THE SUPRARENAL SYSTEM l6l 



accompanied by symptoms of Addison's disease " are to be ex- 

 plained, in the light of our present knowledge, by a pathological 

 condition of the cortex only. Where, however, there were demon- 

 strable changes in the medullary substance, the functional activity 

 of the adrenal system might be carried on by its extracapsular 

 portions. 



Wiesel's findings are confirmed by those of Beitzke, but 

 both v. Hansemann and Karakascheff are opposed to his views. 

 The latter even goes so far as to ascribe Addison's disease to a 

 pathological condition, not of the chromaffine tissue, but of the 

 cortex of the suprarenals. He describes a case in which, notwith- 

 standing complete caseation of both suprarenals, the symptoms of 

 Addison's disease were absent. But in this case there was an 

 accessory suprarenal consisting only of cortical substance an 

 accessory interrenal. Bittorf and Beitzke are of the opinion, 

 however, that not only does Karakascheff's case prove nothing 

 against Wiesel's theory, but that it does not establish his own, 

 that, namely, of the paramount importance of the cortex in the 

 etiology of Addison's disease. Bittorf believes that the patho- 

 genesis of Addison's disease does not lie solely with the 

 chromaffine system. He bases his view upon the localization in 

 the suprarenals of the atrophic disturbances described above ; and 

 upon one case in which distinct symptoms of Addison's disease 

 were present, in spite of the fact that the chromaffine tissue 

 was intact, the suprarenals being only partially destroyed by 

 hypernephrometastases. As Karakascheff and Bittorf pointed 

 out, the chief evidence against Weisel's theory lies in certain 

 findings by him and Hedinger of extreme hypoplasia of the 

 chromaffine system, unaccompanied by any symptoms of 

 Addison's disease. 



It is still more difficult to account by Wiesel's theory for 

 those typical cases of Addison's disease where there is either 

 complete disorganization of the suprarenals or pronounced 

 destruction of the cortex, the medulla being comparatively sound. 

 In the latter class of case, considerable portions of the medullary 

 substance and of the extracapsular chromaffine tissue may still be 

 intact. Wiesel explains these cases by the assumption that, owing 

 to the intimate topographical relationship between medulla and 

 cortex and the fact of their common circulatory system, the 

 affection of the cortex is a secondary condition resulting from the 

 primary disease of the adrenal system. But until very definite 

 grounds upon which to base such an assumption are forthcoming, 

 the only tenable theory concerning the pathogenesis of Addison's 

 disease is that which refers it to the suprarenals as a whole, and 

 not to certain portions of them. From such a point of view, whether 

 the medulla or the cortex is the part primarily affected is 

 immaterial, for the functional disturbance of one part is invariably 

 followed by that of the other ; and it is the disease of the entire 

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