ADDISON'S DISEASE. 357 



grams and presented a similar appearance. The spleen weighed 210 grams, 

 pancreas 90 grams, thj'roid 9.3 grams, and the testes 9.5 and 10 grams re- 

 spectively. The spleen showed some interstitial splenitis, but the rest of these 

 organs the weight of which is given showed no change. The weights of these 

 viscera form about the average of the weights of the organs in the tuberculous 

 cases without adrenal involvement. 



There was no evidence of status lymphaticus in this case and the thymus 

 was embedded in such a mass of mediastinal adhesions that it was not isolated. 

 The miscroscopical examination of the adrenals confirmed the gross anatomical 

 diagnosis. Extensive caseation of the cortex of the adrenal occasionally involving 

 small parts of the medulla constitutes the main lesion. Tlie caseous areas are 

 surrounded by zones of small round cells icUhout fibrosis. This lack of reactive 

 connective tissue is quite uniform throughout this case, and indeed appears 

 characteristic of the tuberculous lesions as encountered in Filipinos. The cortex 

 is not all destroyed, and that which remains shoAvs a nodular hyperplasia and 

 dilatation of the capillaries. The individual cells, except where compressed by 

 the tubercles, show the normal structure ; the protoplasm stains rather poorly 

 with eosin and is reticulated ; the nuclei contain abundant chromatin and occa- 

 sionally assume giant forms. The inner zone of the cortex contains abundant 

 native pigment (not chromaflin). The medulla shows areas of coagulation ne- 

 crosis even where not directly the seat of tuberculosis, with pyknosis of the nuclei 

 and even complete nuclear destruction. Chromaffin is very scant. The semilunar 

 ganglia contain chromaffin. 



The second case, number 1352, is that of a 57-year old Filipino who had been 

 in prison 2.5 years. In 1909, two years before his death, he had a "tuberculous 

 abscess of the scrotum." One week before death he was admitted to the hospital 

 on account of general weakness. His weakness was extreme and for 2 days 

 previous to death he was practically pulseless. Aside from the evidence of the 

 old scrotal abscess, there were but few symptoms on which to base a diagTiosis. 



Dr. J. W. Smith, under whose charge the patient was, made the diagnosis of 

 generalized tuberculosis in spite of the lack of definite physical signs and the 

 absence of tubercle bacilli from the sputum. 



At autopsy the only evidence of excessive pigmentation consisted in 2 small, 

 dark areas on the sides of the tongue. He was extensively emaciated. The gross 

 anatomical diagnosis was : Chronic miliary pulmonary tuberculosis ; emphyseoma 

 of the lungs ; chronic adhesive pleurisy ; tuberculous enteritis ; parenchymatous 

 degeneration of the heart, liver, and kidneys ; chronic perisplenitis ; tiiberculosis 

 of both adrenals, the right kidney, prostate gland, left epididymis, right testicle, 

 and spermatic cords. 



The left adrenal measures 6 by 1.5 by 1 centimeter and weighs 4.1 grams. It is 

 pale and on section presents numerous smaller and larger conglomerate caseoiis 

 foci. The normal architecture of the gland is completely obliterated so that no 

 adrenal tissue can be recognized. The right adrenal measures 5.5 by 3 by 2 

 centimeters and weighs 10.7 grams. This is also distorted in shape and the 

 seat of one large nodule (2 by 2 by 1.5 centimeters) and several smaller ones, so 

 that only a small vestige of the gland can be recognized situated at the lower pole. 

 These nodules are pale, faii'ly firm, with yellow striae traversing them. The 

 spleen weighs 120 grams, testes 9.3 and 8.2 grams, pancreas 54 grams, and thyroid 

 7.3 grams. The weights of adrenals and testes are increased on account of 

 tuberculosis. Microscopically, no vestige of medullary tissue is found in the 

 adrenals. There are islands of intact cortical cells and man.y islands of these 

 cells surrounded by and included in the tuberculous tissue in all stages of 

 degeneration and necrosis. The capsule is thickened and there is a small amount 



