PATHOLOGICAL ANATOMY AND HISTOLOGY 271 



variation in size of the cells and the nuclei and giant nuclei, as well as 

 true tumor giant cells are frequent. 



Hypernephromata and conditions of cortical hyperplasia often have 

 an interesting effect upon the sexual glands and secondary sexual char- 

 acter which will be referred to later. 



The tumors of the suprarenal medulla, aside from hyperplastic change 

 or tumor formation arising in the cortical tissue, carried into the develop- 

 ing organ by the vessels are all of a very special type, genetically related * 

 as the medulla is to the sympathetic system and the chromaphil tissue of 

 the sympathetic trunk. The three types of cells present in the medulla 

 may each give rise to tumors, viz., the embryonic cells of the sympathetic 

 system sympathogonia, the ganglion cells of the sympathetic 

 system and the chromaphil cells themselves, Herxheimer designates 

 the three types of tumors according to the stage of development: neuro- 

 blastomata from the sympathogonia, ganglioneuromata in which more 

 fully differentiated ganglion cells are present, and paragangliomata 

 those which arise from and are formed of cells with chromaphil 

 reaction. The first form, the unripe type, the second and third, the ripe 

 type. The paragangliomata are rare tumors ; not many have been de- 

 scribed, but their rarity in the literature is probably due to the fact that 

 they are small and often overlooked. They occur in adult life, are usually 

 of accidental finding and are not malignant. They consist of cells more or 

 less polyhedrons in form with indistinct cell boundaries, large well stained 

 nuclei ; some cases are described where true tumor giant cells occur. They 

 are characterized by the presence of the chrom reaction. and epinephrin 

 has been demonstrated in them. They not only, occur in the medulla of 

 the suprarenal but may develop in other parts of the paraganglionic 

 system. The chromaphil reaction varies very much in different parts of 

 the tumor and often one finds collections of small cells, evidently sym- 

 pathogonia, amongst the larger tumor cells; in several cases they have 

 shown cystic degeneration. An interesting point is that in a number of 

 cases of von Recklinghausen's neurofibromatosis, either paragangliomata 

 or hyperplasia of the chromaphil tissue of the suprarenal medulla has 

 been found. The tumors of the chromaphil tissue, however, are to be 

 regarded rather as an indication of a general systemic involvement of 

 the sympathetic system, and not as the underlying cause of the neurofibro- 

 matosis. In addition, probably the majority of paragangliomata are not 

 associated with von Recklinghausen's disease. 



The second ripe type of medullary tumor is the ganglioneuromata. 

 Herxheimer in 1914 collected records of twenty-nine cases; only eleven 

 of these were in the suprarenal medulla or closely associated with the 

 glands. The type of cell is evidently the sympathetic ganglion cell but 

 they also contain more or less numerous non-medullated nerve fibers. The 

 ganglion cells are often distinctly embryonic in type, frequently much 



