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Addison's Disease.

Synonyms.—Bronzed Skin Disease; Melasma Suprarenale.

Definition.—A chronic disease characterized by progressive asthenia. A bronzed pigmentation of the skin, irritability of the gastro-intestinal tract, feebleness of the heart's action, with degeneration of the suprarenal capsules.

Etiology.—The disease occurs most frequently between the ages of twenty and forty, and affects males more frequently than females. Blows and injuries to the back would suggest traumatism as a predisposing cause; the lesion is almost constantly associated with tuberculosis of the suprarenal capsules. A rare disease and one of unknown etiology.

Pathology.—Both capsules are usually involved, though occasionally but one is found affected, and in still rarer cases neither appear to be the seat of the disease, the disturbance being confined to the sympathetic plexus around the organs.

The glands are usually enlarged, firm, and nodulated, irregular in form, showing the characteristic caseous masses of the tuberculosis. In rare cases the tubercular lesion seems to be primary and confined to the capsules, though generally associated with tuberculosis of the lungs, bones, and viscera in general.

In some cases, owing to interstitial changes, fibrous tissue preponderates, or the glands may atrophy, becoming sclerotic, or they may be replaced by fatty deposits. Malignant growths may destroy their function.

In a few cases the pathological changes seem to be confined to the sympathetic, and consist of degeneration, congestion, hemorrhages, and infiltration by leukocytes, or new connective tissue in the ganglia and nerve fibers. Parenchymatous or fatty degeneration is sometimes found in heart, liver, and kidneys. The spleen, in some cases, is enlarged, showing more or less degeneration of its tissue. The blood shows the same changes that are found in anemia.

Symptoms.—Asthenia.—Prostration comes on gradually, but sometimes quite rapidly, and is shown by general lassitude. The patient complains of always being tired, and is unrefreshed by his night's rest. He becomes weak, listless, takes but little interest in his surroundings, and grows peevish or despondent. The prostration is progressive.

Cardiac feebleness is manifested by occasional attacks of syncope, any one of which may prove fatal. The pulse shows characteristic weakness, though it may be quite rapid. The heart-sounds are quite feeble. As the disease advances, there is palpitation of the heart, and dyspnea of a distressing character upon slight exertion. Disturbance of vision, dizziness, ringing in the ears, headache, and various other cerebral symptoms appear. In the last stages, stupor, delirium, and coma may follow one another in quick succession, terminating in convulsions and death.

Gastro-intestinal symptoms are nearly always present. Nausea and vomiting are among the early symptoms, and may persist to the end. At times it is violent, coming on in paroxysms, and does not appear to be due to any wrongs of the stomach, as the tongue may be clean and digestion fair, but to irritation of the sympathetic. Diarrhea is the rule, and accompanies the gastric disturbance. Pain in the epigastric, hypochondriac, and lumbar regions is not uncommon.

Pigmentation of the skin gradually appears in the form of a bronze or copper color, after the constitutional symptoms become well marked, though it may be among the first symptoms observed. It usually begins upon the exposed parts of the body, as the face, neck, and hands, and where natural pigmentation is most marked, as around the areola of the nipple, in the axilla, and around the genital organs and in the groin.

The color varies from a yellowish-brown to an olive or bronze color, the patient assuming sometimes the hue of a mulatto. The mucous membrane of the mouth and vagina may show bluish or purplish patches of discoloration.

Renal symptoms may or may not be present; thus polyuria is seen in some cases, while in others the quantity is but little affected. There is but little emaciation, though general evidence of anemia is present. The temperature is normal or subnormal.

Diagnosis.—In typical cases, the diagnosis is comparatively easy. The marked asthenia, feebleness of heart and circulation, gastro-intestinal irritation, anemia without emaciation, and the bronze or brown discoloration, are a group of symptoms that can hardly be mistaken. In atypical cases, where the constitutional symptoms are slight, the diagnosis becomes more difficult. It may be mistaken for malignant or tuberculous lesions of the abdomen, or cirrhosis of the liver, for pregnancy and uterine diseases, protracted cases of jaundice, chronic malaria, nitrate of silver discolorations, arsenic pigmentation, vagabond's disease, and other lesions that are attended by more or less pigmentation of the skin.

Prognosis.—The prognosis is unfavorable, the disease usually terminating fatally in from one to two years, though in rare cases the patient may live five or even ten years.

Treatment.—The treatment will be along the same line as suggested in leukemia, and will consist of hygienic, dietetic, and medicinal measures. The patient should avoid overexertion, either mental or physical, lead a quiet life in the open air and sunshine, take light, easily digested, and nutritious food.

Various drugs, such as iron, arsenic, the iodids, guaiacol carbonate, and many others, have been used, but are of doubtful value. The stomach may be quieted with small doses of ipecac, peach-tree infusion, bismuth, and rhus tox., and cactus may have some influence in strengthening the heart, but we are not to expect too much from medication. The administration of the extract of suprarenal capsules has many advocates, and a few cases have been reported benefited from their use, though the remedy has not been tried sufficiently long to warrant us in hailing it as a specific.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.

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