l6o INTERNAL SECRETION 



and in 25 of these the suprarenals were sound. The occurrence of 

 cases which present all the clinical signs of Addison's disease with 

 anatomically sound suprarenals, when taken in conjunction with 

 certain pathological changes which have been observed in the 

 sympathetic system, suggest that the pathogenetic factor in this 

 condition does not lie with the suprarenals, but is to be sought 

 in the sympathetic system itself. Nevertheless, a critical con- 

 sideration of the material at his disposal compelled v. Kahlden 

 (1896) to adopt the view that the changes in the sympathetic 

 system, and especially in the spinal cord, generally slight in 

 character, though occasionally severe, are without any patho- 

 genetic significance in this condition. 



The nervous or sympathetic theory assumed that Addison's 

 disease originated in a pathologically demonstrable affection of the 

 nervous system, but in its original form this theory is no longer 

 tenable. A certain measure of etiological responsibility is ascribed 

 to the sympathetic system by Neusser, who regards Addison's 

 disease as a systemic affection which may take its rise in any 

 portion of the chain in the spinal cord, the sympathetic nerves, or 

 the suprarenals. Neusser's view is supported by a fact which I 

 have proved, namely, that certain fibres of the splanchnic nerves 

 act upon the suprarenals as vaso-dilators, while others may exer- 

 cise an influence upon suprarenal secretion. 



Owing to the advances which have been made in anatomy and 

 embryology, the sympathetic theory has necessarily changed 

 in form, but in certain directions it receives a measure of support 

 from Wiesel's recent publications. Wiesel does not find, how- 

 ever, that the cause of Addison's disease lies with the nervous 

 system itself, he believes that it is to be sought in the adrenal 

 system, so intimately connected with the nervous system 

 genetically, anatomically, and functionally. He describes six 

 cases in which there was serious degeneration and even destruction 

 of the chrome-brown cells, not in the medullary substance of the 

 suprarenals only, but also in the free parts of the adrenal system 

 in the neighbourhood of the sympathetic. In one case, that of 

 severe double tuberculosis of the suprarenals unaccompanied by 

 symptoms of Addison's disease, not only was there no absence of 

 the chrome-brown tissue, but there was distinct hyperplasia of 

 it. If these findings show that Addison's disease is due to a 

 pathological condition of the chrome-brown tissue, then all the 

 earlier observations of cases of " Addison's disease with sound 

 suprarenals " lose their significance. For those observations were 

 founded upon an imperfect knowledge of anatomy, the adrenal 

 system being at that time little understood. Moreover, there was 

 always the possibility that in such cases the intracapsular portion 

 of the adrenal system, the suprarenal medulla, had at first remained 

 sound, the free portions only being primarily or more severely 

 affected. On the other hand, cases of " suprarenal affection un- 



