316 CLINICAL CONSIDERATIONS 



24 out of his 25 cases. The cells were hypertrophic and hyper- 

 chromatic. The amount of this remaining tissue was esti- 

 mated at less than 5 per cent of the whole normal gland. In 

 only one case was any medulla seen, and this case was the 

 only one in which no pigmentation occurred. In cases in 

 which as much as 80 per cent of the adrenals had been de- 

 stroyed by tuberculosis there were no symptoms of Addison's 

 disease. The process apparently starts in the medulla or mid- 

 cortical region and spreads centrifugally. Healed processes are 

 not observed, indicating the progressive course of the disease. 



Although the adrenals are the chief site of tuberculous infec- 

 tion in many cases, it is doubtful if the lesion in these organs 

 is ever primary. The infection in the adrenals is probably 

 hematogenous in origin. 255 As is the case in tuberculous infec- 

 tion of the eye or kidney, the lesion is first unilateral and then 

 extends to the second organ. The fact that 90 per cent of 

 the cortical tissue must be destroyed before symptoms of Ad- 

 dison's disease are evident, explains why (unlike in the kidney 

 or eye) unilateral infection of the adrenals does not manifest 

 itself during life. At autopsy, however, one frequently ob- 

 serves tuberculous lesions of the adrenals from a slight unilat- 

 eral to a partial bilateral stage of advancement without any 

 clinical symptoms of the disease having manifested themselves 

 during life. 



Miliary tuberculosis of the adrenals is not common, but 

 careful examination of the adrenals in generalized miliary tu- 

 berculosis will usually reveal some small foci of infection. 417 



There is often extensive tuberculous destruction of both adre- 

 nal glands with comparatively little disease of other organs. 

 Elsasser 417 found isolated tuberculosis of the adrenals in 17 

 per cent of 549 cases. 



Atrophy. About 10 per cent of all cases of Addison's disease 

 are caused by atrophy, which may involve the cortex only or 

 may affect the entire gland so that no trace of the glands is 

 visible on gross examination at autopsy. However, careful 



