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Morbid Anatomy - Addisons Disease and Other

tubercular, caseous, organ, changes, found, deposits, nature and bacilli

MORBID ANATOMY - ADDISON'S DISEASE AND OTHER A knowledge of this is, of course, only derived from specimens of adrenal bodies that have undergone such gross and fully developed changes in the disease as to have led to a fatal issue. Of the earlier changes in the organs in Addison's disease we are quite ignorant, and must be content to remain so. We can only argue from the appearance presented in such cases as come to the post-mortem room. We thus find indications of a progressive morbid process, the earliest stage of which apparently is the formation of new material, firm, whitish, or gray, nodular at the margin, and situated in the medullary portion of the organ. Outlying groups of deposit, much' resembling miliary tubercles, are found in close contiguity to the nodules just mentioned.

The latter appear to extend gradually and to encroach upon the cortical portion, causing enlargement and a nodular quality of the en tire organ. This may involve more or less of the capsule, and both are commonly invaded, or the entire organ, or both, may be uni formly enlarged as described, and thus be grossly altered in size and texture, although still retaining much of the original anatomical form. Such organs are readily detected. On section, there i8 no longer any of the normal aspect visible, the medulla and cortex are fused and uniformly involved. The surface is grayish or yellowish, and in parts quite resembles caseous degeneration of tubercular masses. The gray portions are apt to assume a pink tinge on exposure to the air, and this same occurrence is noted, curiously enough, on section of the me dullary portion of healthy adrenal bodies, as I have often remarked. The new growths are found to consist of lymphoid cells lying in deli cate wavy, fibrillary strorna. These cells are apt to develop into fibroid tissue. The masses thus formed may long remain in this condition before caseation and other changes set in. The caseous de generation may become so far complete as to soften and liquefy into creamy, puriform matter. A still later stage shows that, as in the case of softening yellow tubercular masses elsewhere, a process of absorp tion is in progress, and shrinking with obsolescence sets in, leading to small puckered masses, in which calcareous matter is deposited, —so-called cretiform obsolescence.

A chronic inflammatory process simultaneously involves the in vesting fibrous tissue of each organ, leading to thickening and adhe sions to adjacent organs and textures such as the liver, diaphragm, kidneys, pancreas, and, in particular, to the abundant meshes of the solar plexus and semilunar sympathetic ganglia.

Occasionally, marked atrophy, le'aving little but firm fibroid tis sue, occurs, or nodules of caseous and calcareous matter are noted in the room of natural adrenals.

The disease would appear to begin sometimes in one organ and to advance considerably before it arises in the other, the disease being almost obsolete in one, and in active progress in the other.

The histology of the new growth has been carefully worked out in all its stages. The grayish translucent substance consists of a fibril lated stroma, containing numerous lymphoid corpuscles. The caseons material consists of amorphous granular matter mixed with shrunken cells, nuclei, and oil. The most recent examinations reveal almost constantly the existence of tubercle bacilli. Gray miliary tubercles have been found, not always containing bacilli, but the latter are more commonly found in the caseous degenerating portions. Tuberculosis may be either primary or secondary to deposits elsewhere in the body and is perhaps more commonly of the latter variety. This is a mat ter of supreme importance in relation to the whole disease.

Several preparations in the Museum of St. Bartholomew's Hos pital plainly give evidence of the tubercular nature of the deposit in the adrenals, both as to intimate structure and the presence of specific bacilli. We have therefore to consider these deposits as essentially of tubercular nature, and we find that they behave in all respects as such deposits do elsewhere, namely, by gradually extending and en croaching, destroying natural tissue, undergoing caseous changes, and setting up proliferation of connective tissue around them with conse quent adhesions and matting of adjacent structures.

It appears probable that continued researches into the intimate nature of the specific deposit and changes met with in Addison's dis ease of the adrenals will render it certain that these are always of tubercular nature, and at the present time it is well-established that tubercular disease is the most commonly associated disorder, being met with in the lungs and in the bones, especially in the spinal col umn. We may therefore regard this malady as a form of adrenal phthisis. While adopting this view it is necessary to remark that tubercular deposits are, as a rule, not found in these glands in the great majority of cases of pulmonary phthisis due to tuberculosis, even when tubercles due to bacilli are widely spread throughout the organs of the body. These glands therefore resist, somewhat nota bly, a general tubercular infection. This is certainly remarkable and noteworthy.