PATHOLOGICAL ANATOMY AND HISTOLOGY 269 



we can hardly say that we understand as yet the pathogenesis of morbus 

 Addisonii nor the relative importance of the involvement of cortex or 

 medulla in the production of the symptoms. A distinct step forward was 

 taken when Star called attention to the presence of a persistent thymus in 

 the adult in certain cases. Since Star's observation the attention of many 

 authors has been directed to the coexistence of status thymolymphaticus 

 and Addison's disease. Hedinger(a), for example, reports 15 cases in 

 seven of which there was marked status thymolymphaticus, in five cases 

 hyperplasia of the general lymphadenoid apparatus, and three cases in 

 which the data in regard to thymus gland and lymph nodes were negative 

 or uncertain. Kahn, Wiesel(fr) and others have also reported cases where 

 this association existed. The coexistence of the two morbid conditions 

 has an important bearing upon the question of the relative importance of 

 lesions of cortex and medulla in the causation of the disease, because in 

 status thymolymphaticus there is a distinct hypoplasia of the general 

 chromaphil system. A very puzzling fact in a typical case of Addison's 

 disease is the extensive tuberculous destruction of both suprarenal glands 

 with often comparatively slight tuberculosis of other organs. Elsasser(a) 

 found isolated tuberculosis of the adrenals in 17 per cent of 549 cases in 

 the literature. The only possible explanation of such an isolated tuber- 

 culosis is in a lowered resistance of the organ, due to insufficiency either 

 congenital or acquired. Karakascheff reported cases in which cortical 

 destruction was the chief condition and he argues in favor of the greater 

 importance of the cortex in the pathogenesis of the disease. Wiesel(fr), on 

 the other hand, considers that destructive change in the cortex is neces- 

 sary but that lesions of the chromaphil tissue must exist either within or 

 without the gland. In a recent typical case with extensive caseation and 

 fibrosis of the glands we were able to find isolated islands of apparently 

 normal cortical material whilst no trace of medulla could be found. A 

 great difficulty is to understand cases in which there is Addison's disease' 

 with reported normal suprarenals. Lewin in his monograph of 561 

 cases found 12 per cent without lesions of the suprarenals and since his 

 analysis numerous other cases have been reported. The occurrence of 

 destructive disease of the glands without Addison's disease can be ex- 

 plained on the view that the factor of safety in cortical material had not 

 been overstepped and the general chromaphil system was normal or 

 hyperplastic. The general asthenia and low blood pressure are commonly 

 explained on the grounds of chromaphil insufficiency and the gastro-intes- 

 tinal symptoms as secondary to the vasomotor disturbances consequent 

 upon this insufficiency. The explanation of the pigmentation of the skin 

 and mucous membranes present, on the other hand, considerable difficulty. 

 It is true that the pigmentation varies in amount and may be absent, 

 It is apt to be a manifestation of the later stages of the disease and so 

 cannot rank in importance with the other symptoms, but it is such a 



