THE SUPRARENAL SYSTEM 159 



about in man by haemorrhage into the organ. Such suprarenal 

 haemorrhages are seen in still-born children, and these may per- 

 haps occur intra partum. Sudden destruction of the suprarenals 

 may, however, take place in later life as a result of haemorrhage or 

 suppuration of the organ. 



The symptom-complex of this form of suprarenal disease was 

 first described by Virchow. There are very severe nervous 

 symptoms, together with peritonitis, and these end rapidly in 

 death. Post-mortem examination shows that, in the greater number 

 of these cases, the haemorrhage is due to trauma, emboli, or 

 thrombi ; in rare cases, acute suppuration was found. Acute 

 suprarenal suppression to a certain extent resembles the condition 

 produced in animals by the extirpation of both suprarenals. In 

 subacute cases pigmentation of the skin is rarely absent. 



The cases of chronic suprarenal suppression which have been 

 described have a greater significance. Bittorf has recently 

 classified chronic suprarenal insufficiency under two headings. 

 The first group includes those cases in which the disease is primary 

 and is due to atrophy, hypoplasia, or cirrhosis of the organ. The 

 second comprises those cases where the suprarenal insufficiency 

 is secondary, and occurs as the result of tuberculosis, syphilis, or 

 tumours. In the literature of the subject, Bittorf found accounts of 

 forty-seven cases of primary atrophy, and to these he added five 

 cases which came under his own observation, and of which two 

 were clinical only. Anatomically, these were all cases either of 

 simple atrophy or of chronic, inflammatory, connective tissue cir- 

 rhosis. The degenerative changes were not confined to any particu- 

 lar portion of the organ. In some instances the cortex only was 

 affected ; in others the medulla only ; but in the majority of cases 

 both portions were affected, though unequally. Clinically, all 

 these cases were characterized by more or less clearly marked 

 symptoms of Addison's disease; the pigmentation of the skin, 

 in particular, was always present, though in a varying degree. 



Primary disease of the suprarenals is of comparatively rare 

 occurrence, secondary conditions such as those which form the 

 groundwork of Addison's disease being of far greater frequency. 

 The typical anatomical finding in Addison's disease is tubercu- 

 losis of both suprarenals, which may be the sole finding, or it may 

 be associated with a tuberculous condition of other organs. As a 

 general rule, there is complete, or nearly complete, caseation and 

 fibrous induration with chalky deposits or caseous softening. 

 More rarely, syphilitic processes and tumours have been 

 observed. 



This extreme and very typical suprarenal degeneration is, 

 however, not present in all cases. As early as 1885, Lewin col- 

 lected 381 cases of typical Addison's disease, and of these the 

 suprarenals were affected in only 281 cases, in 37 they were 

 intact. In a later communication he describes 316 fresh cases, 



