMt marked immofl lately aft 
 
 or 
 
 Hta^r<ror,s about, Jiko 
 
 the 
 
 to warm Jiis foot. It 
 
 tlie discolouration ot'thi) nk 
 
 fs. osiKH-iallj hi8 hands: hiHfiul 
 s HI warm woathor, and often goin^^ I 
 "' is somewhat more than a year sh) 
 
 •or 
 
 o 
 
 certain! 
 
 y existed miK-li h^ni-or, hooauso it 
 
 (•0 
 
 it 
 wa,s learnt that last 
 
 n wa.s first noticed hy liis friends, hut 
 
 Hummo,. h,s lather, on eomin^i. homo after ar. ahsonee of just a year 
 'Hrdly .-o.o^n.zod his ow.. son. owin-, to the ^reat eham-o whieh 
 md mountune oeeurred in the eolour of his lin. He C nl;;:.' 
 
 ^!ohtn " '"' "'""' "' *'"'*"^ '"' '''''''''' ''' I'^^'l''^^'^-" ^'^• 
 
 Present Condition. Patient is a man rather above the or<linarv 
 ize wen..ult and well-nourished. He has brown hair and b.:;::. 
 ejcs. He has, n bed with a dull, hoavy and stupid expression 
 an when left alone is continually sioopin,, ; in fact, it is\l.,licui; 
 to keep h.m awake long enough to got from him answers to a 
 quesjon or two, and oven then n.eans have to bo taken to kocp up 
 h 8 attention or he would immediately relapse into the ime 
 
 ^7a M T '""" ''-' ^•^"^^^' "^' ''« ^' ^''"^ -'^^ '--t^ 
 
 rtM 1\T ^^'"''"'^'•"^' ''^■^^'•'■"^•*»^«S the forehead con- 
 ractod and tho angles of tho mouth drawn up. Iluvim. o-ono 
 hr<>.gh th. performance, it is g<morally necessao' to^<:;^ 
 
 et:: :::r;r '"r 't '''''- ^^'^ in-nigibi/answo:^:;! 
 
 colom, resomh hng ,„ appearance that of a Malay or a white man 
 
 whohad boon deeply stained with walnut juice. It in all ros; c 
 
 agrees perfectly w.th tho descriptions given of the most t/pica 
 
 cases ^ Morbus Add.sanii~T,e discolouration i« most deep upo. h 
 
 f.tce, neck, n.pplos, lower part of the abdomen, penis uni scrotum 
 
 and .he backs of the hands. It is least marlL over the lot^: 
 
 extremities. The pigment is particularly intense on the gonitl 
 
 organs, winch indeed are nearly as dark us in a veritable no^o 
 
 The backs o the hands are of an extremely dark mahog^ y 
 
 brown, the colour terminating by an abrupt margin on tho lateral 
 
 aspects and contrasting strongly with the corresponding palms 
 
 winch are comparatively quite pale. The line of boundaiy of the 
 
 pale portion in the palm is also well seen on the anterior aspect! 
 
 oi he wrists at winch part the deep colour of the forearm suddenly 
 
 ends by an abrupt straight margin. There are several very d^l^ 
 
 brown (almost blaclc) circular spots or moles nnon both cheX 
 
ADDISON i^ DISEASE. 
 
 121 
 
 and n few also upon tho front of the abdomen and upon llio back. 
 Tbo mucous membrane of tho lips, clieok;* iiiid tongue, all whow 
 nuirUed bliiciv pigmoi\tary nioltliMi^'s and jjatciio.-t. The inside of 
 the lower lip presents about itH middle a beautiful generally dis- 
 tributed marliled appearance. At the inner margin of the rod 
 exposed jiortion of the lower lip is to bo seen an irregularly 
 Hoallopcd dark line, about one line in width and running the whole 
 lei\gth of the lip. There is also a black pateh on the gum of tho 
 lower jaw at a^pot eorrosjjonding with the two left incisor tooth. 
 On the left side of tho tongue are two wimilar dark blotches, ono 
 near the tip and the other a little further back, these look just as 
 though tho back of a pen had been rubbed over them. 
 
 All tho mucous mcmbraiu's visible are of a healthy rod colour, 
 the nails of tV.o tlngers and toes are also of tho ordinary pink 
 colour of health. Tho eyes are somewhat bloodshot, pupils 
 motlerately contra'ited and respond freely to light, Temperature 
 100-2° F. Tongue rather coated with a light brownish fur. Appetite 
 bad. Bowels rather loose. Pulse, 80, small, weak and very easily 
 compressed, ileart sounds distinct but markedly feoblo; not ac- 
 companied by any murmurs. Apex beat in normal situation. 
 Lungs healthy. Liver and spleen occupying their i)roiier areas. 
 No abdominal pulsation detected, lias passed no urine since ad- 
 mission yesterday: withdrew U o/.. with catheter. It is high 
 coloured,' sp. gr. 1008, no albumen, no sugar, becomes very dark 
 when boiletl with nitric acid. 
 
 There seems to be some general hypcracsthesia, as a modorato 
 squeeze anywhere will cause him at once to whino and cry out. 
 Complains much of pains everywhere, and especially headache. 
 He was got out of bed andoi-dered to walk across the ward, wlien 
 he ])lwnged and staggered along in the most headlong way and 
 would have fallen at once if not sup])orted. Ho begged to bo 
 allowed back to bed, and throw himself down utterly exhausted 
 and his heart beating ver^^ rapidly. 
 
 Blood from tho finger was examined ; no increase in the num- 
 ber of tho wliito blo(xl corpuscles. Tho libi-ino fibrils wore un- 
 usually distinct, otherwise it was quite natural. Schultze's 
 " ii-ranular masses, " so common in cachectic states, were not 
 observed. 
 
 Ordered. Milk diet with beef tea and 1^. Morph. sulphat gr.j^g 
 Bism. nitrat. gr. x. every six hours. 
 
 nth June. Passed a very restless night, whines and erics to- 
 
 \ 
 
122 
 
 CANADA MKDICAL ASSOCIATION. 
 
 tiny ovon moro than vestonljiv V(.mW.„i . . 
 
 a ccHuJoniMo «,nount of urii.u, ... <.,. una ^ "> '"n<l. 1 n.sse.l 
 
 ni.ht, an.l ,'r ;h :! ^ 1 J^:^' ^'''•^ ^'^^ ^"-'^" ti- 
 
 von., His oyos we.;;::*; : :^: :;: ;;: -, -'--10,. to 
 
 n;ul appoarnnc.cH were noHccl. The 2 on in / "?'""•" 
 
 abundant, bat not arn,,snallv so to. a la He a ' . ''"' 
 
 l^^A.WHadal.alni,htand:emtZt'^r^^ 
 a-Kl con.plains runvh. Js somewh-.t , ' '%^'^-^'">';«0' weak 
 Veslonl-iv Pn 1 ""-\\n.iL do.it. No vomitinL^ sinco 
 
 >esio.(l<u. lasHod a vory copious stool yo.stordav (,f., 7. 
 
 uur.ng la»t tl.roo duyn. Tcm|>„,,,(,u'c., 05-4° F ,n,d 97-8<> I,' 
 15m Jjmt?. Sent well last nJ.rh* . . i ^i^'ic 
 
 tremoly Bmail and shabby. The foregoing nolo wa m-^c !t ,," 
 «.m., a„d be oo„tin„cd about tho Ham^wa^ u,„ 1 7 m the II 
 became ve,,- ,.e».le.. c.yin« „„t to »e„d for hi, fat bo"' U ^t 
 
 IZr , ': "'" "' "" '■>"'''-' ]^IO-.inn», who f„„,„l him .olli," 
 about ,„ bod, covered with a cold ob.mmy sweat. P„|»e vorvs |1 
 and UTOsula,., and eomphu„i„s of general pain, and 0,000™; v 
 o.-amp, H. the left log. Friction, and wa mth, togoti ^^^ 
 
 
Addison's disease. 
 
 123 
 
 stimulnntH, internal iind oxtornal, wore freely used, hut with only 
 temporary rallyinfjf otroct, for within three-quarters of an hour ho 
 was evidently moribund, and died at 8.15 p.m. 
 
 AUTOPSY, 1»Y DR. 08LER, 16 IIOUR8 P. M. 
 
 Body that of a tall, well-formed young man. MuhcIoh of average 
 development, and in good condition. PanniculuH adipoHUH 
 scanty. Skin prewentH the appearance doHcrihod in the clinical 
 report. Rigor mortis proHent. 
 
 Thorax. — Muscles of a healthy red colour. Thymus (j land a\y\wtir a 
 enlarged, weighs 3 vi. On examination only the normal elements 
 are found. 
 
 Heart, 240 grms. Right auricle distended with blood, and on 
 opening it 3 to 4 ounces of dark semi-coagulated blood escaped. 
 Right ventricle also full of grumous clots. Left auricle contains 
 blood ; Left ventricle contracted and empt3\ On removal of the 
 organ fully 14 oz. of blood escaped. Valves and oritices healthy. 
 Muscular substance of good coloMr ; the fibres are slightly granular, 
 but the strito are not obscured, and there are no definite oil droplets 
 to bo seen. Aorta, healthy. 
 
 Ltintjs, crepitant throughout; no adhesions; no nodules, 
 tubercles, or caseous masses. 
 
 Abdomen. Viscera look natural. 
 
 Spleen not enlarged, slightly adherent to the diaphragm. Con- 
 sistence good. Malpighian corpuscles distinct. Structure normal. 
 
 Kidneys. — Capsules detach easily, surfaces smooth ; one or two 
 small cysts noticed. On section Malpighian corpuscles prominent, 
 cortices and medulla>, with the exception of the maramillro, of a 
 dark brownish-red colour. Nothing abnormal found on microsco- 
 pical examination. 
 
 Supra-renal Capsules. — Left feels firm, and is bound to the 
 neighbouring parts by fibrous adhesions which were with difficulty 
 torn through. On removal it weighs 3 vss., and has lost its 
 cocked hat shape, being somewhat oval, and about the size of a largo 
 testicle. The surface is irregular, puckered, and here and there 
 round nodules softer than the rest project. Two thin remnants 
 of the gland arc attached to the central mass. One, an inch in 
 length, passed downwards from the posterior part, and in it are 
 several small caseous nodules; the other, springing from the 
 anterior part, is not so marked, and contains no nodules. On« good- 
 sized artery and two small ones enter the gland at the lower 
 wider, A few nerves of ordinary appearance are seen going to it. 
 
124 
 
 CAXADA MEDICAL ASSOCIATION. 
 
 On section with a sharp knife, it cuts with considcrabie resistance 
 and is seen to be made up of central caseous masses, surrounded 
 by douse semi-translucent fibrous tissue, '6'" to 4'" in thickness, and 
 in places very firm and hard. The caseous masses are separated 
 indistinctly into two portions by a strand of gelatinous-looking 
 tissue, and are firm, greyish-yellow or cream coloured, soft 
 at the periphery so that they can readily be pealed out of the 
 fibrous investments. In one central spot the caseous matter is 
 becoming very dry and cretaceous. The right capsule is larger 
 than the left, and lies in its normal position on top of the kidney 
 and in contact with the liver, to which it is united by fibrous bands. 
 The investing flit is in small amount, but very fibrous. The oro-an 
 has completely lost its flattened shape, and appears made up of 
 two irregular nodules, the upper of which projects towards the 
 liver, the lower, somewhat triangular in shape, passing down to- 
 wards the hilum of the kidney, and to its under surface the renal 
 vein is attached. To the touch they are firm and elastic. Two 
 medium-sized arteries, one a branch of the renal, enter at the lower 
 border. A few nervous cords are seen entering the gland, but they 
 are neither numerous nor large. On section essentially the same 
 condition is found as in the other organ ; the upper mass has a firm 
 caseous centre, of a uniform greyish-yellow colour, moist, not 
 friable, and softening only at the margins where it is in contact 
 with the fibrous capsules. In the other portion the caseous 
 matter is softer, here and there cretaceous, and interspersed with 
 gelatinous looking fibrous tissue. 
 
 On examination the central caseous masses present nothing of 
 interest, being composed of a finely granular debris in which the 
 remains of degenerated cells and fibres may bo seen. 
 
 Scrapings from the inner surface of the fibrous capsules show a 
 large number of small lymphoid corpuscles, finely gratiular, and 
 not very distinctly nucleated. A few are largo and more granular. 
 With these are numerous spindle-shaped fibre cells, which are the 
 chief elements in the investing capsules, the lymphoid corpuscles 
 occurring in groups or scattered irregularly among them. In the 
 soft gelatinous-looking tissue immediately surrounding the caseous 
 masses and often penetrating them, in addition to the above 
 elements, which also occur in variable numbers, there are found : — 
 
 (1) Cells two or three times the size of white blood corpuscles, 
 with one or two nuclei. Many are in a condition of fatty dogenera- 
 
 i 
 
Addison's disease. 
 
 125 
 
 tion, others have been converted into the compound ji^ranule 
 corpuscles. 
 
 (2) Nunfierous corpuscles resemblinr; the nerve colls described 
 as occurring in the adrenals They are chiefly unipolar, with 
 coarsely granular protoplasm and single nuclei, and with a long 
 process passing off from the body of the cells, rendering them club- 
 shaped ; corpuscles with two or three processes are also common. 
 Many of these look very like ganglion cells, in others the processes 
 are more irregular and the resemblance is less striking. 
 
 (3) Giant cells, of which a number of well marked specimens 
 were found. 
 
 Bladder contains about 3 x of clear normal urine. Walls 
 healthy. 
 
 Stomach. Large veins full, small vessels of mucous membrane 
 at the fundus also injected ; rest of the membrane pale. Scattered 
 throughout the whole mucosa, but chiefly about the cardiac and 
 pyloric extremities, are numerous small, round, white bodies, look- 
 ing like little lenticular glands. Some of them present small 
 orifices in communication with the surface, as if they had ruptured 
 or ulcerated at these points. On examination they are found to 
 be localized lymphoid infiltrations of the mucosa. 
 
 Duodenum is blood-stain 3d, and the small vessels are full of 
 blood. 
 
 Jejunum, and Ileum contain a small amount of dark tarry freces, 
 closely adherent to the mucous membrane. The largo veins are 
 injected. The solitary glands and patches of Poyer are slightly 
 enlarged. Here and there on the mucous membrane of the jejunum 
 are small dark spots which cannot be washed off and appear to be 
 pigmentary depositions. Ab«out six or eight feet from the iloo- 
 Ciecal valve a portion of the intestine 8" in length is curiously 
 thickened, being at least five times as thick as the adjacent parts, 
 and of a somewhat brownish-yellow color. Several thick, partially 
 developed, valvulae conniventes are seen on the mucous surface. 
 On section the surface is uniform, presenting no separation of 
 mucous and mucular coats. 
 
 La)'<je intestine presents nothing abnormal. The solitary glands 
 are very distinct in the ca3cum. There are several masses of dark 
 faeces in the descending colon. 
 
 Liver. Weight, grms. 900. Capsule slightly thickened, especially 
 over the gall bladder. On secLion, organ looks healtliy, surface is 
 imiformly reddened, acini not very distinct. The veins contain 
 
126 
 
 CANADA MEDICAL ASSOCIATION. 
 
 a good deal of blood. In certain regions the substance beneath the 
 capsule is stained of a dark colour; on examination this is found to 
 be due to an accumulation of dark pigment grains in the liver 
 cells, which were, as a rule, slightly granular, and here and there 
 contained oil drops. 
 
 The lymphatic glands of the abdomen, including those of the 
 mesentery, were a little enlarged ; one or two were removed with 
 the supra-renal capsules. 
 
 The caeliac axis with semilunar ganglion and attached nerves 
 were carefully removed. Nothing unusual was observed about 
 them, the sheaths of the nerves were not thickened, and the 
 cells, presented a natural appearance. Long splanchnic nerves 
 and dorsal and lumbar ganglia of the sympathetic also examined. 
 All these parts were compared with those of a woman, aged 40, 
 dead of heart disease, on whom an autopsy was made on the same 
 day, and no appreciable differences found.^ 
 
 Marrow of ribs of a light red colour, abundant, and evidently 
 fatty. On examination, red blood corpuscles exceed all other ele- 
 ments. Marrow cells of usual appearance. The small lymphoid 
 corpuscles, so often met with in marrow, were not noticed. Fat 
 globules more numerous than usual in the ribs. No nucleated 
 red corpuscles, rayeloplaques, or corpuscles containing red blood 
 cells noticed. 
 
 Remarks. I believe this to be the first genuine case of uncom- 
 plicated Addison's Disease which has been publicly communi- 
 cated or published in Canada. The only other report of which 1 
 am aware is one by Prof MacCallum of Montreal, published in 
 the Medical Chronicle for the year 1857. This case, however, 
 must, I am inclined to think, be looked upon as somewhat doubt- 
 ful. The i^atient was the subject of ordinary pulmonary phthisis, 
 and when first seen was in an advanced condition of emaciation, 
 with, at the same time, all the ordinary symptoms and physical 
 signs of this disease. He was distinctly bronzed on the face, back 
 
 1 It is only just to state, with reference to the condition of the nerves going to the cap. 
 sules, tliat no dissection of them was made in situ for the following reason : On tlie evening 
 of the patient's death the father positively refused, in spite of all arguments, to allow of an 
 autopsy, and, as he was going to remove the body in the morning, the supra-renal capsules, 
 with the kidneys and portions of the liver and spleen, were taken out that night per vias 
 unnatiira/es, viz., through the rectum. It was done without any tearing of the capsules, and 
 the riglit one was removed attached to tlie kidney. On the following day the father was in 
 a better state of mind, and consented to an examinsitinn, when, as above mentioned, the 
 caeliac axis, with the semi-lunar ganglion and attached nerves were removed. 
 
ADDISON'S DISEASE. 
 
 127 
 
 1 \.nr^AH and in the axillae. On the chest he had a patchy din- 
 '"i ^fon which was probably chloasma. Affection of the supra- 
 
 lacious as a sign) and P'-^th^lo^ic y constitutes 
 
 true caseous disease in any of its toims, wnicn 
 
 the invariable morbid lesion of this disease, according to Wilks, 
 
 "T e^r^:r:«^^e^^^^ as a typical nnd nncom- 
 
 ^^:^:^^^^--^^^^^ 
 
 ,^f +iii< ntT'pf'tion are concerned, tney n.i\t- i^^w 
 of this ^«^^;;^" ^^^ ti^, essentials may be considered as 
 
 great "^'^^Y^^^J ^^ f' "^^^^ observe how little in 
 
 pretty clearly settled. /^ ^ ^'^^^^^ ^^ .,,1 delineation of the 
 fh\< wav has been done to add to tne oiif^in.u u 
 
 :,;: ;:..:;: o7'r;::inlCp' 'i wmck ,.. .een a,ove 
 
 deWl ,a and on the boaving of Bomo of the fact, npon em-tarn aoc- 
 trh" ; vly broached concerning the alliance between th,. d,«ea e 
 ZIZ forms of anemia, especially progres.ve pern.cous 
 
 ''"'"f^- AstUnia. To show to what a -mavkab^ de^-ee this 
 profound debiUt,..v.,...nty^^^^^^^^^^^^^^ 
 
 r 'r: r;r ::;"r;tition ..r ^he -st e.e,.^n ^^ 
 
 incanabilitv to gva.p with any degree of power, and all th.sw.th- 
 „",t a y parett diminntion in the bulU of the muscles or any 
 
 out aiij '^4^1"^ m.,ri\r rlosoriDtlons 01 tniS 
 
 cuffifiont dc'Tce of emaciation. In many aosciipuun 
 d Lrel.tt:. is placed along with a.tU.ua -; ,^'en n.,do^ o 
 some extent to account for the latter; ''"' ^ '""'' 'V""^ J^^^^ 
 ;ell be double, if anxmia be really an essenUal l»rt of the afl^c 
 tinn (\M-lainlv this casc tcuds rathcr to support the idea that 
 r n,.!:r rrl,:. degrees of asthenia and prostration may be 
 induced by supnwenal disease, without be.ng accompanied by any 
 
128 
 
 Cx\.NADA MEDICAL ASSOCIATION. 
 
 of tl.oso d^nui^, ,n the Wood ,.oir,. under the common term 
 ^—. It wdl be observed th.t the report «t.tes that there ZTe 
 none of theord.nary rnhonul sio-ns of anaemia present , the mucous 
 inen.bra„e., Mi,ere visible, were as red as in heal h, the 3 
 -- ,mte pinic, not white, there was no cardiac bruit.' th^b ::t 
 ^ n d.awn, .van uot at all waterydoolcin. an<l microscopicu 
 oxanunat.on of the same proved that its celhdar elements ap- 
 
 u u 1 In r"r ?'"^"'' ^^'^'"^^ consistence, and of the 
 u f U bnght red colour of perfect health. It is ph.i„ that it 
 
 f, 1 d , "'T:^ ""' ^'"^'"''^^ substantiated to show that the 
 f ll> developed affection may exist and may prove fatal without 
 tlere_ having at any time, been the least appreciable anaemia. 
 ■ ss an interest.n,^ point to settle. Dr. Addison, in his orio.i. 
 >..l descr>pt,o,i, placed anaomia./?r,n.mon^^.sL the prominent symp- 
 torns present; and quite lately Prof Pepper, of Philadelphil 
 li.s ,n an able paper, tried to substantiate an alliance between 
 A.id.son s Disease and some forms of chronic wasting- disease all 
 ^lec'ompanied by profound aiu-emia and which he proposes to call 
 Ana'>,u,tos>s. ^ There is no denying- the fact that it is quite common 
 to f^nd patients with this disease decidedly a.uemic, but that 
 ;.U1. t naturally be expected as a secondary result, from impaired 
 d.gcstion and nutrition. It would be impossible within the limits 
 of these remarks to endeavour to contravert the views of Prof, 
 lepper, but I must content myself with drawing attention to the 
 entiiely negative results of this typical case, as wholly opposed 
 to his theory. This is simply in accordance with the experience 
 Of Dr. Greenhow, for he says - so far as I have been able to ascer- 
 tnin, the composition of the blood does not undergo any important 
 alteration in uncomj.licated cases of Addison's Disease." I have 
 also „nder observation at the present time (singularly enouo-h 
 considering the rarity <,f the complaint) a second patient, a 
 female, with intense bronze ski.,, and who, I am convinced, is the 
 subject of supra-renal disease. Ilor symptoms are, though not so 
 intense, yet just as characteristic of the .Morbus Addisonii as were 
 those in the case of J. P. just read. She has been for ten days 
 at a time in my wards of the Flospital and has been thoroughly ex- 
 amined. >fow this woman, also, though very weak and listh.ss, and 
 suffering from frequent palpitation, yet shou-s no sio-nsof antx)mia • 
 her mucous membranes and nails look quite bright and rod, there is 
 no cardiac bruit, and, under the microscope, the blood appears per- 
 
ADUIS0N''S DISEASE. 
 
 129 
 
 fcctly natural. I miiiht mention tliat in tlioso niiproscopical oxamin- 
 ations T have had the valuable assistance of my colleague Dr. Osier, 
 and therefore, from his known skill and experience in this depart- 
 ment, complete reliance can bo placed upon the results obtained in 
 both these cases. Thus I am convinced that, though ana>mia is very 
 common in Addison's Disease, yet that the essential pathoU.gy of 
 this attection is not to be looked for in the blood. Prof. ro])per, 
 in regarding this disease as of hn'mic origin, has suggested that pro- 
 bably the marrow is at fault, as it coi-tainly is in some of the 
 special forms of antemia. But, in our case, the marrow of all tlio 
 long bo)ics was submitted to careful microscopical examination and 
 found presenting nodiing but the usual healthy ap])earanccs. 
 
 Pains in various parts wore much complained of. The princi- 
 pal site of these was across the abdomen, in the back, and down 
 the thighs. In the female patient to whom I have just alluded 
 similar'pains have been felt for several months. For a long time, 
 on one occasion, it occupied the region of the loft scii.tic nerve, 
 and she was treated tor sciatica. 
 
 Vomiting occurred very frequently, generally spontaneously, in 
 an explosive sort of way, but sometimes catno on as soon as he 
 was made to sit up or to turn round in bed. 
 
 The pJujsiognomij and^ mental c.omlition were both very peculiar. 
 The odd way in which he would whinge and half-cry when spoken 
 to has boon* alluded to, as well as the puerility of his whole con-^ 
 duct. This state was to me very singular. I am not aware of 
 having noticed anything exactly like it in any other disease. I do 
 not tind that this is specially noted in many of the collected cases 
 of Dr. Greenhow, but the very first case of Addison's collection' 
 describes it exactly. He says: " the voice is puny and puerile, the 
 patient speaking with a kind of indescribable whine, and his 
 whole demeanor is childish." I would also remark here the way 
 in which these symptoms abated to a groat extent for a few days 
 before his death. This was co-incidont with improvement m al 
 most all the symptoms. This tendency to intermissions, QV^n in 
 advanced cases of this disease, has often been noticed. 
 
 The temperature followed the general rule, of being almost 
 constantly subnormal, although before his admission there was 
 Blight elevation of temi)erature, probably to be accounted lor by 
 some local inflammatory action. 
 
 \s roo-ards the date of appearance of the discolouration, m con- 
 nection with the generaUymptoms, it was impossible to establish 
 
130 
 
 CANADA MEDICAL ASSOCIATION. 
 
 it very definitely. He was a coal carter, and consequently it 
 would take a considerable degree of darkening to be appreciable 
 through his normally smutty skin. But, as stated, I think from 
 what wo could learn, that he was ailing several months before dis- 
 colouration began, which also would be in accordance with what 
 has usually been observed. 
 
 His occupation calls for a word. He was a coal carter, and 
 therefore much exposed to very heavy manual labor, and frequent 
 heavy lifts and strains. According to Greenhow, the great majority 
 of all cases occur in the lower and the hard-working classes; and 
 he is inclined to attribute some importance to the fact, because he 
 thinks that the disease may, perhaps, be often originated by some 
 violent wrench or strain upon the loins. 
 
 The supra renal capsules were in a stage very commonly met 
 with, viz., that of extensive caseous deposit, with some softening— 
 a sort of medium stage, not having advanced either to the com- 
 pletely-softened or puriform stage, nor to the still later cretifbrm 
 stage, which is sometimes seen, with shrinking of the organ. 
 They were surrounded by very dense and firm connective tissue. 
 The exact connections of this, and the manner in which it involved 
 the surrounding nerves, could not, I regret to say, be as carefully 
 examined as I could have wished, owing, as already explained, to 
 the somewhat peculiar manner in which the autopsy was origin- 
 ally performed. The view adopted by Dr. Greenhow, and 
 very generally accepted, that the disease is caused in some way 
 or other by involvement of large branches of the sympathetic and 
 other nerves in an advancing sclerosis of the adjacent areolar tissue 
 has, I think, everything to commend it. It is certainly the only 
 theory yet given capable of at all explaining the peculiarities of 
 this truly singular disease. One grave argument against it is 
 that a great many cases have been recorded where no lesion of 
 these nerves could be detected : this case adds one more to the 
 number of these, for, though the branches going to the glands 
 were carefully examined, nothing abnormal could be found. 
 
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