HYPOADRENIA 317 



It is impossible, in the majority of cases, to differentiate these two condi- 

 tions either clinically or pathologically. Simple hemorrhage has been 

 noted in a few cases, but the inflammatory changes which have been ob- 

 served are almost always found associated with more or less hemorrhagic 

 extravasation and necrosis. Apart from hemorrhage and inflammation, 

 suppurative processes in the gland substance have been observed in a 

 few cases of acute hypoadrenia. 



Suprarenal hemorrhage was first recognized as a clinical entity by 

 Rayer (1837), since which time the condition has been carefully studied. 

 It is known to be a common cause of death in the new born, and instances 

 of sudden death in adults have been often attributed to suprarenal hemor- 

 rhage the so-called suprarenal apoplexy. The rich vascularity of these 

 glands, ranking next to that of the thyroid, would appear to predispose 

 them to hemorrhage. Simple small hemorrhages occur most frequently 

 within the medullary substance of the gland, and if sufficiently small, may 

 cause only slight destruction of the cortex. Multiple small hemorrhages 

 occur mainly in the cortical tissue, rather than in the medulla, and are 

 usually accompanied by more or less necrosis of the cortical cells. Sud- 

 den death in acute suprarenal insufficiency is usually associated with 

 hemorrhage into the medulla. The hemorrhage may be single or multiple, 

 and vary greatly in size. In Rayer's case the hemorrhage formed a blood 

 cyst weighing two kilos, and in a case recently reported by Lusk and Brum- 

 baugh, the hematoma extended from the brim of the pelvis to the splenic 

 flexure and was estimated to be formed of about three litres of blood. 



Hemorrhage of the suprarenals has been attributed to a manifold 

 variety of causes, including circulatory disturbances, intoxications, in- 

 fections, trauma, superficial burns, asphyxia, inflammatory or suppurative 

 changes in the gland, hemorrhagic diathesis, convulsions, neoplasm, and 

 hydatid cyst. On account of the rich vascularity it is believed that simple 

 alterations in the blood supply, or a sudden rise in the blood pressure may 

 give rise to hemorrhage in the gland. Dudgeon is of the opinion that 

 any disease which is known to produce stagnation of the blood in the 

 veins, or a marked increase in the blood pressure may be a causative factor 

 of suprarenal hemorrhage. Boinet(^) has reported sudden death following 

 the injection of epinephrin in Addison's disease, due to the sudden raising 

 of blood pressure in an already diseased gland. Similarly, paroxysms of 

 coughing, and epileptic convulsions, may produce hemorrhage by a sudden 

 rise in blood pressure. Infectious diseases are frequently accompanied 

 by alterations in the glands, among which alterations hemorrhage and 

 necrosis are commonly found. Trauma has been noted as a factor in only 

 a few instances. Severe superficial burns have been regarded as the 

 cause of hemorrhage in cases reported by Dudgeon and by Arnaud, in 

 both of which instances the clinical symptoms of hypoadrenia appeared 

 before death. More recently, Weiskotten has attributed the changes found 



