GROSSER PATHOLOGICO-ANATOMICAL LESIONS 203 



as amyloid degeneration, gummatous changes, echinococcus disease, etc., occur. 

 Finally, destruction of the organ by hemorrhage has been occasionally men- 

 tioned (in cases running an acute course). 



An important point is that in a large number of the accurately investigated 

 cases the neighiorhood of the adrenals has also been found changed, so that 

 as a result of adhesions and abnormal connective tissue changes (apparently 

 the remains of circumscribed peritonitis) the adrenals have coalesced and 

 become embedded in the neighboring parts. Among the areas thereby afEected 

 the filaments and plexuses of the abdominal sympathetic (above all, of the 

 solar plexus and of the celiac ganglia which are situated in the neighborhood 

 of the suprarenals) have quite often been found embedded in thick masses 

 of connective tissue. 



In the purest cases the changes to be found in the adrenals and in their 

 immediate surroundings are the only abnormal autopsy findings. Frequently, 

 however, other changes take place, among them (naturally and primarily) 

 tuberculous lesions which attack the lungs in about one-third of the cases. 

 But Addison's disease does not often complicate cases of advanced phthisis. 

 Similarly malignant neoplasms of the adrenals may exist alone or be com- 

 bined with tumors of other abdominal organs. 



So far I have purposely considered only the simple typical cases of the 

 disease. This method I should like to continue for the present, excluding 

 the cases above referred to, which present the clinical picture of Addison's 

 disease but show no changes of the adrenals. The question must now be 

 asked: May we, and must we, in such pure cases with a typical symptom- 

 picture and well-developed disease or destruction of the adrenals, refer the 

 former directly to the latter ? 



Before deciding this question, two other questions, it appears to me, must 

 first be solved: (1) May the main symptoms of Addison's disease be produced 

 by certain general conditions which are present in the affection? and (2) Can 

 we believe with our present knowledge of the nature and function of the 

 adrenals that disease of these may produce the symptoms of Addison's disease ? 



In regard to the first question a number of maladies must be considered 

 in which, as a result of a profound anemia and cachexia, with the general 

 symptoms of asthenia (and eventually also gastric and nervous disturbances), 

 an abnormal pigmentation of the skin may develop. To this group belong 

 certain cases of malarial cachexia, pseudo-leukemia, pellagra (Neusser), the 

 so-called vagrant's disease which is produced by deprivation of all kinds, 

 advanced stages of tuberculosis and carcinosis, and others. But it is not 

 likely that any disease of the adrenals exists in these disorders. Moreover, 

 the discoloration of the skin differs in these cases most distinctly from that 

 seen in Addison's disease. In the diseases just mentioned it is usually of 

 slighter degree than in Addison's disease, and is far less generally distributed ; 

 it rarely shows, as in the latter malady, the formation of dark areas on a 

 background of diffusely discolored skin, and above all the accompanying 

 pigmentation of the mucous membranes is absent. On the other hand, in 

 the general diseases enumerated above the principal pathogenic factor is a 



