346 CROWELL. 



of typical Addison's disease collected by Lewin,(i) sound adrenals were 

 found in 12 per cent and diseased ones in 88 per cent. 



Typical cases of Addison's disease associated with destruction of tlie adrenals 

 by causes other than tuberculosis are not infrequent. Some of these have been 

 collected in a recent survey of the literature. 



Simple atrophy of the adrenals has been found in Addison's disease by Gold- 

 schmidt(2) (one case), Philips (3) (one ease), Karakascheff (4) (five cases), 

 Marchand(5) (one case), Bittorf(6) (three cases), RoloflFC?) (one case), and 

 BramwelKS) (one case). 



Complete aplasia of the adrenals was reported in one case by Bramwell.(9) 

 Amyloid degeneration has also been assigned as the cause in one case by Bit- 

 torf.(lO) 



Tumors of the adrenals in association with Addison's disease have been recorded 

 by Bittorf(lO) (two cases, hypernephroma) Marchand,(li) (one case, hyperne- 

 phroma), and Fleiner(12) (one case, sarcoma). 



Thrombosis of the adrenal veins has been described as the cause of acute 

 Addison's disease by Simmonds(13) (one case), Straub(l4) (one case), and 

 Bittorf(lO) (one case). 



Pressure on the splanchnic nerve by an aneurism of the abdominal aorta was 

 reported in one case by Jiirgens.ClS) This case is of interest as suggesting the 

 splanchnic nerve as bearing a trophic relation to the adrenals. Dreyer,(l6) Tsche- 

 boksaroff,(l7) and Asher(l8) have proved that the major splanchnic is the 

 secretory nerve of the adrenals and that the vagus has no influence over the 

 adrenal secretion. 



Instances of adrenal destruction without Addison's disease are also numerous, 

 and in many of these the adrenals are the seat of tuberculosis. 



V. Kahlden(l9) has recorded 6 cases of caseous adrenals without Addison's 

 disease. 



Wiesel(20) reported a case of a 16-year old girl who had no clinical symptoms 

 of Addison's disease although extensive tuberculosis of the adrenals was present. 



Goldschmidt(2) reported 2 cases of tuberculous adrenals without Addison's 

 disease. 



Lewin(l) mentioned 44 cases of destruction of the adrenals by various causes 

 in patients showing no evidence of Addison's disease during life and dying of 

 intercurrent affections. 



Karakascheff (4) has drawn attention to cases of old haemorrhage destroying 

 the adrenal medulla withoiit the production of Addison's disease and records an 

 example of this in a child 5 months old. 



Although tumors in the adrenal are occasionally associated with Addison's 

 disease, as noted above, yet most frequently thej' cause no clinical manifestations 

 suggesting it. The reason for this may possibly be due to the infrequency of 

 destructive bilateral tumors. 



These cases, which have been selected from a very abundant literature 

 on the subject as typical of the difficulties presented, serve to show the 

 complexity of the problem. Such cases form in part the basis for ex- 

 planatory theories. However, they are insufficient without a knowledge 

 of the findings outside of the adrenals, which, I think, can best be con- 

 sidered in a general discussion of the subject. 



