280 BENSON A. COHOE 



currence as : (1) the fibrocaseoiis lesion, due to tuberculosis; (2) simple 

 atrophy; (3) chronic interstitial inflammation leading to atrophy; (4) 

 malignant disease, invading the capsules, including Addison's case of 

 malignant nodule compressing the suprarenal vein; (5) blood extravasated 

 into the suprarenal bodies; (6) no lesion of the suprarenal bodies them- 

 selves, but pressure, or inflammation, involving the semilunar ganglia. 



In a study of 561 autopsy reports in Addison's disease, Lewin found 

 tuberculosis of the glands present in 75 per cent of the cases. Some au- 

 thorities believe the incidence to be even greater. The lesion is usually 

 bilateral, although, at times, only one gland may be affected. In Ad- 

 dison's original series of eleven cases, five showed caseous tubercle of 

 both suprarenals, while in one case, only one gland was diseased. There 

 is reason to believe that the suprarenals may, in some cases, be primarily 

 affected with the tuberculous process; Elsasser(&), in 549 cases, found 

 isolated tuberculosis in 17 per cent of the cases. More frequently tubercu- 

 lous foci are found in other parts of the body especially the lungs (43 per 

 cent, Elsasser), peritoneum, bones and gen ito-uri nary tract. It is thought 

 that the suprarenals may become infected from the neighboring mesenteric 

 glands in tuberculous subjects, or from the vertebrae, since some cases 

 have been associated with caries of the spine. The tuberculous process 

 affects both the cortex and medulla of the gland, in varying degree, with 

 more or less complete caseation, or with softening, fibrosis, or calcification. 

 Tubercle bacilli have been frequently found in these foci. Macroscopi- 

 cally, the glands may be greatly diminished in size, or in some instances 

 enlarged, presenting the appearance of tumors. The gland parenchyma 

 shows varying degrees of destruction, the medulla and cortex being uni- 

 formly involved, as a rule, but in some cases, chiefly cortex, or chiefly 

 medulla have been found affected. 



Atrophy of the gland is the second most frequent lesion found at 

 autopsy. Bittorf(a) was able to collect 50 cases of simple atrophy. Macro- 

 scopically, in such cases, the gland is greatly diminished in size, at times 

 being less than a millimeter in thickness. The normal shape may be pre- 

 served, or the gland may have become entirely shrunken and fused with 

 the surrounding tissues. In some instances, it may have been reduced 

 to a small mass of fat, or one suprarenal may have wholly disappeared. 

 Bittorf states that in all cases the lesion is bilateral. There may be either 

 (1) a simple atrophy, or (2) a chronic interstitial inflammatory type of 

 atrophy of the gland parenchyma, resembling a cirrhosis. In the simple 

 atrophy the alterations in the parenchyma may be only slight, of the 

 nature of an aplasia, or of the absence of one or more layers of the paren- 

 chyma. In other cases fatty degeneration or necrosis may be found. 

 Lymphocytic foci have been noted. In the inflammatory type, the paren- 

 chyma cells show various forms of degeneration, with a marked increase 

 in the intercellular fibrous tissue. 



