Subscription is FREE for qualified healthcare professionals in the US.
10 Articles in Volume 15, Issue #10
2015 Has Been a Good Year for Clinical Progress
Addison’s Original 1855 Cases Reveal Stories of Chronic Pain
Can We Prevent Chronic Pain?
Letters to the Editor: Nerve Fiber Testing, Fibromyalgia
Medication Guide for Pain—A Short Primer for Primary Care
Odd Pet Behavior During SCS Trial—Case Report
Opioid-Induced Constipation: New and Emerging Therapies—Update 2015
Palliative Care: Dying With Dignity
PPM Editorial Board: Year in Pain Management 2015
QT Intervals and Antidepressants

Addison’s Original 1855 Cases Reveal Stories of Chronic Pain

Two of the 11 case reports described severe, intractable pain that appeared to be the cause of adrenal failure and death.
Page 1 of 2

Adrenal failure or insufficiency is commonly referred to as Addison’s Disease or Addison’s Syndrome. Thomas Addison, MD, a physician at Guy’s Hospital, in London, first described this syndrome in 1855 in a report entitled, On the Constitutional and Local Effects of Disease of the Supra-Renal Capsules.1

In the 5 years prior to writing his report, Dr. Addison identified 11 patients who had an unusual clinical disorder. According to Dr. Addison, “The leading and characteristic features of the morbid state … are anemia, general languor, debility, remarkable feebleness of the heart’s action, irritability of the stomach, and a peculiar change of colour in the skin, occurring in the complexion with a diseased condition of the supra-renal capsule.” (In later history, the name of the glands located at the top of the kidney were changed from supra-renal to adrenal.)

Extremely low levels of serum cortisol and other adrenal hormones have been detected in severe pain patients.2,3 These levels can become so low that they are life threatening. Hormone testing and treatment are becoming a more common component of pain management.4 Given the increasing role of hormone testing and treatment in pain management, I reviewed Dr. Addison’s original 1855 report. Most interesting, 2 of his 11 cases of adrenal failure appeared to be due to intractable pain. The other 9 cases were apparently due to tuberculosis or carcinoma.

As part of his report, Dr. Addison had an artist draw a picture of 8 of his 11 patients as well as some internal organs removed at autopsy, which showed dark brown, pigmented, freckle-type lesions along with adrenal insufficiency (Figure 1).

Addison’s Description of the Disease

The clinical description of adrenal failure, including skin discoloration and pigmentation, laid out by Dr. Addison is quite descriptive and eloquent. His verbatim description is given here.1

“The disease presents in the same general character... It occurs in both sexes, generally, but not exclusively, beyond the middle period of life, and so far as I present know, chiefly in persons of a somewhat large and bulky frame, and with a strongly-marked tendency to the formation of fat. It makes its approach in so slow and insidious a manner, that the patient can hardly fix a date to his earliest feeling of that languor, which is shortly to become so extreme…

The countenance gets pale, the whites of the eyes become pearly, the general frame flabby rather than wasted; the pulse perhaps large, but remarkably soft and compressible, and occasionally with a slight jerk, especially under the slightest excitement; there is an increasing indisposition to exertion, with an uncomfortable feeling of faintness or breathlessness on attempting it; the heart is readily made to palpitate; the whole surface of the body presents a blanched, smooth, and waxy appearance; the lips, gums, and tongue seem bloodless; the flabbiness of the solids increases; the appetite fails; extreme languor and faintness supervene, breathlessness and palpitations being produced by the most trifling exertion or emotion; some slight edema is probably perceived about the ankles…

The debility becomes extreme, the patient can no longer rise from his bed, the mind occasionally wanders, he falls into a prostrate and half-torpid state, and at length expires: nevertheless to the very last, and after a sickness of perhaps several months’ duration, the bulkiness of the general frame and the amount of obesity often present a most striking contrast to the failure and exhaustion observable in every other respect.”

In his narrative, Dr. Addison was particularly impressed with the skin discoloration and pigmentation of his patients. He wrote about it with an emphasis indicating that this was a sign for physicians to observe and diagnose the condition while the patient was still alive.

“We discover a most remarkable, and, so far as I know, characteristic discoloration taking place in the skin—sufficiently marked indeed as generally to have attracted the attention of the patient himself, or of the patient’s friends. This discoloration pervades the whole surface of the body, but is commonly most strongly manifested on the face, neck, superior extremities, penis and scrotum, and in the flexures of the axillae and around the naval. It may be said to present a dingy or smoky appearance, or various tints or shades of deep amber or chestnut-brown…

In some instances this discoloration occurs in patches, or perhaps rather certain parts are so much darker than others, as to impart to the surface a mottled or somewhat checkered appearance.”

Dr. Addison called attention to pigment cell abnormalities that manifested in the form of “small black spots,” which were on the skin as well as on some internal organs.

Addison Case #1

Henry Patten was a 26-year-old carpenter and window-blind maker admitted to Guy’s Hospital on November 9, 1854. Up to 6 months prior, the patient stated that he enjoyed very good health. Then he began to be troubled with “rheumatic” pains in the right leg, which, without laying him up, gradually extended to the hips and side, and thence to the bottom of the spine.

Latterly, he described his back as very tender—a jerk or jarring movement caused great pain. For the month preceding hospitalization, he discontinued work due to attacks of “giddiness and dimness of sight, accompanied by a peculiar pain in the back of the head and partial loss of consciousness.” These attacks would occur several times a day, usually upon exertion, upon standing, and were instantly relieved by sitting or lying down.

“Over the face and forehead, which are of a general yellowish hue, are several patches of darkened skin and similar black patches on the lips,” continued Dr. Addison (Figure 2). “There is angular curvature at the second, and great tenderness on pressure over the upper three lumbar vertebrae; he complains also of pain at this part upon moving in bed.”

In the 3 days before he died, the patient developed an incessant hiccough and pain “about the waist,” which was later found to be a psoas abscess on the right side, “extending from Poupart’s ligament to the disease vertebrae, and holding about a pint of flaky pus.”

Dr. Addison wrote the following about Mr. Patton’s autopsy findings: “the [abscess] was between the first and second vertebrae, commencing in the cartilage, and nearly destroying the neighboring vertebrae at their centers. The bone surrounding the cavity was red, soft, and infiltrated with strumous matter…Each supra-renal capsule was completely destroyed and converted into a mass of strumous disease.” (Figure 3)

The report concluded by saying that the patient “labored under a serious affection of the spine,” and the symptoms were also indicative of the clinical syndrome found with adrenal failure.

Last updated on: December 8, 2015
Continue Reading:
Opioid-Induced Constipation: New and Emerging Therapies—Update 2015

Join The Conversation

Register or Log-in to Join the Conversation
close X