! CO icr i o .CD ■: CD THE ADRENALS The ADRENALS Arthur Grollman, Ph.D., M.D. Associate Professor of Pharmacology and Experimental Therapeutics and formerly Associate Professor of Physiology, in the Medical School of The Johns Hopkins University BALTIMORE THE WILLIAMS & WILKINS COMPANY 1936 Copyright, 1936 The Williams & Wilkins Company Made in the United States of America Published March, 1936 Composed and Printed at the WAVERLY PRESS, Inc. FOR The Williams & Wilkins Company Baltimore, Md., U. S. A. For A. P. G. [$& **+> Vv<*\ j LIBRARY )3 ■ 'iU ) ( 1 1 PREFACE The adrenal glands have been an object of intensive re- search since Addison first discovered their relation to a rela- tively uncommon disease. The mass of literature extant on these relatively tiny glands is scarcely commensurate with our knowledge of their function in the animal economy. Despite their small size, the glands must exert a vital influence in the organism for their removal soon leads to a complete breakdown in the normal functioning of practically all the organs and tissues of the body. In the present volume an attempt has been made to analyze the great accumulation of literature on the subject of the adre- nals and present a working hypothesis from which the reader may start on his own efforts. A study of the adrenals illus- trates nicely the dependence of endocrinological advances on many fundamental sciences. Modern Endocrinology has be- come the leading branch of medical investigation by adopting anatomy, chemistry, physiology, pharmacology, pathology, and clinical medicine as its tools, and thereby has advanced from the state of quackery in which it had long floundered. Our knowledge of the adrenals has resulted from the combined efforts of chemical, physiological, pathological, and clinical investigators. It is necessary to consider all these diverse sources of information in order to obtain an understanding of these glands in their relation to the body as a whole. The bibliography on the adrenals embraces many thousands of references, inclusion of all of which would be undesirable. I have, therefore, cited only a fraction of the literature, particu- larly the more recent work. The adrenals have hitherto been looked upon as glands con- taining two essentially separate divisions — the cortex and the medulla. In the present volume I have considered the glands Xll PREFACE in man and in certain animals as composed in early life of three distinct physiological entities — the medulla, the cortex, and the androgenic tissue. The last named term has been coined to describe that portion of the adrenal which, in certain path- ological conditions, gives rise to disorders of the reproductive system. This view of the tripartite nature of the adrenal is supported by many well-established facts. It affords a ra- tional explanation of the relation of the adrenals to certain pathological conditions of the reproductive system and avoids assuming a relation between the cortex proper and the sex glands as previous writers have unjustifiably done. Many of the views expressed in the present volume are based on the results of experimental studies in which my colleagues, to whom I am deeply indebted, have collaborated. Dr. War- field M. Firor has performed surgical operations and enthusi- astically cooperated in these researches; Dr. Evelyn Howard is jointly responsible for the studies dealing with the relation of the adrenals to the reproductive system; and Mr. Ellis Grollman has aided in the preparation of the adrenal extracts. I wish also to express my sincere appreciation to the pub- lishers for their cooperation and unfailing courtesies. A. G. Baltimore, Maryland. INTRODUCTION Chapter I AN HISTORICAL RfiSUM^ Probably as a result of their small size and yellowish, fat- like consistency, the adrenals were not recognized as specific organs by the ancients, being overlooked as parts of the peri- renal fat. The claim that the adrenals are mentioned in the Bible is based on an error in the Vulgate translation. The single Hebrew word, "Kalayot" (kidney) of Leviticus (Chap- ter III) appears in the Latin of the Vulgate both as "ren" and as "renunculus." To consider the latter as referring to the adrenals is thus unjustified. 65 * Bartholomaeus Eustachius 190 gave the first clear description of the adrenal glands. The sixth chapter of his "Opuscula Anatomica" published at Venice in 1563 is entitled "De glan- dulis quae renibus incumbunt." It describes and pictures the adrenals as they occur in man. Despite the clear exposition of Eustachius many of his followers still denied the glandular entity of the adrenals. Thus Piccolomini still spoke of the glands as displaced fragments of the kidney. Others ignored their existence entirely. Eustachius called the adrenals the "glandulae renibus in- cumbentes," a name, the connotation of which is retained in our modern expression, "suprarenal." Subsequent writers used a variety of appelations to designate the glands. Thus Casser- ius called them the "renes succenturiate" which as "reins suc- centurieux ,} was used in the French literature until displaced by the modern expression, "glandes sun -enales . ," Winslow first * Superior figures refer to the numbered entries of the bibliography. For the literature before 1850, the reader is referred to the excellent historical reviews of Biedl 66 and Shumacker. 6661 ' 1 2 INTRODUCTION introduced the English term, "suprarenal" which, although descriptive of the glands as located in man, is a misnomer when applied generally, and hence should be replaced by the more generally applicable term, "adrenal." The term "glandulae renales" introduced by Dienerbroeck was adopted in the German "Nierendriisen" which has been displaced by the more appropriate term "Nebennieren." The Italians refer to the glands as "giandola" or "capsula surrenale" or as "soprarenale." The Spanish use the expression, "swprarrenales." The seventeenth century contributed little to our knowledge of the adrenals. The literature of this period consists of ana- tomical descriptions which distorted the actual facts in order to give support to fantastic hypothetical theories. Thus Spigelius considered the adrenals as mere fillers of the ab- dominal cavity to help support the stomach. This theory was later retained by Highmore who also expressed the view that the adrenals absorbed humid exudates from the nearby blood vessels. Riolan believed that the adrenals supported the ab- dominal nerve plexuses thereby preventing their weighing on the renal vessels. This theory was refuted by Bartholin and Molinetti who pointed out that the adrenals lay above the nerve plexus and that the latter being firmly attached to the vertebral column were in no need of any support. The proximity of the adrenals to the abdominal nerve plexus suggested to Thomas Wharton that the glands withdrew some- thing from the nerves. He therefore called them the "glandu- lae ad nerveum plexum." Glisson maintained a similar view while Collins was more specific and suggested that the adrenals transported a fermentative liquor from the nerves to the kid- neys. The association of the adrenals and the kidneys gave rise to Molinetti's theory according to which the adrenals diverted the blood from the kidney in order to avoid the excretion of urine by the fetus. Molinetti's views were supported by Coxe 133 of the University of Pennsylvania, the earliest Ameri- can writer on the subject. 6668 HISTORICAL 6 Sylvius suggested the idea that the adrenals altered the blood in such a way as to prevent its coagulation in the body. This theory was supported by Boerhave, Deidier, Tauvry, and others. Bartholin first described the brownish fluid present in adre- nals which are removed from the body sometime after death. This fluid results from autolytic processes in the medulla but was considered by Bartholin as an "atabiliary" juice derived from the spleen and liver. He, therefore, called the adrenals the "capsulae atabiliarae." Kerckring claimed that the adre- nals secrete a juice which gives color and animates the blood and produces fermentation in the heart. Severinus, apparently mistaking a band of fibrous tissue for a duct, described the existence of an excretory duct leading from the adrenals to the testicles. Valsalva described similar ducts to the ovary and testicle and therefore claimed that the adrenals were necessary for the proper functioning of the re- productive organs. He supported this theory experimentally by removing the adrenal of one side of a dog and the testicle of the opposite side. The animal failed to copulate after this operation which proved to Valsalva that the adrenals were in- dispensable parts of the reproductive system. Meckel also considered the adrenals as part of the sex glands. B66a The Academie des Sciences of Bordeaux in 1716 offered a prize for the best thesis on the subject, "Quel est V usage des glandes surrenalest" Montesquieu, the celebrated author of the "Esprit des lois" was appointed to judge the contributions. His subtle irony and apt criticisms exposed the sophistry of the various theories advanced to explain the function of the adrenals. He found no contribution worthy of the prize. 55 During the eighteenth century, some advance was made in the anatomical knowledge of the adrenals but more fantastic theories were elaborated to explain their function. Thus Senac suggested that the adrenals secreted meconium in the fetus while Von Helmont believed that they elaborated a juice which prevented the formation of renal calculi. Goodsir con- 4 INTRODUCTION sidered the adrenals, thymus, and thyroid to be of functional importance only in the embryo, while Riegel suggested that the adrenals were responsible for the secretion of fat into the abdominal cavity. Morgagni first noted the existence of accessory adrenal bodies in man, an observation already made in the dog by Hartmann. Morgagni also noted the relatively large size of the adrenals in the fetus and deduced that their function was limited to intra-uterine life. He believed that the adrenals filtered a fluid from the blood into the receptaculum chyli and thoracic duct in order to ensure the patency of these vessels during fetal life when no chyle was being derived from the gastro-intestinal tract. Winslow gave an accurate anatomical description of the adrenals. Nevertheless, subsequent writers failed to adjust their concepts of the physiological function of the glands to the anatomical facts. Thus Boerhave thought that the glands diluted the blood leaving the kidney. Haller 263 also disre- garded Winslow's description. With the 19th century began the study of the comparative anatomy of the adrenals. Meckel 448 , whose friend, Cuvier, put at his disposal the vast zoological collection of the Royal Gar- dens at Paris, examined and described the adrenals of many species. He described the variations in birds and mammals but missed the glands in the reptilia. He noted too the "ab- sence" of the glands in anencephalic monsters 447 and suggested that the adrenals were related to the reproductive system. Retzius, in 1819, first described the adrenal homologues in the Selachian fishes and Stannius 584 , in the teleost fishes. Rathke in 1825 described the true nature of the glands in the amphibia, and Nagel 464 first recognized the adrenal glands in the birds. Bergmann in 1839 first noted the relation of the adrenal medulla to the nervous system. Meckel 448 , Johannes Miiller, and Rokitansky 535 finally disposed of the idea that the adrenals were related to the kidneys. HISTORICAL 5 During the middle of the nineteenth century advances were made in the anatomical study of the adrenals. The work of Pappenheim, Schwager-Bardleben, Henle, 293 and others laid the foundation for the comprehensive study of the minute anatomy of the glands. Ecker 169 first demonstrated the glandular nature of the adrenal cells and concluded that these organs must pour some secretion into the blood either directly or by way of the lymphatics. Kollicker (1854) in his "Microscopischen Anatomie oder Gewebelehre des Menschens" gave a good microscopic descrip- tion of the adrenals. Arnold 19 first introduced the conven- tional division of the gland into zones while Leydig's 396 studies demonstrated the relation of the adrenals to the nervous sytem. The modern study of the physiology of the adrenals may be said to have begun with Thomas Addison. 7 His classic descrip- tion of the disease of the adrenals, which has since been asso- ciated with his name, initiated a series of researches which have continued unabated to the present day. Addison's de- scription, published in 1855, is one of the classics of medical literature, and remains today an accurate and almost com- plete account of the syndrome observed in the disease. Al- though many cases of Addison's disease have been carefully observed by subsequent workers, little has been added to Ad- dison's description of the clinical symptoms and course of the disease. It is remarkable that despite the characteristic symp- toms of this morbid condition, only three accounts of the disease are known which pre-date Addison's description. The earliest case on record is the fragmentary account by Jose de Sigiienza 426 in his "Historia de la Or den del glorioso doctor San Jeronimo." Not only did Addison recognize the condition as a morbid entity but he also accurately correlated it with a pathological state of the adrenals. Addison's work served as a stimulus for a number of clinical studies as well as for the 6 INTRODUCTION physiological investigations on the adrenals which followed the appearance of his classic paper. Addison's publication prompted Brown-Sequard 96 in 1856 to extirpate the adrenals from a number of laboratory animals. The rapidly fatal consequences of these operations led him to the correct conclusion as to their indispensability for life. Some subsequent workers failed to confirm Brown-Sequard's conclusions. This controversy, regarding the period of sur- vival of animals following adrenalectomy has continued to the present day. During the latter half of the nineteenth and early part of the twentieth century, the comparative anatomy of the adre- nals was fully investigated. The earlier work of Stannius, 594 Gray, 239 Leydig, 396 Remak, Kolliker, His, and Braun 81 culmi- nated in the researches of Balfour, 28 Soulie, 581 Poll, 508 Vin- cent, 648 Kohn, 357 and others. The observations of Oliver and Schaefer 480 in 1894 of the remarkable pressor effects of extracts of the adrenal medulla turned attention to epinephrine, the existence of which had been noted in 1856 by Vulpian 652 who described the green coloration occurring when the medulla was moistened with ferric chloride. The high concentration of epinephrine in the gland (as compared to the relatively low concentrations in which other hormones occur) led to its isolation and identifica- tion in the course of a decade following Oliver and Schaefer's publication. It was thus the first hormone to be crystallized, identified, and synthesized. The remarkable pharmacological effects of epinephrine soon found for it a permanent place in therapy. Physiologists looked upon its production as the obvious function of the adrenal glands and numerous studies appeared describing its actions under various conditions. Bitter controversies raged regarding the functional importance of epinephrine to the organism. The adrenal cortex, in the meantime, was for the most part HISTORICAL 7 neglected. The realization that the cortex of the adrenal, rather than the medulla, was vital to the organism soon turned increasing attention to this part of the gland. With the ad- vance of Endocrinology during recent years, the adrenal has shared in the intensive study which has been applied to the glands of internal secretion. Although the function of the glands is still a mystery and the product elaborated by the cortex still unidentified, much progress has been made. The field has been sufficiently clarified to reveal the problems open for investigation and the prospects of their solution. The preparation of extracts which are capable of furnishing a com- plete replacement therapy in the adrenalectomized animal has opened new fields of investigation and supplied a new thera- peutic agent for the treatment of human disease. PART I. ANATOMICAL CONSIDERATIONS The anatomy of the adrenals has been studied very ex- tensively particularly from the comparative and embryological viewpoints. Much confusion still exists regarding the finer details of the microscopic structure of the glands due to the great difficulty of properly preserving and preparing the tissue for histological study. Many descriptions of the microscopic appearance of the cells of the glands are in reality based on artifacts. Despite these difficulties a great body of facts has been accumulated which throws light on the probable function of the adrenals. Many theories which have been advanced on the basis of physiological or clinical evidence must be dis- carded because they are in conflict with the anatomical facts. On the other hand, the available anatomical data lead to certain definite conclusions which are useful in shaping the course of future physiological investigations. Chapter II GROSS ANATOMY The adrenal glands of mammals are compound organs de- rived by the union of two originally separate types of tissue. Because of their topographical relationship to one another these tissues are referred to as cortical and medullary. These expressions so commonly used in referring to the mammalian adrenal are inappropriate when applied to the corresponding tissues of the lower animals, and hence a nomenclature more suitable from the point of view of comparative morphology is desirable. We shall, therefore, refer to the cortex of the mam- malian adrenal and its analogues in other genera as the in- terrenal body or tissue, a term introduced by Balfour 28 in 1878. Although a topographical term, this has the advantage, over the expression, "cortex," in that it is correct for vertebrates in general during the early stages of their development. We shall refer to the medullary portion of the mammalian adrenal and its analogue in other vertebrates as the chromaphil tissue, a term introduced by Stilling 596 in allusion to the specific staining reaction of this tissue when treated with chromates. Kohn 357 introduced the term "chromaffin" and Poll 508 the expression "phaeochrome" to denote the same tissue. These expressions frequently occur in the literature synonymously with the term "chromaphil." The teleological significance of the particular relation existing between the cortical and medullary portions of the adrenal is still a matter of conjecture. Their independence in the early stages of ontogeny is a repetition of the condition occurring during phylogeny as indicated in the elasmobranch fishes where the two elements remain separate. 11 12 ANATOMY COMPARATIVE ANATOMY Tissues corresponding to the interrenal body or the cortex of the mammalian adrenal have not been demonstrated ana- tomically in animals below the cyclostomata (hags and lam- preys). The homologue of the chromaphil or medullary tissue has, however, been demonstrated in a number of the lower invertebrates. The ease with which this chromaphil tissue may be identified (staining reactions, pressor effects, etc.) have aided in its detection in these lower forms. It is possible that the discovery of a corresponding micro-chemical or biological test for the internal secretion of the interrenal tissue may also lead to the demonstration of the interrenal homologue in the lower genera. Poll and Sommer 509 have described cells in the abdominal ganglia of leeches (Hirudo medicinalis, Gnathobdella, and Rhynchobdella) which resemble the chromaphil tissue of the higher genera. That these cells probably secrete epinephrine was demonstrated by Biedl 56 and by Gaskell 211 who showed that extracts of the ganglia of the leech inhibit the contractions of the uterus of the virgin cat, a reaction typical of epinephrine. In the mollusc {Paludina vivipara), Leydig 396 described tissues which he thought corresponded to the chromaphil tissue of vertebrates. Vincent, 646 however, failed to obtain a pressor effect by injecting extracts of this tissue and hence Ley dig's opinion is open to question. On the other hand, Roaf, Nierenstein, and Poll 649 have described tissues in Purpura lapillus, and in Nephthys scolopendroides which resemble closely the chromaphil tissue of the adrenal. In none of the above species has any evidence been adduced to indicate the existence of any interrenal tissue. The lowest vertebrates in which both adrenal elements have been shown to exist are the cyclostomata. In the lamprey (Petromyzon) Giacomini 216 described small lobulated structures projecting into the lumen of the posterior cardinal veins and renal arteries GROSS ANATOMY 13 which appear anatomically to be homologues of the interrenal tissue. The chromaphil tissue is represented in the lamprey by a series of thin strips running along the large arteries and their branches and extending from the region of the second gill cleft to the tail. 649 In the hagfish (Bdellostoma myxinidae) chromaphil cells have been described but no interrenal tissue has been iden- tified. 649 It is only in the Amniota (mammals, birds, and reptiles) that we find the adrenal as a definite organ composed of dis- tinct parts, the chromaphil and interrenal tissues. In the Anamniota (amphibia, fishes, and cyclostomes) the compact union of chromaphil and interrenal tissues has not occurred and these tissues are represented by a number of separate bodies. The amphibia are intermediate between the mammals and the lower Anamniota for in them we find the union of interrenal and chromaphil tissue into a single organ, but without the penetration of the latter tissue to assume a true medullary position. In the fishes and cyclostomes the homologous tissues of the cortex and medulla of the mammal are present as distinct and separate bodies. The adrenal system of the Elasmobranchs (sharks, dogfish, and rays or skates) was first described in detail by Balfour. 28 He assigned the name interrenal to the homologue of the adrenal cortex of mammals and the name "suprarenal bodies" to the homologue of the medulla. The term "suprarenal bodies" is now replaced by the more suitable term "chroma- phil bodies." The interrenal bodies of the elasmobranchs are usually arranged as a pair of ochre yellow, ribbon-shaped structures lying medial to and in the region of the posterior part of the kidneys. They are sometimes contiguous to the midline and fused into a single organ or joined by strands of tissue. The glands are usually paired in the skate 409 and unpaired in the dogfish and shark. Microscopically the cells 14 ANATOMY resemble those of the Stannius' corpuscles, (their homologues in the teleost fishes) and the adrenal cortex of the higher vertebrates. The chromaphil tissue of the elasmobranchs occurs in the form of segmentally paired bodies arranged on branches of the aorta in close relation to the ganglia of the sympathetic chain. 649 Direct evidence exists for the physiological identity in func- tion of the chromaphil bodies and the adrenal medulla. Thus Vincent 646 ' 647 ' 648 showed that the saline extracts of these bodies in the dogfish had vasoconstrictor and pressor activity similar to that of extracts of the adrenal medulla. Similar extracts prepared from the interrenal bodies manifested no such actions. Vincent's observations were confirmed by Biedl and Wiesel 57 . Lutz and Wyman 409 demonstrated the mydriatic action of extracts of the chromaphil tissue of certain elasmobranchs, which is indicative of the elaboration of epinephrine by these bodies. Extracts of the interrenal body, on the other hand, were free of any sympathomimetic activity. The homology of the interrenal bodies of the elasmobranchs with the adrenal cortex has also been proven by physiological experiments. Thus Biedl 56 demonstrated that removal of the interrenal bodies in the skate and the torpedo results in symp- toms (weakness, pallor, cachexia, etc.) and ultimate death analogous to that observed after removal of the adrenal cortex in higher animals. Kisch 353 confirmed and extended these observations. The operative difficulties involved in perform- ing interrenalectomy in fishes renders conclusions based on extirpation experiments of doubtful value. Less equivocal evidence was obtained by Grollman, Firor, and Grollman 260 who demonstrated that extracts of the interrenal body of the skate (Raja stabuliforis, Raja diaphanes, and Raja erinacea), when administered to bilaterally adrenalectomized rats, mani- fested a complete replacement therapy. In the teleost fishes the interrenal bodies occur as small GROSS ANATOMY 15 round or oval pale pink bodies on the spinal or ventral surface of the kidney. They lie either free on the surface of the kidney or embedded in its substance. These structures are known as the corpuscles of Stannius. Interrenal tissue is also present in certain of the teleosts at the cranial border of the head kidney, on the anterior and posterior cardinal veins. This tissue was first described by Giacomini. 218 Their existence, in addition to the corpuscles of Stannius, account for the fact demonstrated by Vincent 647 that extirpation of the corpuscles of Stannius in the eel does not result in death. The chromaphil tissues of teleost fishes were also discovered by Giacomini. 217 This tissue is found in the wall of the cardinal veins towards the cranial end of the body along the head of the kidney. In the Dipnoi (lung fishes) the existence of interrenal tissue has not been demonstrated with certainty. Parker and Giacomini 649 have described a lymphoid tissue in Propterus annectens having an epithelial appearance which they suggest has replaced the interrenal tissue of other species. Further study of this tissue is desirable before one can justifiably deny the existence of interrenal tissue in these fishes. The chromaphil tissue of the Dipnoi has been demonstrated by Giacomini 218 as segmentally arranged bodies around the inter- costal arteries and the wall of the posterior cardinal vein and the right azygos vein. The chromaphil and cortical tissues are first found together in the amphibia. In the frog the adrenal is seen as a thin, golden-yellow ribbon closely attached to the ventral surface of the kidney. In Figure 1 are reproduced the kidneys of a frog with their attached adrenals. The greatest part of the adrenal in the amphibia is composed of columns of cortical interrenal cells, the chromaphil cells occurring at the borders of the columns of the cortical cells. This arrangement is transitional between the complete independence of chromaphil and cortical tissue as observed in the fishes and the inclusion of the chroma- 16 ANATOMY phil tissue within the rim of cortical cells as observed in the mammal. In Urodela the adrenal occurs as a series of strips which extend along the kidney and project anteriorly as far as the origin of the subclavian artery. 700 An intimate relation between the chromaphil and interrenal tissues is first encountered in the reptilian adrenal. Here we find the relation of these tissues to vary from that described above for the amphibia to the condition met with in the bird and described in the next paragraph. Thus in the crocodiles and sea turtles (Chelonia) the arrangement is practically iden- tical with that seen in the bird while in the tortoise (Testudina) the arrangement occurring in the frog is encountered. 498 - 608 In the birds the adrenals consist of ochre colored bodies situated on each side of the vena cava. The left gland is usually lenticular in shape with its internal border excavated and molded around the vena cava or abdominal aorta. The right gland is pyramidal in shape and also in intimate contact with the vena cava. The adrenals in the bird lie at the anterior end of the kidney in intimate contact with the reproductive organs. Microscopically, the adrenals in the bird consist of an interlacement of the interrenal and cortical tissues. Each occurs in the form of strands of cells which intertwine with one another. These strands have been designated as "chief" and "intermediate" strands to denote the interrenal and chromaphil tissues, respectively. It is only in the mammals that we find the interrenal tissue as a cortex surrounding a medulla composed of chromaphil tissue. The cortex is the homologue of the cortical or inter- renal columns of the reptile, bird, and amphibia, of the cor- puscles of Stannius in the Teleosts, and of the interrenal body in the Elasmobranch fishes. The right adrenal in the mammal is situated in close contact with the vena cava. It is usually in close apposition to the kidney but in some species it may be separated from and situated a short distance anteriorly to the kidney. The left adrenal is, in most species, situated away Fig. 1. The Amphibian Adrenal The kidneys of a frog (Rana catesbiana) with the adrenals attached to their ventral surface (XI). GROSS ANATOMY 19 from the vena cava but in some species {e.g., the rabbit) it lies in close contact to the large abdominal veins. GENERAL MORPHOLOGY The adrenals of the different mammalian species differ in their gross anatomical appearance and topographical arrange- ment as shown in Figure 2 in which are reproduced the photo- graphs of representative types of glands. The apposition of the glands to the kidneys or the vena cava gives depressions which modify the simple bean-shaped or spherical forms observed in some species. The weight of the adrenals compared to the body weight or kidney weight in different animals has been the subject of several investigations since Meckel 448 and Cuvier 144 first ini- tiated this type of comparative study. In general the adrenals of most mammals weigh from 0.01 to 0.02 per cent of the total body weight. The guinea pig and several of its wild relations are exceptional in this respect, their adrenals weighing almost ten times as much per unit of body weight than other animal species. The relatively large gland of the guinea pig is com- posed chiefly of cortical tissue. 108 The medulla bears the same relative relation to the body weight as it does in other mammals. 183 Except during the period of degeneration of the androgenic zone, described in Chapter IV, the adrenals increase in size as the body grows (although not proportionately) except in fowls 183 where there is a marked reduction in adrenal size after maturity despite an increase in body weight. This may sug- gest the presence of androgenic tissue in the fowl's adrenal. 79 In the guinea-pig the medulla attains its full development by the end of the first month of life, subsequent growth of the gland being limited to the cortex. In other animals likewise the medulla increases but slightly in size after the first period of life. In birds the medulla forms a very large fraction of the whole gland, the cords of medullary cells being interwoven in a Wl 20 ANATOMY uniform network with the strands of cortical tissue. The medullary cells, however, are capable of multiplication after adolescence and have been noted to increase in the gland re- maining after unilateral adrenalectomy. The weights of the adrenal glands vary readily in response to the metabolic requirements of the body. Thus the fever of infectious processes, cold, heat, etc. call forth an hypertrophy which is very obvious even on casual inspection. The adrenals of ill-nourished or unhealthy animals are much larger than those of normal healthy ones. The adrenals of the grey wild rat are much larger than the glands of the domesticated albino. 162 This increase in size involves the cortex chiefly and the medulla to a much lesser extent. The large gland of the wild rat may be attributed to the less favorable conditions under which it nourishes and its greater vigor and activity which involve a greater metabolic requirement. Domestica- tion reduces the size of the adrenals. In the rat the adrenals are somewhat larger in the female than in the male. 286 THE ADRENALS OF MAN The adrenals in man sit "cap-like" on the upper poles of the kidneys. The right gland is somewhat triangular in shape bearing a resemblance to a "cocked-hat." It is situated be- hind the inferior vena cava and right lobe of the liver and in front of the diaphragm and upper end of the right kidney. The upper part of its lateral surface is devoid of peritoneum and lies opposite the liver, while the inferior portion is covered by peritoneum reflected onto it from the coronary ligament. Near the anterior border of the gland is a short furrow (the hilum) from which emerges the adrenal vein. The left adrenal is crescentic in shape with its concavity placed in apposition to the medial border of the upper part of the kidney. The upper area of its anterior surface is covered by the peritoneum of the omental bursa which separates it from the cardiac end of the stomach while the lower area is Fig. 2. The Mammalian Adrenal The adrenals, showing the diversity of their shape in various mammals. /, the left gland of a sperm whale (Physeter macrocephalus) (XJij) (Courtesy of Dr. E. M. K. Getting); 2, the beef (Bos taurus) (X%);3, the sheep (Ovis aries) (X2); 4, the rat (Mus Norvegicus var. albinus) (Xl l A)\ 3, the pig (Sus scrofa) (xH);6, The monkey (Macacus rhesus) (XI); 7, the cat (Felis catus) (X\ l A); 8, the dog (Canis familiaris) (Xl). GROSS ANATOMY 23 devoid of peritoneum and is in contact with the pancreas and splenic artery. Along its posterior surface is a ridge dividing it into a lateral area resting on the kidney, and a medial area on the left cms of the diaphragm. The surface of the adrenals is surrounded by aveolar tissue containing fat and is invested by a fibrous capsule through which pass numerous fibrous processes and vessels entering the organ. Externally the glands appear yellowish or brownish-yellow. When cut into they are seen to consist of a firm external or cortical portion, deep yellow in color, and striated, forming the greater mass of the gland, and an internal or medullary, soft and pulpy portion, of dark-brownish appearance due to the presence of blood. The fibrous coat of the adrenals consists of an outer looser, and an inner firmer layer. The latter is intimately connected with the deeper parts of the gland and is continuous with the septa which enter into the formation of the organ. The arrangement of these septa gives rise to the structure charac- terizing the microscopic appearance of the gland and its division into zones as described later. The size of the adrenals varies widely depending on the previous life history of the individual from which they were derived. Thus infection increases their size and hence in persons dying after an infectious process enlarged adrenals are encountered. After sudden accidental death, relatively small adrenals are found. Rarely a single gland only is encountered or the two glands are fused. The average combined weight of the two glands in the human adult varies from 5 to 15 grams. 444 - 614 There is thus a con- siderable variation in their normal size and it is therefore difficult, by mere inspection of size, to determine whether or not a given gland is normal. The majority of normal glands, however, weigh between 3.5 and 5 grams each. They are on an average about 25 to 30 mms. in height, 40 to 50 mms. in 24 ANATOMY breadth, and 2 to 8 mms. in thickness, except at the bases where they are twice as thick. The medulla makes up about 10 per cent of the weight of the glands. Circulation. The blood supply of the adrenal is peculiar in several respects. 201 • 213 There is a separate arterial supply to the cortex and medulla. The cortex, however, has no marked venous system, the blood being drained into the capillary network of the medullary arteries and ultimately drained by the well developed venous system of the medulla. The transition of the arterial network of the cortex to that of the medulla occurs in the reticular zone in which is found an exceedingly fine capillary system with very narrow meshes each of which appears to surround a single cell. It has not been established if this network consists of closed capillaries or of unwalled spaces. The adrenal cortical capillaries behave on vital staining like the reticuloendothelial cells of the spleen, liver, etc. in which loosely built or interrupted capillary sys- tems are found. 10 Aside from the above described circulation there is a second venous circulation of the cortex in which tiny branches from the left adrenal (possibly also from the right) communicate with branches of the splenic and pancreatic veins and thus with the portal system. The arterial blood reaches the adrenals through channels derived from the aorta, the inferior phrenic, and the renal arteries. Three arteries, one of which supplies the medulla, penetrate into the capsule and break up into capillaries which end in the venous plexus of the medulla. The adrenals are richly vascularized. Houssay and Molinelli 315 observed a blood flow of 0.35 cc. per minute per kilo of body weight in dogs. Neumann found the blood flow through the adrenals to ex- ceed that of any other organ, viz., 6 to 7 cc. per gram of adrenal tissue per minute. Subsequent workers have found smaller blood flows. 545 The great muscular content of the adrenal vein is striking. GROSS ANATOMY 25 Some investigators have considered it as capable of blocking the blood leaving the adrenal. It is more likely, however, that this muscular development acts to help propel the venous blood into the caval system thereby ensuring the circulation of the vital products of the adrenal gland. The adrenal vein receives the blood from the medullary venous plexus and from the cortex. It emerges from the hilum of the gland and opens on the right into the inferior vena cava and on the left into the renal vein. Under certain conditions, the venous blood from the adrenals reaches the portal vein. According to Cow 131 part of the blood supply to the medulla in the cat goes to the kidney. In the dog this venous anastomosis of adrenal and renal vessels occurs only rarely. The efferent blood vessels of the adrenals are divided by Ferguson 194 into four types: the sinusoids, the small central vein, the large central vein, and the suprarenal vein. Each of these types presents distinctive features but in all of them circular muscle is conspicuously deficient or absent. The large central vein is characterized by prominent and charac- teristic muscular ridges. Lymphatics. The lymphatics of the adrenals run in the trabeculae of the cortex and are connected with spaces between the trabeculae and the cell columns and by clefts between the cells within the columns. They communicate with efferent- valved lymphatics in the fibrous capsule and in the medulla where they form a close plexus around the central vein. The lymphatics of the adrenals drain into the lateral aortic lymph glands. Nerve supply. The adrenals receive their chief innervation from the splanchnics. It is questionable if twigs from the vagi and phrenics also innervate the adrenals, as some writers claim. In the rabbit the right adrenal is supplied by both right and left splanchnics while the left gland receives fibers from the right splanchnic only. The fibers to the adrenals are derived 26 ANATOMY from the adrenal (or suprarenal) plexus and are probably all postganglionic and unmyelinated. 179 The efferent nerves of the adrenal are not accurately known. Elliott 179 assumes the existence of a center controlling epineph- rine discharge near the bulbar vasomotor centers. Others place it in the subthalamic region. 419 THE CHROMAPHIL TISSUE The medulla of the mammalian adrenal and its homologues in the lower animals are components of the chromaphil system. The tissue comprising this system is characterized by the brownish discoloration which it undergoes when fixed in a chromate solution. Stilling 596 in 1890 observed that this chromaphil reaction was given not only by the adrenal medulla but also by groups of cells associated with the sympathetic nervous system. Stilling applied the generic term "chromo- phil" to these cells which Vincent 649 altered to the more euphe- mistic expression "chromaphil." Kohn, 357 who applied the term chromaffin to these cells, introduced the term "para- ganglia" to denote the cells found in association with the sympathetic nervous system. 358 The adrenal medulla itself was indicated by Kohn as the "paraganglion suprarenale." Kohn also called attention to the conspicuous strip of chroma- phil cells situated ventral to the abdominal aorta and superior to the inferior mesenteric artery. He named this tissue the "paraganglion aorticum ahdominale" Zuckerkandl 697 discov- ered a pair of similarly staining bodies in the region of the inferior mesenteric artery of the new born. These bodies are known as the organs of Zuckerkandl. The paraganglia are small round masses, 1 to 3 mms. in diameter, placed within or contiguous to the capsules of the ganglia of the sympathetic system. Usually one paraganglion is associated with each ganglion of the coeliac, renal, adrenal, aortic, and hypogastric plexuses. Sometimes they are also associated with the ganglia of the cardiac and inferior mesen- GROSS ANATOMY 27 teric plexuses and have been reported in association with ganglia on the kidney, prostate, ureter, et cetera. In addition to the paraganglia a number of masses of chroma- phil tissue are also developed in relation to the abdominal sympathetic plexuses. Of these, the most prominent are the aortic bodies (ZuckerkandPs bodies) which lie on either side of the aorta at the origin of the inferior mesenteric artery. In the new-born they are about a centimeter in length but de- generate and gradually disappear (except under certain patho- logical conditions) so as to be seen only microscopically from puberty until the age of about forty. The carotid gland also forms part of the chromaphil system. It is a bilaterally paired organ situated in close relation to the bifurcation of the common carotid artery. It is oval or wedge-shaped depending upon its position in relation to the artery and is about 7 mms. long, and 2 to 5 mms. in diameter. In appearance it is grayish, yellowish or brownish red. 356384 The coccygeal body has been erroneously referred to by some authors as a part of the chromaphil system. This body does not, however, give the chromaphil reaction. 698 It cor- responds to the caudal glomeruli of lower animal forms. 649 The chromaphil tissue of mammals occurring in the para- ganglia of the sympathetic trunk is homologous to the seg- mentally arranged chromaphil bodies of the elasmobranchs. The chromaphil bodies of the abdominal plexuses are, on the other hand, formations peculiar to the higher vertebrates, while the inclusion of chromaphil tissue within the capsule of cortical tissue, as in the adrenal glands, is a development found only in the mammalia. Although similar anatomically, it is ques- tionable if all the component tissues of the chromaphil system are functionally equivalent (cf. Chapter VI). The method for demonstrating the chromaphil tissue as introduced by Stilling 596 and Kohn 357 consisted simply in ex- posing the tissue to a solution of potassium bichromate and subsequently washing and examining the tissue for brownish 28 ANATOMY patches. A more satisfactory technique, described by Wis- locki, 683 consists in staining with bichromate and fixing in 10 per cent formalin. The tissue is then washed and bleached by placing in the sunlight for 6 to 24 hours in a solution of hydro- gen peroxide. In this way the chromaphil tissue stands out prominently against the bleached surrounding tissue. Wis- locki was able to demonstrate abdominal chromaphil tissue in the dog, cat, rabbit, and man, as described by earlier workers, as well as in the opossum, guinea-pig, squirrel, and monkey. In the rat no abdominal chromaphil tissue could be demon- strated. Biedl and Wiesel 57 demonstrated the pressor effects of extracts of the organs of Zuckerhandl to be similar to those obtained from epinephrine. Vincent, 648 Fulk and MacLeod 209 , and Kahn 344 showed that the accessory chromaphil tissue of the dog, guinea-pig, rat, and other animals also manifested bio- logical effects similar to epinephrine. Kahn showed that the abdominal chromaphil body possesses about one-twelfth to one-thirtieth as much epinephrine as the adrenal medulla. Kahn also claimed to have demonstrated the presence of epineph- rine in the venous blood draining the paraganglia, but the method which he used is open to criticism. There is no evidence to indicate that the accessory chroma- phil tissue takes over the function of the adrenal medulla when the latter is extirpated. Wislocki and Crowe 685 removed one adrenal from dogs, together with one-fourth to three-fourths of the remaining gland, and implanted radium emanations into the remaining fragments. In this way, all medullary tissue was destroyed. Hypertrophy of the abdominal chromaphil bodies did not occur following the operation. EMBRYOLOGY The primordial cells which give rise to the adrenals are differentiated at an early stage of embryonic life. 674 The medulla and the chromaphil tissue in general, and the sympa- thetic nerve cells arise in common from the neural crest and GROSS ANATOMY 29 are thus ectodermal in origin. Although the chromaphil tissue develops in intimate relation with the sympathetic nervous system, the two are developmentally distinct in origin. The differentiation of chromaphiloblasts from sympathoblasts be- gins in the embryo but is not complete until late in gestation or in some species after birth. When any cells in a given area of the sympathoblasts differentiate, all do, and hence no inter- mixture of chromaphil and sympathetic cells results despite their ultimate intimate relations and common origin. The cortex of the adrenal and the interrenal tissue in general are derivatives of the ventral portion of the coelomic epi- thelium. They are thus mesodermal in origin. Embryo- logically, therefore, the cortex and medulla are quite distinct in origin. It is not until we reach the amphibia that the union of the two anlage begins to form the compound organ denoted as the adrenal. In the present section we shall outline briefly the embryo- logical development of the adrenal and its homologues in the elasmobranchs, amphibia, birds, and mammals. For more detailed descriptions the excellent monographs of Balfour, 28 Soulie\ 581 and Poll 608 should be consulted. Elasmobranchs. The development of the interrenal in the dogfish (Scylliwn) has been studied by Poll. 508 In this elasmo- branch the interrenal first appears in the 7 mm. embryo as a number of irregularly distributed thickenings of the splanchnic mesoderm, ventral to the dorsal aorta, and extending from the pronephros as far back as the cloaca. These rudiments meet and become continuous taking the form, in the 10 mm. embryo, of a cellular rod lying under the dorsal aorta. In the 16 to 28 mm. embryo, the interrenal body gradually becomes separated from the coelomic epithelium and the nephrotomes along which it had previously been in apposition. Only the posterior half of the rudiments take part in the above described fusion to form the interrenal. The anterior rudiments atrophy or develop into small accessory bodies. The chromaphil bodies of Scyllium develop at a much later 30 ANATOMY stage than the interrenal organ. In the 53 mm. embryo, differentiation of the lateral parts of the sympathetic ganglia begins. The chromaphil cells become smaller than those which are to become ganglionic cells and assume their characteristic reaction with chromic acid. In the 90 mm. embryo the chromaphil organs have assumed their definitive forms. In subsequent development, modification of the segmentally arranged chromaphil masses occurs, some disappearing, others undergoing fusion. There is a marked variety in the final adult arrangement in the different genera. Amphibia. The development of the adrenals in amphibia has been described by Brauer 80 for Hypogeophis. As in the Elasmobranchs, the interrenal first appears as segmentally paired proliferations of the coelomic epithelium which extend from the pronephros to the cloaca. The chromaphil bodies develop as in the Elasmobranchs but shift and take up their position in intimate contact with the interrenal bodies. In the posterior paired region, they lie on the medial face of the interrenal. Elsewhere they lie dorsal or lateral or even sur- rounding the interrenal. Bird. The development of the adrenal in the bird has been described by Soulie. 581 The cortical portion of the gland arises next to the anterior and dorsal part of the germinal epithelium, posterior to the pronephros. At the 96th hour of incubation in the hen's egg, and continuing for 4 or 5 hours, groups of cells bud off into the underlying mesenchyme lying between the mesonephros and aorta. These cells, arranged in the form of epithelial cords increase in number by cell division filling the entire space above and medial to the mesonephros. The chromaphil system of the adrenal begins to form at about the eighth day with the migration of sympathetic ganglion cells into the adrenal to occupy their permanent position as the adrenal medulla. 288 - 616 Mammals. In man, the first development of the cortical system is noted at the beginning of the fourth week. At GROSS ANATOMY 31 this time there occurs a proliferation of the epithelial cells lying between the mesonephros and the root of the mesentery. The buds of tissue thus formed, as found in a 12 mm. human embryo, lie as a continuation of the suprarenal ridge. In the 20 mm. embryo, the sympatho-chromaphil cells begin to migrate into the developing cortex along the line of the central vein to form the medulla of the adrenal gland. It is not until the embryo is 10 cms. in length that the migrating chromaphil cells have reached the central vein and formed a true medulla. In man this penetration of the epithelial anlage by the sympa- thetic is accompanied by a special formation of folds and a process of invagination. 376 On cross-section the cortex appears invaginated deeply at certain points, especially along the central vein, so that this vein is almost entirely surrounded by cortical tissue, particularly in the adult. This peculiar process, which is not limited to man, results in a more intimate contact between medulla and cortex. Differentiation of the chromaphil cells in man begins in the 18 mm. embryo but is not complete until about birth. The chromaphiloblasts (cells destined to become chromaphil tissue) are larger in size and stain less intensely than the sympatho- blasts. Their specific reaction with chromates appears at this stage. Epinephrine does not appear in the human adrenal until after birth. 393 In mice the first appearance of the chromaphil reaction takes place between the fourteenth and fifteenth day of develop- ment. 317 At this time the future medullary cells are just beginning to penetrate into the interrenal tissue leaving the sympathetic ganglion anlage which at this time is closely applied to the interrenal ridge. The sympatho-chromaphil mass at this time is made up of cells of embryonic type. The differentiation of the chromaphil cells is accompanied by the acquisition of darker nuclei and the assumption of a chromaphil reaction. The interrenal tissue at this time is surrounded by a layer of fibroblasts. That the chromaphil reaction, as observed at an 32 ANATOMY early state of differentiation is in reality due to the presence of epinephrine is demonstrated by the inhibition of intestinal movements by extracts of this tissue. 317 • 669 ACCESSORY ADRENAL BODIES The tissues of the adrenals are not confined to that which occurs in the main glands. As we have already seen, the medullary tissue is only one part of a widely distributed chromaphil system. The cortical tissue is also composed of several masses of glandular tissue located at a considerable distance from the main gland. Previous writers have con- sidered all of this tissue, because of a similarity in its gross histological appearance, as being functionally part of the same tissue. This view, however, is not supported by physiological or pathological findings and we shall, therefore, classify the cortical (or interrenal tissue) into two groups: 1) the true cortical tissue and 2) the androgenic tissue. The cortical tissue proper elaborates a hormone essential for life. It forms the outer layers of the adrenal gland and occurs at times as accessory adrenal bodies in the near vicinity of the adrenal. A second part of the cortical tissue, resembling the first histo- logically in many respects, occurs as the internal layer of the cortex in certain animals during the early period of develop- ment, but soon disappears (except under some pathological conditions). This tissue also appears in the form of temporary accessory bodies which are widely distributed. The second type of cortical tissue shall be designated as the androgenic tissue because of its masculinizing effects and shall be described in the next chapter. Accessory adrenals were first described in the dog by Hart- mann in 1699 and in man by Morgagni in 1740. Du Vernoi in 1751 described their occurrence in man with particular clarity. 55 Accessory adrenal tissue also frequently occurs as islets in the medulla or in the cortical tissue and was first noted by Nagel 464 and subsequently by Rokitansky, 535 Arnold, 19 Marchetti, 431 and others. These islets resemble benign adenomata and Fig. 3. Accessory Adrenals An adrenal of the cow (Bos taurus) showing an accessory adrenal projecting from its surface and two discrete accessory bodies found in the connective tissue surrounding the main glands (XI). GROSS ANATOMY 35 represent most probably hypertrophied nodules similar to those often encountered in other secretory glands. The term accessory adrenal is applied to small islets of tissue which are present in the fat and connective tissue surrounding the adrenal glands. These islets are for the most part micro- scopic in size except in large animals such as man, the horse or cattle. In the last named they frequently attain the size of a walnut. In the cat, rabbit, or dog they are occasionally visible to the naked eye, but in the rat or mouse they can only be detected in microscopic sections. These accessories at times are said to resemble the main gland in their histological arrangement and contain chromaphil tissue in their medulla. For the most part, however, they consist of cortical tissue only the cells of which resemble in their arrangement those of the Stannius corpuscles of the Teleost fishes (cf. Figure 6) . In Figure 3 is reproduced an adrenal of the cow containing an accessory body which projects like a wart from the surface of the gland. This type of accessory is in reality merely an hyper- trophic nodule which has formed near the surface of the gland. In Figure 3 are also reproduced two discreet accessory adrenal bodies obtained from the connective tissue surrounding the main glands. These represent true accessory bodies. On cross section they are found to be composed of cortical tissue arranged in columns resembling the fascicular layer of the main gland. The accessory adrenals situated in the vicinity of the adrenals are commonly found in most animals. Although said to occur with greater frequency in some species than in others, this view is based on indirect evidence derived from extirpation experiments. Thus the accessories are said to be relatively uncommon in the cat or dog because adrenalectomy is fatal in these animals. In the mouse, rat, or rabbit, however, the presence of accessory adrenals is considered to be very common because these animals often survive adrenalectomy. As a matter of fact, even in these animals, meticulous care in 36 ANATOMY adrenalectomy leads to the same fatal outcome as in the cat or dog. The glands, being relatively large in the cat and dog, may be easily extirpated without leaving bits of tissue which might hypertrophy. In the mouse or rat, on the other hand, the glands being extremely small and friable, it is easy to detach bits of cortical tissue which, although microscopic, suffice to permit regeneration and survival of the animal. In the rabbit, the right adrenal is often so firmly attached to the vena cava as to render its complete extirpation difficult. That the frequency of occurrence of accessory adrenals in the rat or mouse is not based on sound grounds but is explicable on the basis of the above interpretation has been demonstrated by many recent workers. The relative infrequency of these accessories in the rat and mouse can also be definitely proven by serially sectioning the adrenal sites including all the sur- rounding connective tissue. 385 When this is done one finds surprisingly few accessory bodies and these are always present in the connective tissue investing the adrenals. They are not scattered throughout the abdominal cavity as was formerly believed. Some authors have claimed that certain breeds of rats con- tain diffusely scattered accessory bodies and hence survive adrenalectomy while others being devoid of such accessory tissue do not survive the operation. These authors, however, give no specific identification of these breeds but apparently arbitrarily differentiate certain animals as being of a different strain on the basis of their survival following adrenalectomy. All recognized strains of the common rat {Mus Norvegicus) have been subjected to adrenalectomy in the author's lab- oratory without encountering the hypothetical accessory- endowed strain assumed by certain authors. The true accessory cortical tissue occurs usually only in the near vicinity of the main glands. The accessory tissue which is found in various parts of the abdominal cavity at some dis- tance from the main glands is usually a part of the androgenic tissue and shall be described in Chapter IV. Chapter III MICROSCOPIC ANATOMY The adrenals of many animal species have been studied microscopically in great detail by numerous workers. Un- fortunately much of the histological literature is conflicting and unsatisfactory because of certain difficulties attendant upon the study of the adrenals. These glands are noteworthy for the rapidity with which they undergo autolytic change after death. Moreover, the adrenals are extremely delicate organs, and, as Hoerr 301 has pointed out, even the slightest pressure will often cause artifacts to appear in the microscopic sections. It is also difficult to fix the glands so as to avoid the production of these artefacts. As a fixative, Hoerr recom- mends Bensley-Helly's "Formol-Zenker," prepared by adding nine volumes of an aqueous solution, containing 2.5 gs. of potassium dichromate and 5.0 gs. of mercuric chloride per 100 cc, to one volume of neutralized formalin. In order to study properly the morphological details of the cells Hoerr suggests the use of several fixatives and different stains. Failure to appreciate the difficulties inherent in obtaining good sections has undoubtedly contributed to the confusion and misinter- pretations which abound in the anatomical literature. Many of the morphological descriptions of bizarre cell structures are mere artifacts to which no physiological significance is to be ascribed. It is particularly difficult to obtain specimens of human adrenals soon enough after death to avoid post-mortem changes. The adrenals of some species undergo radical changes dur- ing certain periods of life. The most striking of these changes involves the development and involution of the androgenic zone to be described in the next chapter. Failure to appre- 37 38 ANATOMY ciate this temporary appearance of a new tissue in the gland has led to certain of the discrepancies found in the litera- ture. 319 - 671 As Kolmer 362 has indicated, the microscopic appearance of the adrenals of every animal has certain distinctive properties so that an experienced histologist could determine from a given section the animal species from which the adrenal was ob- tained. On the other hand, it is impossible to say from a study of an adrenal from which order or genera it was derived. Closely related species often have adrenals which differ widely in their appearance. As we have already seen in the preceding chapter, the adre- nals as compound organs are first encountered in the amphibia. In the fishes the interrenal and chromaphil tissue are present as separate organs. In the bird these two types of tissues are intimately mixed. The interrenal tissue (corresponding to the cortex of the mammal) is arranged in the bird in irregular columns surrounding the blood vessels. The latter form a network of irregularly arranged sinusoids throughout the gland. The columns of interrenal tissue are called the " chief strands" because they appear to form the foundation for the other elements of the glands. The chromaphil cells have no regular arrangement but occur in groups of 2 or 3, to 30 to 40 cells which, for the most part, lie in direct contact with the venous sinusoids. The chromaphil elements are denoted as the "intermediate strands." On cross section the adrenals of the mammal are seen to consist of an external (or cortical) and an internal (or medul- lary) portion. The former which constitutes the chief part of the organ is usually of a deep yellow color, due to the presence of lipids, while the latter is soft and pulpy and of a dark red- dish or brownish color due to the presence of blood. In cattle, the cortex when viewed soon after slaughter of the animal is either ochre-yellow or brownish red, depending upon the age, sex, and nutritive state of the animal, while the medulla pre- HISTOLOGY 39 sents a greyish appearance. The medulla is not entirely sur- rounded by cortical tissue in all mammals. In some, the medullary tissue clusters about the adrenal vein with part of it surrounded by cortical tissue while the remainder is directly under the adrenal capsule. Such a condition, for example, is encountered in certain marsupials (Metachirus oppossum), in the flying fox (Pteropus medius), and in the stone-marten (Mustela foina) . The separation of the cortex and medulla is also very vari- able. In the Monotremes, as in the spiny ant-eater (Echidna aculeata) and in the duckbill (Ornithorhynchus paradoxus), the medulla and cortex are most imperfectly divided, the former penetrating far into the cortical tissue. On the other hand, in some species, a definite band of connective tissue separates the medulla from the cortex, at least during a certain period of life. This is true of the mouse (Figure 9), little ant-eater (Tamandua tetradactylus) , porcupine (Hystrix cristata), ele- phant (Elephas indicus), armadillo (Dasypus septemcinctus) , and man. The significance of this band of connective tissue shall be discussed in the next chapter. There is considerable variation in the relative sizes of the cortex and medulla of different mammals. In man and the anthrapoid apes, the medulla is represented at birth by a small strip of undifferentiated tissue. The medulla in these animals is a post-natal development. The medulla forms a relatively large proportion of the gland in the porpoise (Pho- caena communis), rhinoceros (Rhinoceros unicornis), flying fox (Pteropus medius), chimpanzee, and spider monkey (Ateles). On the other hand, the medulla is relatively small in the guinea pig (Cavia cobaya) and porcupine (Hystrix cristata). The adrenals of man and the higher apes Cgorilla, orangutan) are characterized by folds or lobulations in the cortex which are reflected in the medulla thus making the point of contact of medullary and cortical tissue much more extensive than it is in the more simply shaped adrenals of other species. The 40 ANATOMY adrenals of certain other large mammals (rhinoceros, hippo- potamus, giraffe) also show this lobulation to a lesser extent. The adrenal of the porpoise is characterized by an irregular surface and when sectioned gives the appearance of cerebellar tissue due to many strands of connective tissue which pene- trate the cortex from the capsule. THE CORTEX Although considerable variation exists in the cellular ar- rangement of the adrenal cortex in different species, a more or less general pattern is present according to which the cortex is divided into three zones: the glomerulosa, fasciculata, and reticularis (Figures 4, 5, and 9). The layer beneath the cap- sule is known as the zona glomerulosa and consists of cells ar- ranged in rounded groups with an indication of an alveolar structure. The cells of this zone are usually very granular and stain deeply. The zona fasciculata is continuous with the glomerulosa and consists of columns of cells arranged radially. This zone in most species is very rich in fat. The innermost zone of the adrenal is known as the reticularis because of the irregular arrangement of its cells. This zone is in contact and to some extent interlaced by strands of the chromaphil tissue of the medulla. The above described division of the cortex into zones is not clearly defined in all animal species and is probably only of morphological significance. The cause for this peculiar ar- rangement of the cells is probably a combined effect of the manner in which the cortical cells are constantly being re- newed during life and the restraining influence of the capsule and connective tissue framework of the gland. New cells are constantly being formed in the inner glomerulosar and outer fascicular zones and removed from the reticular zone. The pressure of the newly formed cells in the vicinity of the glomer- ulosar-fascicular boundary would tend to compress the cells on the surface thus giving the glomerulosa its characteristic il (a , ' V§&$ :./%" '.•: "f-tf^ £ aiegt "v-A /■ L-Vtw " ■ . ; ' ; v ' V. .V - ' >-^. ■'.. ■ " Mv^V.>\^J^rV: ; - ; ' Fig. 4. Microscopic Appearance of the Adrenal Section through the adrenal of a wild rat. Note the penetration into the cortical substance of the medullary tissue, shown in the lower center of the photograph (X62). (Courtesy of Dr. W. M. Firor.) HISTOLOGY 43 appearance 362 (cf. Figures 4 and 5). In the fetus and in the accessory cortical bodies the cells usually all show a fascicular arrangement (cf. Figure 6), without any tendency towards a division into zones. In the oppossum (Trichosurus vulpecula) the adrenal can not be divided into the conventional zones. 77 In many other species it is only by a stretch of the imagination that one is able to differentiate the conventional zones. In the monotremes, the glomerulosar type of arrangement is found not only at the surface of the gland but also as islets in the interior of the cortex. Differentiation of the cortex into the conventional zones is not discernible in the members of this order. 362 The glomerulosa is poorly developed in many species as in the rat (cf. Figure 4), the lemur (Lemur rufifrons), and monkey (Cebus albifrons). In the lemur, the glomerulosa is completely absent at certain parts of the gland, the fasciculata coming directly to the surface at these points. On the other hand, the glomerulosa is developed so well in the hedgehog (Erinaceus europeus) as to be differentiable even macroscopically. In the horse (Equus caballus) and giraffe (Camelopardalis giraffa) , the glomerulosar cells are irregularly arranged in radial columns for which reason this zone is often referred to in these species as the "zona arcuata."™ 2 In man the cells of the glomerulosa are small and round (Figure 5). Each round mass of these cells is surrounded by fine connective tissue with capillaries lying between them. In women the glomerular zone is said to become hypertrophied during pregnancy and to store up lipids so as to render it scarcely differentiable in appearance from the fascicular zone. 123 The glomerular layer of the human adrenal usually contains little lipid, which, when present, exists in the form of fine droplets. The fascicular zone comprises the greatest part of the adre- nal cortex. It varies in the arrangement of its cells from strands of a single row of cells as in the rat (Figure 4) and bats (Chiroptera) to thick strands comprised of many rows, as in 44 ANATOMY the Primates and Ungulates. In man the cells of the fascicu- lata are filled with fine granules and droplets consisting of cholesterol ethers. During childhood this zone is narrow but after puberty the columns are long, two or three cells in width, and closely packed (Figure 5). In late life, the columns be- come shorter and less closely packed. 123 The outer portion of the fasciculata in man has also been denoted as the "spongy zone" while the inner portion has been referred to as the "siderophile zone" because of the ap- pearance of certain cells in this region. 231 These siderophile cells, which possibly represent exhausted cells, are most promi- nent in the guinea pig (Cavia cobaya)™ 1 The zona reticularis, or innermost layer of the cortex mani- fests the most diverse cytological appearances in different species. It is the zone in which degenerative changes occur and hence its appearance will depend on the rate at which the cells of the adrenal in a given species are being renewed. In man, the cells of the zona reticularis contain fine droplets of lipid as do also the endothelial cells of the blood capillaries within the reticular layer. The reticular layer of the human adrenal is also characterized after the second decade of life by the presence of a pigment which increases in amount with age. This pigment is usually considered as analogous to the "wear and tear" pigment observed in other organs. It has no special significance or relation to the pigmentation of Addison's dis- ease as was formerly believed. In man the reticularis is clearly differentiated from the fasciculata by the arrangement of its cells and its rich blood supply. It is more open in tex- ture than the medulla (c/. Figure 5). The cells of the reticular zone are the largest in the cortex. They are rounded and well-defined with a coarsely granular and finely vacuolated cy- toplasm. The zona reticularis becomes wider and more vascu- lar as age advances. In late life it may equal the fascicular zone in width. 123 In the guinea pig the zona reticularis appears speckled due *Q gs> 3i? i- $2 2 a _i. 3-— - a 5C ~ <* ~^ gx t, < gxl 5 — - X ** w r E ; 2 ■S a « "^ c T3 ^ cj - oS s a o3 . 5 g 3 S -3_0 -^ CD "3 — TJ"^ HISTOLOGY 47 to the unequal staining of two types of cells which have been described as dark and light cells. The former are large rounded cells, with a finely granular pale-staining cytoplasm and con- tain few mitochondria, little lipid, and little pigment. The latter stain deeply, have a hyperchromatic or pyknotic nucleus and abundant mitochondria, lipid, and pigment. 301 The rabbit possesses no reticularis, the fasciculate cells being contiguous with the medulla. In the mouse, likewise (Figure 9) no clearly defined zona reticularis is distinguishable but in the other ro- dents (Figure 4) the inner part of the cortex is characterized by an irregular or reticulate arrangement. In man at birth there is a large zone between the reticularis and the medulla. This zone undergoes involution during the first year of life and is replaced by a very thin "juxta-medul- lary" zone. 231 Both of these zones, as well as their homologues in other animals, shall be described in the next chapter. The cells of the adrenal cortex in almost all animals are characterized by the presence of large amounts of lipids, the nature and significance of which shall be discussed in Chapter XX. The most frequent point of deposition of this lipid is in the fascicularis. However, in the armadillo (Dasypus septem- cinctus) the lipid is found in the glomerulosa. In the cat also this zone contains fatty inclusions. In the rabbit, guinea pig, elephant, bear, and rhinoceros, there is a deposition of much lipid in the zona reticularis. The adrenals of certain Insecti- vores (hedgehog, mole) and of the marmot (Arctomys marmot) are relatively free of lipid as observed histologically, while in a normal healthy specimen of the emu (Tragulus javanicus) Kolmer 362 was unable to detect any lipid. This finding is of particular interest since many authors have looked upon the lipid as the specific secretion of the adrenals. The cytology of the cortical cells has been the subject of frequent study in the hope of elucidating the function of the adrenals. These glands offer a rich field for the microscopist, but it is difficult to evaluate the significance of the results 48 ANATOMY which have thus far been obtained. Many of the described structures are probably only artifacts resulting from fixation and staining. Particular attention has been paid to the mito- chondria which assume an important part in the structure of the cortical cells. In the glomerulosa of the guinea pig they are so abundant as to constitute almost all of the cytoplasm. 301 They are present throughout the cortex. The significance and function of the mitochondria, however, is still a mystery. The Golgi apparatus of the adrenal has recently been studied by Bourne. 78 The adrenal of the living frog as observed microscopically 576 appears filled with small, evenly distributed yellow granules which change to a globular form. By fluorescent light a fine network of fibers are seen around the granular cells which dis- appear on the appearance of the globular form. Pithing and the injection of curare or mercuric chloride induce changes in the structure of the cells indicative of a diminution of their lipid content. These limited observations of Singer and Zwemer 576 are deserving of a more thorough investigation with the hope of obtaining a more normal histological picture than can be derived from dead tissue. THE MEDULLA The chromaphil cells of the medulla differ in their morph- ological arrangement in different animals. In some species the medullary cells are arranged in compact bundles held to- gether by strands of connective tissue; in others they are ir- regularly scattered without any semblance of order. The type of cell found in the medulla is also variable ranging from a cylindrical to an irregular polyhedral type. 362 In man and the common laboratory animals the cells of the medulla are irregularly arranged without the suggestive form observed in the cortex (c/. Figures 4 to 9). The medulla in man is characterized by a rich content of elastic supporting fibers. It is very vascular and is composed of large irregular Fig. Accessory Interrenal Tissue Section through an accessory interrenal body of the white rat to show the arrangement of the interrenal cells (X600). eg. 7. The Medulla High power view of the ehromaphil cells of the medulla of a wild rat (X440). HISTOLOGY 53 polyhedral cells arranged in a network. These cells have a finely granular cytoplasm. In the intercellular meshes are sinusoids which allow an intimate contact between the cells and the venous blood. In many places the endothelial lining of the blood sinuses is in direct contact with the chromaphil cells and, according to some observers, is completely absent. There is a loose network of supporting connective tissue con- taining smooth muscle fibers throughout the medulla. The medulla is supplied with many non-medullated nerve fibers and an occasional sympathetic ganglion. 123 The extra-adrenal chromaphil tissue resembles closely that of the adrenal medulla. Both tissues stain characteristically with bichromate due to the presence of epinephrine. The cell columns are thicker in the adrenal than in the abdominal chromaphil bodies. The blood spaces are also wider in the medulla and, according to Vincent, 648 the medulla gives an appearance of a higher organization than does the accessory chromaphil tissue. The cytoplasm of the medulla is also more distinctly granular than that of the abdominal chroma- phil body. Some observers have described the presence of two types of cells in the medulla of certain animals. Such an apparent diversity in the cytological appearance of the cells is due in some cases to poor fixation, as shown by Kolmer, 362 for the bats ( Vesperugo noctula et pipistrellus) . However, Kolmer describes two types of cells in the hamster (Cricetus frumentarius) , the horse (Equus caballus), and other species. Both types of cells show the chromaphil reaction. It is difficult to say what significance, if any, is to be attached to the morphological dif- ference between these two types of cells. The constant regeneration of new cells so characteristic of the cortex is not observed in the medulla. However, mitotic activity is observed, particularly in the hedgehog (Erinaceus europeus) in which the cytological detail of the chromaphil cells is most striking. 362 54 ANATOMY One often encounters islets of cortical cells imbedded in the medulla, particularly in those species in which the division of cortex and medulla is not sharply defined. The adrenal medulla of man and the higher anthrapoid apes is a post-natal development. During early infancy the ex- tra-adrenal chromaphil tissues degenerate simultaneously with the rapid growth of the medulla which occurs at this period. PATHOLOGICAL CHANGES IN THE MICROSCOPIC APPEARANCE OF THE ADRENALS The microscopic appearance of the adrenals is markedly affected by a number of pathological conditions. There is a loss of lipids with the formation of vacuoles in certain infec- tious diseases, particularly diphtheria. Similar changes occur following endogenous toxicoses as in peritonitis or burns, and following metabolic disturbances as in diabetes or pernicious anemia. In septic processes, as in scarlet fever, there is often an edema of the cortex with the accumulation of an exudate between the cells of the fascicular layer. 21 - 156 • 157 In chronic starvation, as Landau 376 first showed, there is an increase in the cholesterol store of the cortex, probably due to the liberation of this substance from the catabolized cells. The changes in the appearance of the adrenals with the state of nutrition must be taken into account before ascribing any observed abnormality to other causes. Thus the changes ascribed to epilepsy, dementia praecox, and other mental dis- eases can be explained solely on the basis of the altered nutri- tive condition of the patients suffering from these diseases. Although the characteristic doubly refractive substance of the cortex increases with rest, vanishes in exhaustion, and un- dergoes characteristic changes in other conditions, 181 it cannot be an essential factor in cortical activity, for it is not present in the adrenal of the sheep and certain other animal species. In pathological states, exhausting changes of the medulla and cortex, as noted histologically, move in close parallelism. HISTOLOGY 55 After stimulation of the splanchnic nerves, however, the me- dulla alone appears to be chiefly affected. 183 The cells of the adrenal cortex move towards the center to replace the innermost cells near the medulla which are con- stantly dying. Degenerative processes can be seen in many cells of the normal reticular zone with mitosis in the outer por- tion of the cortex 362 The process of degeneration can be ac- centuated by a number of toxic agents — phenol, chloroform, mustard gas, bacterial suspensions, metallic poisons, malnu- trition, starvation, etc. — thus permitting the experimental study of the regeneration of the destroyed tissue. The guinea pig has been particularly useful in the study of these processes for its adrenals are extremely sensitive to toxic agents. 301 As von Behring showed in 1895, hyperemia and hemorrhage of the adrenals of the guinea pig follow the injection of diphtheria toxin before any other organ is affected. The reticular zone is the site of the normal degeneration of the cortical cells and invariably suffers the most damage in infectious or toxic processes. It is also the site of most marked congestion, hemorrhages, focal degenerations, or other results of injury. In older animals the area of degeneration is greater and there is less evidence of mitotic activity than in young individuals. 301 The normal and pathologically induced degenerative changes observed in the adrenal are repaired by mitotic activity, which is found mainly in the outer portion of the fasciculata or in the border level between the glomerulosa and fasciculata. The connective tissue of the adrenal also proliferates rapidly after hemorrhage, trauma, or other severe injury. The nec- rotic area becomes enveloped by connective tissue, the cellular debris is gradually absorbed, and finally only a scar remains at the site of injury. The removal of the constantly degenerating cells of the re- ticularis is brought about by infiltrated polymorphonuclear leucocytes in severe lesions and by macrophages, plasma cells, 56 ANATOMY monocytes, and lymphocytes after moderate degrees of injury. The reticulum cells may be transformed into macrophages and the endothelial cells may become phagocytic. In the human adrenal the plasma cells are most common and lymphocytes second in order of their frequency. After severe experimental injury of the adrenal in guinea pigs, the macrophages are most abundant. The infiltrated small cells noted in the adrenal occur in perfectly normal animals and although they may be increased in numbers in disease, their presence is not of any pathological significance as some authors have assumed. These cells probably serve the physiological function of re- moving the debris normally resulting from degeneration of the reticular cells. 301 The areas of infiltration of leukocytes and lymphocytes ob- served in the adrenals of tumor-bearing rats represent a reac- tion to the necrosis occurring in the large tumors. Similar infiltrations occur in other pathological conditions and are not indicative of any relation of the adrenals to cancer. 412 Chapter IV THE ANDROGENIC ADRENAL TISSUE Besides the interrenal (or cortical) and the chromaphil (or medullary) tissues described in the preceding chapter, one finds in the adrenals of man and certain other animals a third type of tissue, which has been designated as "embryonic," "boundary zone," "fetal" or "x-zone" but to which we shall refer as the androgenic tissue. This tissue differs from the remainder of the cortical tissue not only in its morphological and histochemical properties but also in the fact that it nor- mally exists only during a certain period of life. The hyper- trophy of this tissue under certain pathological conditions in man (cf. Chapter XXIII) gives rise to a symptom-complex char- acterized by masculinization of the female. Because of this property, the author has designated the tissue as androgenic (from the Greek, avdpoyevos, to masculinize). This differentiation of the adrenal cortex into two function- ally distinct moieties has not hitherto been made. Although experimental evidence remains to be adduced to prove defi- nitely the exact relation of the function of the androgenic zone to the reproductive system, the facts at hand suffice to indicate that the cortex comprises two tissues, one of which (the inter- renal tissue) produces the hormone which is essential for life, and the other (the androgenic tissue) which has some as yet incompletely defined function relating to the reproductive system. The most characteristic property of the androgenic tissue is its persistence normally for only a relatively short period of time. In man it develops during fetal life and disappears al- most entirely during the first year of life. 182 In the mouse, it develops before puberty and disappears in the male at 57 58 ANATOMY puberty, while in the female it undergoes involution shortly after ovulation is well established. 318 This disappearance of the androgenic tissue is not a result of a decreased demand of the organism for interrenal tissue, for removal of one adrenal does not prevent the observed involution of the androgenic tissue in the remaining gland. 320 The probable relation of the androgenic tissue to the reproductive system is indicated by the changes which it undergoes at puberty, during preg- nancy, 231 after castration in the male, 318 and by the disorders of the reproductive system, described in Chapter XXIII, which are accompanied by hypertrophy of this tissue. THE ANDROGENIC TISSUE IN MAN During early embryonic life the human adrenal exceeds the kidney in size; at birth it is one-third as large as the kidney. This large size of the adrenal at birth is due to the presence of a relatively thick zone of tissue separating the true cortex (or interrenal tissue) from the medulla. This tissue has been con- sidered by previous authors as part of the interrenal system and as exercising the same function as the rest of the cortex. Such a view, however, fails to take into account the facts to be presented below and we shall therefore consider this tissue which comprises what we have designated as the androgenic zone, as a glandular entity, specific in its function, and to be differentiated from the rest of the cortex. Much of the tissue which has in the past been described as accessory cortical tissue is, in reality, also a part of this andro- genic tissue and completely independent functionally from the cortex proper and the true adrenal cortical accessory bodies. This accessory tissue is very common in man at birth, disap- pearing during infancy with the androgenic zone of the main gland but persisting in cases of hermaphroditism (cf. Chapter XXIII) and occasionally giving rise to tumors which in the female cause adrenal virilism. These accessory adrenals are situated at some distance from the main glands and are re- ANDROGENIC TISSUE 59 ferred to as androgenic tissue, in the present book, because like the androgenic zone they are transient and disappear at an early age, hypertrophy when associated with certain herma- phroditic conditions, and give rise to virilism when the site of a cancerous growth. The term androgenic is introduced to indicate their functional masculinizing potentiality. These accessory bodies were described by Marchand 430 and are often referred to in the literature as Marchand's bodies. The accessory androgenic tissue occurs in various parts of the organism, beneath the lower pole of the kidney, 430 along the internal spermatic artery, 431 on the ileopsoas muscle, 453 in the solar 507 or renal plexuses, 556 between the transverse colon and the spleen, in the right lobe of the liver, 478 in the pan- creas, 535 and particularly in association with the reproductive organs. This tissue when associated with the reproductive organs of the male occurs along the spermatic cord, between the testis and epididymis, in the rete testis, and in the para- didymis. 453 In the female it is observed in the ligamentum latum, 623 on the Fallopian tubes, and in the ovaries. 363 - 656 Schmorl 656 found such androgenic tissue in 92 per cent of autop- sies. Wiesel 678 found it in 76 per cent of the genitalia of new- born children and Aichel 8 found it in the broad ligament of every newborn female child which he examined. Aschoft" 21 denies this, however, and thinks Aichel confused chromaphil with interrenal tissue. On the basis of his embryological investigations, Aichel 8 con- cluded that Marchand's bodies or as we have termed them, the accessory androgenic bodies, are entities to be differentiated from the true accessory bodies which he in close proximity to the main glands. According to Aichel the androgenic bodies arise from the degenerating tubules of the paroophoron and the epoophoron and are thus embryologically distinct from the true accessory adrenals. AichePs views have received little attention from subsequent authors who have inclined to the view that the androgenic bodies represent adrenal tissue dis- 60 ANATOMY placed from its original position by the migration of the repro- ductive tract during embryonic development. Physiological experiments as well as pathological observations are, however, in accord with Aichel's conclusions. INVOLUTION OF THE ANDROGENIC TISSUE IN MAN The post-natal involution of the androgenic zone was first described in 1911 almost simultaneously by Thomas, 626 Elliott and Armour, 182 and Kern. 352 In the embryo of eight weeks the adrenal lies anterior to and in contact with the kidney. The two organs at this stage of development are of equal size. The peripheral cells are filled with lipids and represent the cells which will subsequently form the cortex of the adult adrenal. The central part of the gland is composed of larger, angular cells filled with granular cytoplasm. These cells which are loosely arranged constitute the androgenic zone of the adrenal. During most of the period of intrauterine develop- ment, the true cortex remains as a comparatively thin rim of closely packed small cells with deeply stained nuclei. The an- drogenic zone grows rapidly and forms the main bulk of the gland. At birth the true cortex has assumed its division into definite zones. The androgenic zone begins to involute soon after birth and this involution continues during the first years of life. It is not until about the third year of life that the gland assumes the characteristic appearance of the adult gland. 123 The androgenic zone in the new-born differs from the cortex proper in several respects. It does not contain the characteris- tic doubly refracting substance which characterizes the true cortical tissue. It is characterized by an extremely abundant vascular supply with some extravasation of blood. This ap- pearance of hemorrhage has been attributed to injury during birth but the existence of this hemorrhage in the adrenals of newborn delivered by Caesarian section and during fetal life demonstrates that it is not a result of injury. 376 ANDROGENIC TISSUE 61 Soon after birth involution begins, assuming a massive form during the second week of life. During this period the cells of the androgenic zone are found in all stages of nuclear and protoplasmic degeneration. Fat droplets appear in the de- generating cells which are displaced and compressed by the concomitant hyperaemia and growth of the medulla which occurs rapidly at this stage. Phagocytosis of red blood cells with pigmentary degeneration occurs with thickening of the intercellular reticulum. 182 The degenerating androgenic zone is sharply marked off from the true cortical tissue which re- mains intact, and from the growing medulla. At the end of the first year the above involutionary proces- ses are almost complete and the androgenic zone is replaced with connective tissue in the meshes of which may still be found degenerating pigmented cells. This connective tissue by compression becomes narrow and ultimately assumes the layer separating the medulla from the adult cortex. Neither prematurity nor inanition were found by Lewis and Pappenheimer 395 to affect the involution of the androgenic zone, but syphilis markedly retarded its disappearance. In- fection by penumonia caused an increased size of the true cor- tex while the involution of the androgenic tissue continued, which is evidence for the functional independence of the two tissues. Lewis and Pappenheimer also showed the simulta- neous disappearance of the "accessory cortical tissue" or ac- cessory androgenic bodies, as we have called them, which is evidence for their physiological homology with the androgenic zone of the adrenal. The significance of the involution of the androgenic zone in man has often been the subject of speculation but the theories heretofore advanced to describe the phenomenon are easily re- futed. The idea that it results from pressure by the growing medulla was shown by Lewis and Pappenheimer 395 to be un- tenable since a similar degeneration occurs in the accessory bodies where there is no growth of medullary tissue. Ma- 62 ANATOMY rine's 433 suggestion that the involution represents a physiologi- cal response due to diminished demands for cortical tissue because of the antagonistic action of the thyroid takes no ac- count of the morphological features of the process nor of the results in the mouse where the degeneration occurs sometime after birth. In pneumonia also, as we have already seen, an actual stimulation of the growth of the true cortex occurs while degeneration of the androgenic zone proceeds at an undi- minished rate. The peculiar deposition of lipids characteristic of the involu- tion of the androgenic zone is evident in early fetal life (4th month) in the cells of the innermost cortical layer which sur- round the medullary vein. 694 This lipid, as judged from its staining reactions and appearance under the polarizing micro- scope, differs from that which later characterizes the cortex proper. In those animals in which no involution occurs, the appearance of the lipoidal deposits in the cortex at birth re- sembles that of the adult gland. It is interesting to note that in hemicephaly, the adrenals at birth, as Morgagni first observed in 1723, are extremely small. 696 This is due to the absence of an androgenic zone associated with maldevelopment of the reproductive system. 182 In spina bifida or hydrocephalus no abnormalities of the an- drogenic zone are observed. The period of infancy during which the androgenic zone is at its height of activity is also a period of activity of the interstitial cells of the testes which is in accord with the view that the androgenic tissue exerts a masculinizing effect analogous to that exerted by these cells. In the adult human adrenal one can observe a thin juxta-med- ullary zone which differs from the rest of the cortex by the disposition of the cells and their chemical and morphological properties. 231 These cells are osmophilic and pigmented and are denoted by some writers as part of the reticularis. Others have described these cells as "embryonic in character." As pointed out by Goormaghtigh 231 these cells which border the ANDROGENIC TISSUE bS medulla resemble the cells of the androgenic zone of the infant and are probably a remnant of this involuted tissue. Goor- maghtigh observed an hypertrophy of this juxta-medullary tissue in a woman at the menopause who developed hirsutism, in an old woman, and in a third woman during pregnancy. It is thus probable that the androgenic tissue may remain throughout life as a small inactive group of cells, which hyper- trophy when the female reproductive system undergoes fun- damental changes. When this hypertrophy becomes pro- nounced the adreno-genital syndrome described in Chapter XXIII results. According to this theory remnants of the androgenic zone which have not undergone degeneration are responsible for the pathological manifestations of the repro- ductive system which are associated with certain tumors of the adrenal. The true interrenal tissue is not involved in the genesis of these disorders (cf. Chapters XXII and XXIII). THE ANDROGENIC ZONE IN THE MOUSE Howard 318 first demonstrated an area in the mouse, which she designated as the X-zone and which she considered to be homologous to the human androgenic zone. In the young female, this tissue may comprise two-thirds of the entire cor- tex. Although appearing during extra-uterine life, this zone is temporary in its existence and apparently is the functional homologue of the human androgenic zone. Howard showed that the androgenic zone in mice (or X-zone as she called it) disappeared at 38 days (on an average) in male mice. In fe- males the zone underwent involution during the early part of pregnancy, persisting, if the animal did not conceive, for 3 to 6 months before it disappeared. Castration caused a pro- longed persistence of the zone in the male but was without effect in the female. Deansley 153 and Whitehead 672 have also made detailed studies of the development and involution of the androgenic^tissue in the mouse adrenal. In Figure 8 are reproduced cross sections of the adrenals of 64 ANATOMY 12 week-old male and female mice, showing the presence of the androgenic zone in the latter. In Figure 9 are shown the histological appearances of the androgenic zone in the mouse, showing the manner of its involution and its ultimate replace- ment by a band of connective tissue. The androgenic zone of the mouse is characterized histologi- cally by its being more deeply stained by Hemotoxylin-Eosin than is the adjacent true cortical tissue of the zona fasiculata. It also does not stain with Sudan due to the absence of the doubly refracting lipids which are characteristic of the perma- nent cortical tissue. In shape, the cells of the androgenic zone are superficially like those of the fasiculata except that they are smaller and at the boundary of the fasiculata they are elongated and flattened. After its degeneration, this zone assumes the appearance of alveolar connective tissue which re- places the previously existent glandular tissue. 153, 318 - 673 The above anatomical considerations would not in themselves characterize the androgenic zone as a specific tissue from the standpoint of its functional capacity in the body. Obviously the different staining reactions and cell shapes might be mere morphological deviations independent of any functional sig- nificance. It is in this respect that the anatomical methods manifest their limited value. However, the changes occurring in the androgenic tissue indicate the abolition of a function previously fulfilled by the androgenic zone. Failure to appreciate the true nature of the androgenic zone in mice has led to several flagrant misinterpretations of experi- mental observations. Thus the observations of Cramer 134 and his conception of the role played by epinephrine under various conditions are vitiated by his failure to note the transient exist- ence of the androgenic zone in mice. 319 - 671 ANDROGENIC ZONE IN OTHER ANIMALS Attempts have been made to find the involution characteris- tic of the human and mouse adrenal in other animal species. } , Fig. 8. The Adrenal of the Mouse Cross-section views of the adrenal of the mouse (Mus musculus). On the left is a gland from a 12 week-old male, showing the appearance of the adult gland after involution of the androgenic zone. On the right is a gland from a 12 week-old female showing the full development of the androgenic zone ( X50). m, medulla; z.g., zona glomerulosa; z./., zona fasciculata; z.r., zona reticularis; z.x., androgenic zone; b.v., blood vessel. (Reproduced through the courtesy of Dr. R. Deansley 1 * 3 and the Proceedings of the Royal Society of London.) o u- 00 CM 53 -g M *-' eg -xj '- r.± "f *-■ i a - c, si — 1 — * tsj o g 3«r8.s 1 2 " H 3 ' — r - - 2 ^ C 33 45 55 2 z < ages ispic a (d tely tes t X -e - '£ =v c3 ._• 50 -- - — - rv ^3 o a? o g'c? o Z O ►J xf c o -e ~ s» showii A ba and gl almog c whic ■tunics C =*S > x^ki $ ■ z - r — o s 1-1 O .£ ^— *" ~~ a g C * m « ^ H ^.Sd g 5 S > ja » Jg ANDROGENIC TISSUE 69 None has been demonstrated in the dog, cat, rabbit, or cow. It is very improbable that this tissue is limited to man and the mouse, and future studies shall undoubtedly reveal an analogous structure in other animals. The accessory bodies observed by Wiesel 676 in the reproduc- tive tract of young rats are possibly androgenic tissue for they disappear, according to Wiesel, with age and do not hyper- trophy or support life in adrenalectomized animals 198 as they should if they comprised part of the interrenal system. No one has, however, confirmed WiesePs description of these bodies. 335 A tissue has also been described in the pig embryo 95 which resembles the androgenic tissue of man and may represent its homologue in this animal. Incomplete studies 694 on the an- thrapoid apes (Orangutans and chimpanzees) also indicate the occurrence of a post-natal involution similar to that of man. Kolmer 362 from his histological study of the adrenal of a nine-month old elephant (Elephas indicus) was led to believe that a process of involution similar to that which occurs in the human adrenal, also takes place in this animal. His descrip- tion of the adrenals of certain other species also suggests the presence of an androgenic zone in the little ant-eater (Taman- dua tetradactylus) , the armadillo (Dasypus septemcinctus) , and the porcupine (Hystrix cristata). The thick layer of connec- tive tissue which surrounds the medulla in these species is analogous to that seen in the mouse after the involution of the androgenic zone. The unique structure in the adrenal of the oppossum {Trichosurus vulpecula), described by Bourne, 77 is also suggestive of the development of an androgenic zone in this species. Further work with these species will be neces- sary to determine if an androgenic zone is present during the early development of these animals. It is questionable if the involution of the cortex recently described by Whitehead 673 represents the degeneration of an- drogenic tissue in the rabbit.* *Cf., however, Jour, of Anatomy, vol. 70, p. 126. PART II. THE MEDULLA The medulla of the adrenal is characterized by the presence within it, in rather high concentration, of epinephrine, a sub- stance whose remarkable pharmacological actions has made it the subject of intense study. The existence of this chemically potent substance was first observed by Vulpian, 652 who, in 1856, noted the green coloration which occurred on moisten- ing the medulla with a dilute solution of ferric chloride. Henle 293 first observed the "bichromate" reaction in which the medulla assumes a characteristic brownish discoloration when treated with a solution of a salt of chromic acid. Because of this reaction, which is shared by certain extra-medullary tis- sues, the generic term "chromaphir' tissue is applied to these structures. Oliver and Schafer 480 in 1894 and Szymonowicz, 616 inde- pendently, first called attention to the remarkable blood pres- sure rise which followed the injection of an extract of the adrenal medulla. Lewandowsky, 391 in 1898, and Langley, 378 in 1901, called attention to the similarity in the pharmacody- namic effects of epinephrine and the effects elicited by stimu- lation of the sympathetic nerve fibers. With rare exceptions this similarity in function has been confirmed, and epinephrine is classed as a sympathomimetic substance because it mimics in its effects the results of sympathetic nervous stimulation. 36 The iron chloride reaction of the adrenal medulla (Vulpian's reaction) and the relatively high concentration in which epi- nephrine occurs in the adrenals rendered it relatively easy to isolate and identify this substance. The discovery of epi- nephrine, its isolation, and the demonstration of its powerful pharmacodynamic action focused all attention on this sub- stance as the important product of the adrenal gland. For the following two decades much work was done on its pharma- 71 72 MEDULLA cological effects. Numerous experiments were devised and theories elaborated concerning its supposed physiological ac- tion in the body. This preoccupation with all phases of in- terest in connection with epinephrine left relatively little atten- tion for the problems associated with the cortex. It is only in recent years that this part of the adrenal gland has received its due share of attention. In the present section we shall consider the chemical, physi- ological, and pharmacological actions of epinephrine. Chapter V THE CHEMISTRY OF EPINEPHRINE Epinephrine is found in highest concentration in the medul- lary portion of the adrenal gland. Considerable controversy once raged as to its occurrence in the cortex, some authors maintaining that it was actually elaborated in the cortex and merely stored in the medulla. This view was based on the demonstration of epinephrine in the cortical cells. 278 This presence of epinephrine in the cortex is attributable, however, to its rapid diffusion, post mortem, from the medulla. If proper care be taken to remove the gland from the body before the circulation has stopped and immediately cut away the cortical tissue, no epinephrine will be found in the cortex. The oc- currence of epinephrine in other chromaphil tissues besides the adrenal, its presence in the chromaphil bodies of certain Selachian fishes in which the cortical tissue is present as a separate organ, and finally its presence in the embryo, before the fusion of the chromaphil and interrenal tissues, all speak against the view that the cortex is involved in the elaboration of epinephrine. Nor is there any valid evidence for the exist- ence of a pharmacodynamically more potent precursor from which epinephrine is formed. The epinephrine content of the adrenals varies from about one-half to three milligrams per gram of adrenal tissue. Thus a pair of human adrenals contains about 8 mgms. of epi- nephrine. Both adrenals of the beef contain about 40 to 70 mgms., the pig, 9, dog, 2, cat, 0.5, and rat, 0.15 mgms. The epinephrine content of the adrenals is variously given in the literature depending upon the methods used for its determina- tion. 638 Epinephrine is also present in the chromaphil tissue in other 73 74 MEDULLA regions of the body besides the adrenal. According to Elliott 181 the paraganglion aorticum of the newborn contains twenty-four times as much epinephrine as both adrenals despite the twenty- five-fold size of the latter. 393 In the dog, Kahn 344 found one- twelfth to one-thirtieth as much epinephrine in the extra- chromaphil tissue as in the adrenals. Many sympathetic ganglion cells also contain small amounts of chromaphil tissue. 259 Whether or not these contain epi- nephrine is doubtful. 209 The carotid sinus, although a chroma- phil tissue, gives only a feeble reaction for epinephrine. 384 It would thus appear that although chromaphil tissues may con- tain epinephrine, this substance is not invariably present and hence is probably not an indispensable mediator for their activity. Epinephrine is not limited in its occurrence to the chroma- phil system of the sympathetic ganglia but occurs in certain secretions of reptilia. The skin-glands of the toad, Bafo agua, contain about 5 per cent Zeyo-epinephrine as Abel and Macht 2 demonstrated. Certain poisonous Chinese toads also contain epinephrine in their skin glands. 339 The skin glands of the European and North American toad contain none. Histo- logical investigations also indicate epinephrine to be present in many invertebrates; e.g. in leeches in which six chromaphil cells are present in the ganglia of the central nervous system. In certain molluscs as in the mantle of Purpura lapillus, chromaphil tissue, extracts of which manifest an epinephrine- like action, are also present. 639 ISOLATION AND STRUCTURE OF EPINEPHRINE Abel 1 first applied the term epinephrine to a crystalline compound which he obtained from the adrenal gland and which he considered to be its active principle. Subsequent work showed Abel's compound to be the A^-benzoyl derivative of the active principle, but the term epinephrine has been re- tained for the base itself. Aldrich 9 and Takamine 618 in 1901 first isolated epinephrine as the free base. They called their CHEMISTRY OF EPINEPHRINE 75 compound "adrenalin," the name recognized officially in the British Empire and European countries and used extensively in the United States despite the official preference for the term "epinephrine." "Suprarenin," another commonly used term for this compound, was introduced by von Furth 208 who pre- pared insoluble metallic salts of the active principle but failed to isolate the free base in pure form. The correct empirical formula of epinephrine (C 9 Hi 3 3 N) was first derived by Aldrich. 9 The existence of a catechol nucleus OH (T in this compound was suggested by the green coloration given when epinephrine is treated with ferric chloride. This color reaction is common to catechol and its derivatives. Takamine 9 showed that fusion of epinephrine with KOH yielded proto- catechuic acid. OH tf)H COOH More direct evidence of the position of the side chain of the catechol nucleus was given by Jowett 342 who methylated the hydroxy groupings in the benzene ring of epinephrine (to pro- tect the aromatic radical) and on oxidation of the resulting methyl ether obtained the dimethyl ester of veratic acid. OCH 3 PCH 3 COOH This reaction showed the position of the side chain relative to the hydroxyl groupings in the epinephrine molecule. The fact 76 MEDULLA that methylamine could be split off from the compound sug- gested the presence of a methylamino group in the side chain. Friedmann 207 oxidized the tribenzenesulphonyl derivative of epinephrine to a ketone, thereby demonstrating the existence of a secondary alcoholic grouping in the side chain. It thus became probable that epinephrine was represented by the structural formula OH lOH CH(OH).CH 2 NHCH 3 which conforms to the requirements of the reactions cited above. The existence of an asymetric carbon atom in this formula accounts for the optical activity manifested by epi- nephrine solutions, as first observed by Pauly. 487 The systematic name for epinephrine as represented by the above formula is dioxyphenylethanolmethylamine, a-methyl- amino-j3-hydroxy-j3-(3 , 4-dihydroxyphenyl) ethane, or methyl- aminoethyl-(3 , 4-dioxyphenyl)-carbinol. The ultimate proof of the correctness of the above described formula was furnished by Dakin 146 and Stolz 599 who synthesized epinephrine. This synthesis, which has received commericial application for the preparation of the compound, consists of the following steps: OH OH iOH AOH + CH 2 C1C0C1 ► + HC1 COCH 2 Cl (Catechol) (Chloracetylchloride) (Chloracetocatechol) OH OH 0H +CH3NH, > Q 0H COCH 2 Cl COCH 2 NHCH 3 (Methylamino-ketone of paracatechuic acid) The last compound on reduction yields epinephrine. CHEMISTRY OF EPINEPHRINE 77 Synthetic epinephrine prepared as just described is optically inactive. To obtain the levo-rotary form which occurs natur- ally, the racemic compound is resolved by Flacher's 199 method in which the d-tartaric acid salt of ^^-epinephrine is extracted with methyl alcohol in which the dextro-rotary salt is soluble, leaving behind the insoluble /-epinephrine-d-tartrate, from which in turn the /-epinephrine is liberated by treatment with alkali. In this way a compound identical with the natural product is obtained. Since d-epinephrine has little pharmacological activity, it is also converted to the Z-form in the synthetic preparation of epinephrine. This is accomplished by racemizing the cZ-form by heating with mineral acid and then repeating the above described process for resolving the racemic mixture into its /-and d-rotatory constituents. 35 At present both the natural and synthetic sources are utilized in the manufacture of the epinephrine of commerce. PREPARATION OF EPINEPHRINE Epinephrine is prepared in large quantities for medicinal use either synthetically or by extraction from adrenal glands. Its preparation from glandular material is relatively simple and consists in extraction of the minced glands with dilute acid, removal of proteins (after concentrating the aqueous ex- tract) with alcohol, and precipitation of the free base by the addition of ammonia after evaporation of the alcohol. In manufacture on a large scale the theoretical yield, about 0.2 per cent of the weight of the fresh glands, is obtained. 35 A convenient laboratory method for preparing pure epi- nephrine, as described by Bertrand, 53 is as follows: 600 grams of finely minced defatted adrenal glands are mixed with 5 grams of oxalic acid and sufficient 95 per cent ethyl alcohol to fill a two liter flask. The flask should be well filled to exclude air, stoppered, and shaken at intervals for two days. The con- tents are then filtered through muslin and well pressed. The filtered extract is concentrated in vacuo until the alcohol is re- 78 MEDULLA moved. Lipoidal substances separate out at this stage. To eliminate further these lipoidal substances, the aqueous residue is cautiously shaken with petroleum ether. The aqueous layer is separated and precipitated by adding neutral lead acetate, avoiding any excess of this reagent. The lead precipitate is removed by centrifugalization and the remaining fluid con- centrated in vacuo to about 200 cc. A slight excess of NH 4 OH is added to precipitate the epinephrine. To repurify the crude product thus obtained, it is dissolved in 2\ times its weight of 10 per cent H 2 S0 4 and an equal volume of ethyl alcohol is added. After filtering, the epinephrine is again precipitated by NH 4 OH. 204 The racemic form of epinephrine as obtained synthetically is only half as active as the naturally occurring levo-rotatory form. This is due, as Cushny 143 first showed, to the fact that d-epinephrine is only about one-fifteenth as active, for a given weight of substance, as the naturally occurring levo-form. Due regard of this fact has not always been taken and certain syn- thetic products have been utilized whose pharmacological ac- tion was much inferior to the natural product. To determine the activity of a given preparation one must resort to the biological assay described in the next section. The degree of racemization of a chemically pure preparation can be determined more easily by the use of a polarimeter 627 Epinephrine is usually supplied in commerce as a solution of one part per thousand of the hydrochloride dissolved in physiological salt solution. To stabilize the solution, about \ per cent of chloretone is added. The solution is saturated with carbon dioxide to exclude dissolved oxygen and stored in amber colored containers. In faintly acid solution, the drug is stable for a long period. However, in using such prepara- tions, one must consider the possible pharmacological effects of the free acid and the chloretone. Failure to do so has caused some of the discrepancies recorded in the literature. 637 For refined work, obviously, a fresh solution of the crystalline base should be used. CHEMISTRY OF EPINEPHRINE 79 PHYSICAL PROPERTIES Epinephrine is a white, micro-crystalline, hygroscopic com- pound which rapidly decomposes when exposed to the air. 135 Ultraviolet light, particularly, hastens its oxidation. Herme- tically sealed, however, it may be permanently stored. Epi- nephrine melts with decomposition at about 216° or at 263° on Maqnenne's block. The natural epinephrine is levorotatory, (a)™* being variously given by different authors, as -50.72° to -53.3°. Epinephrine is scarcely soluble in water, a saturated solu- tion containing 0.095 milligrams per cc. at 20° to 25°. It is practically insoluble in alcohol and insoluble in chloroform, petroleum ether, benzol, or ether. 138 Despite the relative insolubility of epinephrine in water, aqueous solutions of certain salts have a marked solvent ac- tion, (e.g., the borates) and epinephrine hydrochloride itself exerts such an action. The phenolic groupings of epinephrine form water-soluble salts with strong alkalies. The alkaline carbonates or ammonia can not effect this salt formation and hence may be used, as in the isolation of the compound, for precipitating epinephrine as the free base. The NH 2 -grouping of epinephrine imparts to it a feebly basic character in virtue of which it forms salts which are readily soluble. Epinephrine hydrochloride, thus formed, is the compound used in medicine. CHEMICAL PROPERTIES The chemical properties of epinephrine are inherent in the phenolic, alcoholic, and amino groupings which it contains. Like derivatives of catechol (compare, for example, the action of pyrogallol), epinephrine is easily oxidized in neutral or alka- line solution. In fact, epinephrine in aqueous solution is stable only at a pH of 5 or less. In a more alkaline solution oxidation on exposure to air rapidly occurs as evidenced by the gradual change in color of the solution to pink, then red, 80 MEDULLA and finally brown, with the formation of an insoluble brownish precipitate. Blood according to Maiweg 422 stabilizes epineph- rine so that despite its alkalinity (pH 7.4) epinephrine is not as rapidly destroyed as might be anticipated from its re- action in aqueous solution. In the animal body, indeed, a number of substances are present (glutathione, cysteine, as- corbic acid and other reducing agents) which prevent the ir- reversible oxidation of epinephrine and account for its pharma- cological effects obtained at points distant from the site of its injection. 666 Epinephrine, like catechol, when oxidized is probably first converted to an ortho-quinone. This quinone is destroyed with such extreme rapidity that it is impossible to form an oxidation-reduction system with epinephrine. 29 Epinephrine forms relatively few stable salts. The hydro- chloride which is the salt of commerce has already been men- tioned. Boric acid forms a stable complex, C1SH27O11N2B3, freely soluble in water. This complex is claimed not to be decomposed by alkalies. A dibenzoyl derivative of epineph- rine and a chlorbenzoyl derivative have also been described. 34 COLORIMETRIC ANALYSIS The numerous reactions by which epinephrine forms colored solutions has led to their utilization for its colorimetric analysis. These methods for determining epinephrine are limited in their applicability due chiefly to their non-specificity. Other catechol derivatives as well as certain reducing substances also give the same color reactions so that their presence in the solu- tions to be tested lead to erroneously high results. Only the most widely used methods will be discussed here. The green coloration produced by epinephrine or other catechol derivatives when reacting with ferric chloride has been used at times for their colorimetric determination. The reaction is very sensitive to pH changes and gives unsatisfac- tory results. According to most recent studies, the Vulpian CHEMISTRY OF EPINEPHRINE 81 reaction should be carried out in slightly alkaline solution, in the presence of an excess of ferric chloride. 553 The purplish coloration thus produced is proportional to the molar concen- tration of the catechol derivative present in the solution tested. The ease with which epinephrine is oxidized to give a red coloration has given rise to a number of methods for its analy- sis. For this purpose, many oxidizing agents have been sug- gested — iodine, iodic acid, chlorine, mercuric chloride, persul- fates, osmic acid, et cetera. 639 Iodic acid has been used by a number of workers. 664 The addition of sulphanilic acid in- creases the sensitivity of this method so that a dilution of as little as 1 part of epinephrine in 5,000,000 is detectable. 341 Unfortunately this delicacy is not specific to epinephrine. The use of persulphate for the estimation of epinephrine has recently been investigated by Barker, Eastland, and Evers. 37 These authors consider this reagent the most accurate for the colorimetric determination of epinephrine. The use of iodine as an oxidizing agent in the colorimetric determination of epinephrine has been revived by Euler 188 who has worked out an exceedingly accurate procedure using the spectrophotometer. This method is not interfered with by the presence of reducing agents such as ascorbic acid. Perhaps the most widely used colorimetric method for the determination of epinephrine is the method of Folin, Cannon and Denis. 202 This consists in reducing tungstic acid to its blue oxides. This is an exceedingly sensitive method capable of detecting as little as 0.003 milligrams of epinephrine. Al- though yielding accurate results when applied to pure solu- tions, it is so non-specific as to yield erroneously high values when other reducing substances are present. Uric acid, for the determination of which the reagent was originally devised, and ascorbic acid react like epinephrine to give the blue color. Their presence in many biological fluids thus vitiates the re- sults obtained in analyses of epinephrine. Although epineph- rine is destroyed by the passage of air through its alkaline 82 MEDULLA solution, the oxidation products formed still reduce phospho- tungstic acid. Folin's method is also inapplicable in the presence of cocaine or procaine. The use of the Folin-Denis colorimetric method can not therefore be relied upon as a test for the presence of epinephrine. Thus extracts of the cortex often show the apparent presence of as much as a milligram of epinephrine per gram of tissue when biological assay reveals the absence of any epinephrine. Other less important color reactions are also given by epineph- rine and have been suggested for its determination. Thus it gives a permanent red color with CuS0 4 and KCN. The Frankel-Allers color reaction depends on the formation of a rose-color when epinephrine hydrochloride is heated with KI0 3 and dilute H 3 P0 4 . Seidell suggested the use of the red color produced on oxidizing epinephrine with Mn0 2 . 639 Whitehorn 675 has recently described a method for the deter- mination of epinephrine in biological fluids which depends upon its adsorption by silica. The adsorbed epinephrine is eluted by sulfuric acid and determined colorimetrically. The method is sensitive to one part of epinephrine in 50 million parts of solution. As may be seen from the preceding comments the colorimet- ric determination of epinephrine, despite its simplicity and accuracy in pure solution, is fraught with errors in most condi- tions in which it is desired to be applied. Careful check by one of the biological methods, to be described in Chapter VI, is thus always necessary 601 - 659 if one is to obtain reliable results. THE ORIGIN OF EPINEPHRINE IN THE BODY The origin of epinephrine in the body is still unproven al- though several suggestions have been offered to account for its probable origin. The close structural relation which epi- nephrine bears to the two amino acids, tyrosine and phenyla- lanine, suggests that either might give rise to epinephrine by CHEMISTRY OF EPINEPHRINE 83 successive oxidation, methylation of the nitrogen atom and decarboxylation. Attempts to carry out experimentally these processes have, however, not been successful. Tyrosine is oxidized in the presence of tyrosinase to give 3,4, dihydroxy- phenylalanine (acrostically abbreviated to dopa), which repre- sents the first stage in the above described series of reactions by which tyrosine would be expected to be converted into epinephrine. Moreover, dopa, although never demonstrated in animals, has been found in the pods of the bean (Viciafaba) and in certain insects. If tyrosinase is allowed to act on the methyl ether of dopa (3,4-dihydroxyphenyk/V-methylalanine) a small amount of a pressor base is formed whose activity is much enhanced by reduction. Heard and Raper 290 consider this pressor base to be adrenalone, the ketone of epinephrine (adrenaline), represented by the formula, COCH 2 (NHCH 3 ) OH OH which on reduction gives epinephrine. The above reaction occurs simultaneously with the main series of reactions which give rise to indole derivatives and ultimately to melanin. 35 Although the intermediate compounds have not been iso- lated, we can, according to Heard and Raper, 35 represent the probable changes occurring in the transformation of tyrosine to epinephrine by the following formulae: CH 2 CH(NH 2 ) -COOH CH 2 CH(NH 2 )COOH +0 I Jqjj methylation OH OH tyrosine dopa 84 MEDULLA CH 2 • CH(NHCH 3 )COOH CH 2 • CH(NHCH 3 )COOH OH -2H I U > OH V +H >° N-methyl dopa quinone of N-methyl dopa CH(OH)CH 2 (NHCH 3 ) + co 2 OH Epinephrine Attempts to carry out the above reactions by perfusing the adrenal gland have heretofore failed. This could be accounted for by assuming a very rapid loss of its synthetic powers after removal of the gland from the body or that certain of the intermediate steps of the reaction occur in organs other than the adrenal. Repetition of the experiment by perfusion of the organ in situ and insertion of the necessary cannulae before interrupting the normal blood supply of the gland would promise greater success than the use of a "chilled" gland re- moved from the abattoir to the laboratory as employed by previous workers. The earlier theories concerning the origin of epinephrine in the organism, as described above, presuppose its derivation from tyrosine or from dopa. However, no evidence has ever been adduced to show that either of these substances can be converted to epinephrine in the adrenal. On the other hand, as Nikolaeff 472 first demonstrated, perfusion of the surviving adrenal with a solution containing tyramine results in the production of a substance having the properties of epinephrine. Schuler and Wiedemann 657 using slices of fresh adrenals were able to demonstrate the formation from tyramine of a sub- stance which, like epinephrine, reduces the Folin-Dennis re- agent and also raises the blood pressure when injected into CHEMISTRY OF EPINEPHRINE 85 an animal. This formation of an epinephrine-like substance did not occur when an emulsion of the gland was used and hence is a property of the intact cell. The addition of other substances, related structurally to epinephrine, such as dopa, tyrosine, hordenine, phenylalanine, or phenylethylamine did not result in the formation of an epinephrine-like product. It would appear from these experiments that the adrenal medulla forms epinephrine from tyramine. The latter substance, ac- cording to Schuler and Wiedemann, is formed in the kidney by decarboxylation of tyrosine. THE DOPA REACTION The pigmentation observed in Addison's disease has been attributed by Bloch to an abnormal metabolism of epinephrine or its precursors. Bloch 63 showed that an isolated piece of skin if soaked in dioxyphenylalanine (Dopa) assumes a pig- mented form similar to that observed in Addison's disease. Since dopa is closely related chemically to epinephrine and may be considered as a precursor of epinephrine in the body, Bloch assumed that disease of the medulla, by preventing the formation of epinephrine from its assumed precursor, dopa, allows the latter to discolor the skin. This discoloration of the skin is assumed to be brought about by a specific enzyme (dopase) which converts dopa into melanin. Raper 36 has studied the reaction whereby tyrosine is con- verted to dopa which on further oxidation yields an indole carboxylic acid which can be transformed into dihydroxyin- dole, H0 M — II H0 \/\ / N H which in turn condenses to a black pigment similar to the melanin of the skin. The black appearance of bean pods on :#* , 86 MEDULLA exposure to the air is also due to their content of dopa. Epi- nephrine, too, may be oxidized in the presence of certain oxi- dases (such as that found in the ink-bag of the cuttle fish, {Sepia officinalis) or in toadstools) to give a black pigment resembling the natural melanin found in the skin. 466 In view of the above described reactions, it has been as- sumed that epinephrine, tyrosine, phenylalanine, or dopa, are precursors of the melanin pigment of the skin. However, in considering the chemical theories which have been elaborated to account for the abnormal deposition of melanin in the skin of persons afflicted with Addison's disease, it must be remem- bered that the characteristic pigmentation also occurs in cases in which the medulla appears to be normal. This would in- dicate that disease of the cortex is primarily responsible for the pigmentation and that any abnormalities in epinephrine metabolism must be only secondarily involved (c/. Chapter XXI). OTHER COMPOUNDS RELATED TO EPINEPHRINE The important pharmacological properties of epinephrine have led chemists to prepare a number of related compounds some of which have interesting actions, similar to those of epinephrine. None of these has, however, seriously rivalled the natural product and we need only refer to them here. Besides ephedrine, a closely related naturally occurring com- pound, the most important of these compounds are dihydroxy- phenylethanolamine (arterenol) or epinephrine without the methyl group and dihydroxyphenylpropanolamine (homo-ar- terenol). Of interest in connection with the last named com- pound is the fact that its levo-rotatory isomer is over 30 times as active as the dextro-rotatory form. The study of numerous synthetic and natural products related more or less to epineph- rine has formed an interesting contribution to our knowl- edge of the relation of chemical structure to biological activ- ity 35, 36,204, 284 Chapter VI THE PHYSIOLOGY OF THE ADRENAL MEDULLA No product of the glands of internal secretion has been studied with such thoroughness as has been epinephrine. This intense study has been made possible by the fact that this substance can be detected and assayed in extremely minute concentrations. It has thus been possible to determine the rate of secretion of epinephrine under various conditions. The results of these studies shall be considered in the present chap- ter with particular reference to their bearing on the functional significance of epinephrine in the organism. Epinephrine manifests its presence, even in extremely dilute solution, by a number of pharmacological reactions. These have been utilized for determining the concentration of epi- nephrine present in the blood leaving the adrenals. Despite their apparent simplicity and great sensitivity, the methods used in the study of epinephrine secretion are open to a number of criticisms particularly as regards the physiological significance of the data obtained. It is not surprising, therefore, that authors, utilizing different techniques, have obtained conflict- ing data and come to diametrically opposed conclusions as regards the significance of their results. In order to evaluate properly the existent data it is necessary to consider first the various methods utilized for determining the rate of epi- nephrine discharge from the adrenals. For determining the rate of discharge of epinephrine from the adrenals at any given time, it is obviously necessary to know the concentration of epinephrine in the blood of the adrenal veins and the amount of blood leaving the glands in unit time. 525 Many of the earlier workers, unfortunately, neglected to take the last factor into consideration, assuming 87 88 MEDULLA that an increase in the concentration of epinephrine in the blood leaving the adrenals was in itself evidence of an increased rate of secretion. Since many physiological conditions are accom- panied ,by a decrease in the rate of blood flow through various organs, 243 neglect to consider this factor will invalidate the conclusions based solely on concentration changes in the blood. In the following sections we shall consider the various pro- cedures used in the biological assay of the epinephrine content of the blood and the methods used for determining the output of epinephrine from the adrenals. Besides the biological methods of assay listed below, certain of the more sensitive chemical methods already described have also been utilized in studies on the physiology of the medulla. Instead of deter- mining the rate of secretion by analysis of the blood, attempts have been made to obtain this data by analysis of the epi- nephrine content of the adrenals in various conditions. Deple- tion of the epinephrine store indicates a stimulation of the rate of secretion. However, if the rate of synthesis follows changes in the rate of secretion, such depletion will obviously not occur. METHODS FOR THE BIOLOGICAL ASSAY OF EPINEPHRINE 1. The intestinal strip method. The inhibition of intestinal muscle by epinephrine serves as a very delicate test for epi- nephrine. Cannon and Hoskins 105 claim this test to be sensitive to epinephrine in a dilution of 1 to 400 millions; Stewart and Rogoff 588 claim 1 to 800 millions. The blood to be tested is added to Ringer's solution in which is suspended a strip of intestine (rabbit or guinea pig) arranged to record on a kymo- graph. The resulting inhibition is compared with that ob- served after the addition of a known quantity of epinephrine. Although extremely sensitive, this method suffers from the defect that interfering substances present in the blood may also inhibit intestinal movements. 587 2. Blood pressure method. This method was first suggested by Houghton and carefully worked out by Elliott. 177 Al- PHYSIOLOGY OF EPINEPHRINE 89 though less delicate than the intestinal strip method it is ad- vantageous for many purposes. The spinal animal is more sensitive for the application of this method and hence the animal is pithed and maintained under artificial respiration. Suc- cessive injections may be made, each of which causes a rise proportional to the epinephrine concentration of the sample tested. The pressor response of the unknown solution is com- pared with that elicited by the injection of a known amount of epinephrine. 639 The method just outlined is vitiated if depressor substances are present in the fluids to be tested. This is particularly true of choline and acetylcholine, which as Hunt 324 showed, antagonize the pressor effects of epinephrine. Since choline may be a constituent of extracts prepared from the adrenals, the use of this method alone for assaying the epinephrine con- tent of such extracts is not justified. The contraction of a strip of artery, arranged as in the "intestinal segment method" has also been used for epinephrine assays. This method is relatively insensitive, and not fre- quently employed. 3. The perfusion method. The assay of epinephrine by determining its effect on the caliber of the blood vessels was described by Lawen 375 and perfected by Trendelenburg 636 as a highly sensitive method. A frog is decapitated and its spinal cord thoroughly destroyed. It is placed on its back and the abdominal wall reflected. The bladder and intestines are removed and the renal vein ligated. The remaining viscera including the heart are removed, care being taken to preserve the abdominal aorta intact. A cannula, connected to a Marriotte bottle containing frog Ringer's solution is introduced cephalwards into the abdominal aorta. An outflow cannula is introduced into the anterior abdominal vein which lies exposed on the reflected abdominal wall. A drop recorder marks the rate of outflow of the perfusing fluid. A sensitive preparation permits the detection of a change in the rate of the perfusion 90 MEDULLA when as little as 1 part of epinephrine is present in 100 million parts of the perfusing fluid. Pisemsky's method is similar in principle to the Lawen- Trendelenburg procedure just described. It utilizes the rab- bit's ear as test object. Krawkow 367 finds this method to be sensitive to epinephrine in a dilution of 1 to 10 to 50 million. 4. The uterine strip method. Epinephrine inhibits the uterus of the rat and stimulates the uterus of the rabbit. Concen- trations of one part in 20 million inhibit uterine movements of the non-pregnant cat. 148 As shown by Cannon and Hoskins 105 the blood in asphyxia may contain a substance other than epinephrine which inhibits intestinal contractions. This substance inhibits the con- traction of the non-pregnant rabbit's uterus, while epinephrine increases the tone of this preparation. Hence by utilizing both the intestinal strip and uterine contraction methods, one can determine if the observed effect is really due to epinephrine. 5. The excised-eye method. Epinephrine exerts a mydriatic action on the enucleated eye. 174 A dilution of one part of epinephrine hydrochloride per million causes maximal expan- sion of the pupil. One part in 10 million causes a detectable mydriasis. 451 6. The anastomotic method of Tournade and Chabrol. 631 In this method the adrenal vein of the experimental animal is anastomosed with the jugular vein of an adrenalectomized dog. The decrease in volume of the spleen of the recipient, as deter- mined by an oncometer, serves to detect an increase in the epinephrine content of the blood of the donor. Besides the effect on the splenic volume one can also utilize other pharmacodynamic changes, induced by epinephrine; e.g., the rise in blood pressure, dilatation of the pupil, tachy- cardiac response, etc. 7. Auto-assay method. 102 Instead of the anastomosis, just described, the animal's blood may be allowed to act on its own organs and the epinephrine determined by its effect on 1) the PHYSIOLOGY OF EPINEPHRINE 91 blood pressure, 2) the pupil (in cats) of an eye (sensitized by- previous extirpation of the superior cervical ganglion), 3) the rate of the denervated heart, or 4) on the volume of the spleen or limbs. The auto-assay method has been widely used particularly with the denervated eye or heart as described in the following sections. 8. Denervated iris method. The so-called paradoxical eye reaction 451 for assaying epinephrine depends upon the fact that the pupil dilates after an intravenous injection of epinephrine. The eye of the cat is utilized for this reaction after sensitizing it to the action of epinephrine by extirpating the superior cervical ganglion. At least several days should elapse after the ganglionectomy before utilizing this preparation. The transverse diameter of the pupil is measured and the dilatation caused by the injection of the unknown solution is compared with that obtained by injecting a known concentration of epinephrine. Stewart and Rogoff 687 demonstrated the diversity in results obtained in the assay of epinephrine by the auto-assay method (using the paradoxical eye reaction) as compared to the intestinal segment method. Although Cannon and Rapport 102 have critized the conclusions of Stewart and Rogoff, the experi- ments of Sugawara 601 and others, also indicate that these two methods of assay do not give concordant results. Suga- wara showed that the auto-assay method gave results indi- cating the presence of only about two-thirds as much epi- nephrine in a given sample of blood as is obtained by using the isolated intestinal segment of the rabbit. Similar dis- parities are also obtained when the blood is assayed by the paradoxical eye reaction of a second cat and compared with the results obtained by the intestinal segment method. The blood of the adrenal vein must exert, therefore, a more power- ful inhibiting effect upon the movements of the intestinal strip than can be accounted for by its epinephrine content or else 92 MEDULLA this blood must contain a substance which inhibits the normal epinephrine effect on the denervated pupil. Kojima and Saito 360 also found that the intestinal segment method gave results which were higher for epinephrine than the colorimetric method of Folin, Cannon, and Denis. 9. Denervated heart method. In their earlier experiments Cannon and Hoskins 105 obtained blood from the adrenal vein by means of a catheter passed through the femoral artery and pushed forward until it reached a point near the entrance of the adrenal vein into the vena cava. The blood obtained was assayed by the intestinal segment method. This method of Cannon and Hoskins although applicable to the unanesthetized animal suffers from the fact that it cannot give quantitative results and was therefore discarded for an auto-assay method depending on the use of the denervated heart. Cannon and his collaborators 102 have utilized the denervated heart as a sensitive test object for the assay of epinephrine. This preparation is prepared by severing all the nervous con- nections of the heart. After recovery from the operation, the heart rate is considered by Cannon to be under hormonal con- trol and to react only to changes in the blood concentration of epinephrine or related substances. Stewart and Rogoff 587 criticized the method of Cannon on the basis of their experiments in which they showed that an increase in the rate of the denervated heart may be elicited even after extirpation of the adrenals. Cannon and Rapport, 102 using the denervated heart as an indicator, found that stimulation of the splanchnics caused an increase of 29 beats in the pulse rate. After removal of the adrenals the increase was only 6 beats and they concluded, therefore, that the difference was caused by secretion of epi- nephrine in response to splanchnic stimulation. The increase noted after adrenalectomy was attributed to the liver, for section of the hepatic nerves abolished this increase. Since removal of the adrenals caused a slowing of the pulse rate PHYSIOLOGY OF EPINEPHRINE 93 which was counteracted by the injection of 0.0007 mgs. of epinephrine per kilo of body weight per minute they concluded that the normal output of epinephrine is about 0.0035 mgs. per kilo per minute which is more than ten times the amount found by Stewart and Rogoff in their more direct measure- ments, and fifty times greater than the results of Satake and his collaborators to be described in a subsequent section. 10. The "cava-pocket" method. This method originated by Stewart and Rogoff 525 for determining the rate of secretion of epinephrine from the adrenal glands involves the determination of the amount of blood leaving the glands per minute and the concentration of epinephrine in this blood. The veins empty- ing into the vena-cava are ligated or clamped with the excep- tion of the adrenal veins so as to form a pocket by the occlusion of the vena cava beneath the diaphragm and below the entrance of the adrenal veins. Into this "cava-pocket" only blood from the adrenals can enter. By releasing the clamp at the diaphragm the blood enters the general circulation and its epinephrine content may be determined by an auto-assay method. By releasing the lower clamp on the vena cava, through a cannula, the rate of blood flow is measured. The epinephrine content of the blood can also be determined by assay on a segment of rabbit's intestine and confirming, if necessary, on a segment of non-pregnant rabbit's uterus. 11. The method of Satake, Sugawara, and Watanabe. Si5 Since anesthesia, pain, operative manipulations, etc. all may modify the normal rate of secretion of epinephrine from the adrenals, it is obvious that the methods already described are inapplicable for determining the normal resting rate of epi- nephrine discharge. The results obtained by these methods may also be rendered abnormal due to the interference of the above mentioned factors. In order to avoid the effects of these vitiating factors, Satak6, Sugawara, and Watanabe* devised a method whereby the rate of epinephrine secretion in the dog could be determined without necessitating anesthesia, laparot- 94 MEDULLA omy, pain, or even fastening the animal. In order to do this, these authors in a preliminary operation cut the dorsal roots from the ninth thoracic to the third lumbar vertebra, thereby rendering the area in the vicinity of the adrenals anesthetic to manipulation. After about one month when the animal had recovered from this preliminary operation, an incision was made below the costal margin and the adrenal vein cannulated. As pointed out by Satake" and his collaborators, their method obviously will interfere with the normal blood flow of the adrenal. Despite this objection their experiments offer a decided improvement on those of their predecessors and the results obtained are undoubtedly of greater physiological significance. To avoid the interference with the normal blood flow occasioned by introducing the cannula into the adrenal vein, it would be of interest to repeat the experiments utilizing the thermostromuhr method for determining the blood flow. Measuring the rate of blood flow by this procedure and remov- ing samples of blood for analysis with a syringe and fine needle inserted into the exposed adrenal vein, would enable one to obtain results which more closely represent normal physiological conditions. The average blood flow through each adrenal observed by Satake et alii was 0.3 cc. per kilo per minute. The authors used the rabbit's intestine for the assay of epinephrine. 12. Eider's method. Euler 188 has utilized a method for determining the epinephrine content of blood serum based on the activating action of this substance on the reduction of methylene blue added to muscle extract. Although, as Euler showed, such activation by blood serum is not entirely due to epinephrine, the method has been found useful under various conditions. THE NORMAL RATE OF EPINEPHRINE SECRETION Considerable work has been done to determine the rate at which epinephrine is normally secreted from the adrenal glands. PHYSIOLOGY OF EPINEPHRINE 95 It has been found that epinephrine is detectable in the blood of the adrenal veins so long as the nerve supply to the glands is intact. There is thus presumably a steady secretion of epi- nephrine into the circulation. The exact amount of this secre- tion has been a matter of controversy. The ease with which an increased secretion is stimulated renders difficult the attain- ment of truly normal basal values for the unavoidable manip- ulations (particularly anesthesia) would be expected to give too high values. The lowest values obtained are those of Satake* and his collaborators whose method, as we have seen, involves less abnormal conditions than those of other authors. In a series of twenty dogs, Satake* and his collaborators 545 found the epinephrine content of the blood from the adrenal vein to vary from 0.00005 to 0.000225 with an average of 0.0001 mgms. per cc. The total output from both glands was equal to 0.00007 mgms. per kilo of body weight per minute. The results just quoted are of a much smaller magnitude than the oft-quoted results of Stewart and Rogoff. 587 The rate of epinephrine secretion as measured by the latter authors was about 0.00025 milligrams per minute per kilogram of body weight. This rate was approximately the same in cats, dogs, monkeys, and probably (judging from the values obtained by other authors) in many other animal species. The results obtained by Stewart and Rogoff are probably abnormally high because of the stimulating effect of the operative procedures involved in preparing the "cava-pocket." The preparation of the "cava-pocket" as Satake* and his collaborators showed stimulates the secretion of epinephrine unless the animal is deeply anesthetized. 546 Except for the blood of the adrenal vein, the epinephrine content of the blood stream is so slight as to be undetectable by most methods of analysis. 92 Thus Whitehorn, 675 using a method capable of detecting one part of epinephrine in fifty million parts of blood, was unable to detect this substance in the peripheral venous blood of man. Euler 188 using his method 96 MEDULLA based on the stimulating effect of epinephrine on oxidation in Thunberg's methylene blue -muscle extract system, found the peripheral venous blood of man and the rabbit to contain about 0.000,000,0001 mgm. of epinephrine per cc. THE NERVOUS CONTROL OF EPINEPHRINE SECRETION The rate of secretion of epinephrine has been shown to be readily affected by impulses from the splanchnic nerves and hence it may be assumed that these nerves normally control the rate of secretion. Stimulation of the nerves to the adrenal increases the rate of epinephrine secretion; sectioning the nerves, abolishes the secretion. Elliott 178 showed that the epinephrine store was protected against depletion by anes- thesia and certain other stimulants to secretion if all the fibers coming to the semilunar ganglion were cut. If the spontaneous discharge of epinephrine be under nervous control, we must explain Elliott's results by assuming that anesthesia and certain drugs which ordinarily deplete the adrenals of epineph- rine act by preventing the formation of epinephrine and at the same time do not interfere with its discharge. The blood pressure rise observed on stimulating the splanch- nics is only partly due, however, to the liberation of epineph- rine, for this pressure effect is in great part obtainable after occlusion of the adrenal veins. The second peak of the blood pressure curve obtained during splanchnic stimulation usually disappears after exclusion of the adrenals from the circulation. The occurrence of this peak has, therefore, been attributed to the release of epinephrine into the general circulation under the influence of the splanchnic stimulation. 270 • 639 Continued stimulation of the splanchnics may cause the discharge of large amounts of epinephrine from the adrenals. Thus Stewart and Rogoff 625 found that 0.4 mgms. of epi- nephrine was discharged from one adrenal of a cat during 4 hours of intermittent faradic stimulation of the splanchnic nerve. This quantity represents about twice the normal PHYSIOLOGY OF EPINEPHRINE 97 content of a cat's adrenals. Despite the great amount of epinephrine discharged, the adrenal in the above cited case still contained 0.14 milligrams at the conclusion of the experi- ment. This indicates the rapidity with which the epinephrine store of the adrenals is restored. After an hour's stimulation, the epinephrine content of an adrenal may still be found to be but little reduced below normal. Several attempts have been made to localize a center for the nerves regulating epinephrine secretion, but the results of different observers are discordant. Stewart and Rogoff 587 claimed the center to exist in the thoracic cord since section of the cord at the level of the last cervical vertebra did not reduce the rate of secretion of epinephrine. Elliott, 178 on the other hand, found that anesthesia no longer produced a dis- charge of epinephrine after cutting the spinal cord at the level of the first thoracic vertebra. Removal of the brain anterior to the corpora quadrigemina did not affect the secretion. Elliott, therefore, concluded that the center existed at a point just posterior to the corpora quadrigemina. The existence of a center at the base of the fourth ventricle has been assumed on the basis of the results of piqure in this region of the brain stem. Following piqure, a number of reactions typical of epinephrine are induced. The hyper- glycemia attendant on piqure is not entirely due, however, to liberation of epinephrine but is in part a result of nervous reflexes. 419 Stimulation of other parts of the brain stem results in only slight hyperglycemia and apparently in little reflex stimulation of epinephrine secretion. Stimulation of the hypothalamus gives only a slight and transient hyperglycemia. Stimulation of the cerebral cortex causes an epinephrine secretion only when convulsions are incidentally elicited. 419 Feldberg, Minz, and Tsudzimura 192 have recently shown that a substance manifesting the pharmacological actions of acetylcholine is liberated from the adrenals during splanchnic stimulation. The previous injection of eserine greatly en- 98 MEDULLA hances the epinephrine discharge caused by splanchnic stimu- lation, which is what one would expect if the discharge of epinephrine caused by splanchnic stimulation were due to the liberation of acetylcholine. The action of acetylcholine or of splanchnic stimulation of the adrenal medulla manifests the two types of peripheral effects which the choline esters show generally; viz., 1) a "nicotine" action which is abolished by large doses of nicotine and 2) a "muscarine" component abolished by small doses of atropine. Feldberg and his collab- orators conclude that acetylcholine is the humoral transmitter of splanchnic impulses to the adrenal medulla. This cho- linergic action of the preganglionic sympathetic fibers is not limited to the splanchnic nerves. FACTORS AFFECTING EPINEPHRINE SECRETION Sensory stimulation. After stimulation of sensory nerves, such as the central end of the sciatic, brachial, or vagus, the blood of the adrenal vein induces the characteristic reactions of epinephrine. It has, therefore, been claimed that such stimuli, by reflex action, cause a discharge of epinephrine. The evidence adduced by earlier workers was criticized by Stewart and Rogoff. 591 As these authors pointed out, ob- servations made without regard to changes in the rate of blood flow through the adrenals and without quantitative determina- tions of the amount of epinephrine liberated per unit of time offer no criterion for determining the influence of stimulation of afferent nerves. Stewart and Rogoff's failure to demonstrate that sensory stimulation does not increase the secretion of epinephrine was due probably to the experimental methods which these authors utilized. As shown by Satak6 et alii, 546 with the "cava-pocket" procedure on anesthetized dogs or cats, one does not obtain an increased secretion of epinephrine. However, in the non- anesthetized dog the output of epinephrine is increased from two to five times by stimulation of sensory nerves. Narcosis PHYSIOLOGY OF EPINEPHRINE 99 apparently inhibits the reflex output of epinephrine and it is necessary to view with scepticism all experiments on deter- mining epinephrine secretion which were performed under anesthesia. 548, 617 In any case, the mobilization of carbohydrate observed after stimulation of sensory nerves is not completely due to the action of liberated epinephrine for some hyperglycemia is obtained even in adrenalectomized animals. 345 - 346 Bazett and Quinby 48 found that the pressor response of cats under urethane anesthesia to sciatic stimulation was almost entirely nervous in origin and not affected by adrenalectomy. Fastening an unanesthetized dog to the table, struggling, and barking were all found by Satake, Sugawara, and Watanabe 546 to be accompanied by a marked increase in the epinephrine secretion from the adrenals. Anesthesia. Anesthesia markedly affects the rate of secre- tion of epinephrine from the adrenals. The epinephrine content of the adrenals may be reduced to a half or a third of its normal value. Section of the splanchnic nerves prevents this depletion of the epinephrine stores. 178, 548, 617 Asphyxia. That asphyxia affects the secretion of epineph- rine as claimed by Anrep was not confirmed by the experi- ments of Pearlman and Vincent, 488 nor by Stewart and Rogoff. 587 Hartman et alii, 210 on the other hand, found that asphyxia causes mydriasis in the cat after excision of the superior cervical ganglion. Adrenalectomy prevented the reaction. Houssay and Molinelli 315 also noted a decrease in the volume of a denervated limb during asphyxia, an effect not elicited after cutting the splanchnic nerves or excising the adrenals. The conflicting results of these various authors are to be attributed to the different experimental methods utilized. The type of asphyxia is also a matter of importance for al- though asphyxia caused by inhalation of carbon monoxide stimulates the secretion of epinephrine, low oxygen tension of 100 MEDULLA the inspired air may not induce the same result. 105 The hyperglycemia of asphyxia is only partially due to epinephrine discharge for it occurs to some extent after removing the adrenals. Hemorrhage. Applying the "cava-pocket" method to dogs under ether, Saito 542 found that it was necessary to deplete the blood about one-fifth of its total volume to elicit an increased secretion of epinephrine by hemorrhage. In the unanesthe- tized dog, on the other hand, the loss of only one-tenth the total blood volume caused the liberation of two to ten times the normal amount of epinephrine. This hypersecretion con- tinued for about three hours. If one-third the total blood volume was lost by hemorrhage, an output of epinephrine 10 to 30 times the normal occurred and continued for some hours. The hyperglycemia observed after hemorrhage is due in part only to this increased epinephrine discharge. Temperature. Hartman and Hartman 277 found an increase in the epinephrine discharge from the adrenals (as measured by the denervated iris) of cats when immersed in cold water as a result not of the fall in body temperature but of the periph- eral stimulation of cooling. Cannon and his collaborators 107 working with the denervated heart corroborated Hartman's results and also found an augmentation in epinephrine dis- charge during experimental fever, induced by the injection of killed typhoid bacilli. They therefore inferred that epineph- rine has a calorigenic function which in conjunction with shivering serves to protect the organism against a drop in body temperature. Saito, 642 on the other hand, in non-anesthetized dogs detected no increase in the epinephrine discharge from the adrenals of dogs subjected to cold. The application of excessive heat (giving a rectal temperature of 41°C) resulted in an aug- mentation of the epinephrine discharge. In man the cardio-vascular responses to cold are not such PHYSIOLOGY OF EPINEPHRINE 101 as would lead one to assume any calorigenic function for epinephrine. The available evidence is thus against the supposition that epinephrine (in man and the dog at least) plays any important calorigenic function in the reaction to cold. 243 Exclusion of the carotid sinus. Ligation of both carotid arteries of dogs under deep anesthesia causes an increased secretion of epinephrine into the blood stream. 189 The in- creased oxygen consumption which accompanies this occlusion does not take place after adrenalectomy and hence has been attributed to the liberation of epinephrine. THE EFFECT OF DRUGS ON THE SECRETION OF EPINEPHRINE Many drugs when injected into the body exert an influence which, in part at least, is due to the secretion of epinephrine from the adrenals. Morphine, chloroform, ether, strychnine, nicotine, strophanthus, camphor, etc. cause a discharge of epinephrine which in turn exerts an influence on the organism. Thus, as Dale and Laidlaw 148 showed, while nicotine and pilo- carpine stimulate the isolated uterus of the non-pregnant cat, these same drugs inhibit uterine movements when injected into the living animal. In the latter case the discharge of epinephrine caused by these drugs preponderates in its effect on the uterus over the action of the small amount of the drugs which reach the uterus through the circulation. Similarly insulin causes a decrease in the amino acid content of the blood, as a secondary effect of the epinephrine secretion which it stimulates. 152 Convulsants. Strychnine 590 • 657 causes a marked increase in the output of epinephrine, which persists for over an hour. There is no evidence that this increased secretion is accompanied by any appreciable diminution in the epinephrine store of the medulla. The effect of strychnine occurs after section of the spinal cord in the cervical region but is prevented by division of the efferent secretory pathway and is thus the result of a central 102 MEDULLA action on the cord. As Watanabe 657 showed, small doses of strychnine do not cause an augmentation in the rate of epi- nephrine secretion. Moderate doses (| to 3 mgms. per kilo of body weight) cause an increase of four to five times the normal rate of secretion. Other centrally acting convulsive drugs also cause a marked discharge of epinephrine when injected in doses below the convulsive level. 590 Thus picrotoxin 624 is more effective than strychnine in stimulating epinephrine secretion. Santonin, in sub-convulsive doses, camphor, in convulsive doses, caffein, 658 theobromine and guanidine 604 also cause a discharge of epi- nephrine from the adrenals. All of the above mentioned drugs apparently act by stimulating the higher centers controlling epinephrine secretion. 637 Sympathetic paralyzers. Nicotine, and its related drugs, coniine, quaternary ammonium bases, etc. paralyze sympathetic ganglia and, as might be anticipated, exert an analogous action on the adrenal medulla. Gley 223 concluded that the pressor effect of nicotine after destruction of the spinal cord and bulb in dogs is practically entirely due to an increase in the epinephrine output. Dale and Laidlaw 148 showed that the effects of nicotine on the non-pregnant uterus of the cat and on the eye after removal of the superior cervical ganglion are in part due to the liberation of epinephrine for they do not occur when this liberation is prevented. The action of nicotine and its related drugs is directly on the medullary cells and is elicited in the denervated organ. As Stewart and Rogoff 590 showed, after the injection of nicotine there is first a marked increase in the output of epinephrine which lasts for less than half a minute. This stimulation is followed by a period of depression at the maximum of which no epinephrine is liberated and finally the normal output is gradually resumed. It is probable that nicotine not only releases epinephrine from the medulla but also sets free the epinephrine store of the extra-adrenal chromaphil tissues, for PHYSIOLOGY OF EPINEPHRINE 103 after adrenalectomy mydriasis of the pupil (after a previous excision of the superior cervical ganglion) is still elicited by nicotine injections. It has been suggested that the hyper- glycemia which accompanies tobacco smoking is due to the liberation of epinephrine. Other pharmacologically related compounds behave similarly to nicotine, e.g., the tetramethyl- ammonium salts, neurin, hordenin methyliodide, hydrastinin, and 0-dimethyl telluronium salts. Cystisine, coniine, arec- oline, spartein, gelsemin and lobelin also cause a discharge of epinephrine. Choline and acetylcholine do not manifest an appreciable effect on epinephrine secretion. 639 Sympathetic and 'parasympathetic stimulants. Tetrahydro- /3-napthylamine, which is a powerful stimulant of the sympa- thetic nervous system, also stimulates the centers controlling epinephrine secretion. The hyperglycemia following the injec- tion of this drug is probably due to the liberation of epinephrine for it does not occur in adrenalectomized animals or after cutting the splanchnic nerves. The hyperpyexia following the injection of tetrahydro-j3-napthylamine occurs in adrenalec- tomized animals, and is thus not due to the liberation of epinephrine. 75 - 602 Although a sympathetic stimulant, epinephrine itself appar- ently does not stimulate the medulla for its administration does not increase the rate of discharge of epinephrine from the adrenals. 603 - 635 Of the parasympathetic stimulants, physostigmin is an active stimulant of epinephrine secretion. Pilocarpin has only a feeble action. 171 Atropin does not inhibit epinephrine secretion but appears to stimulate it. Quinine causes an increased secretion. Curare in doses sufficient to paralyze the skeletal muscles of the cat markedly depresses the output of epinephrine from the adrenals. Morphine. Morphine may reduce the epinephrine content of the cat's adrenals to one-seventh of their normal value. 590 104 MEDULLA An injection of 10 to 20 mgms. of morphine may elevate the blood sugar to 250 milligrams per 100 cc. After exclusion of the adrenals the blood sugar does not rise above 115 milligrams per 100 cc. Hence in the cat, in which morphine is an ex- citant, morphine produces a marked stimulation of epineph- rine secretion. In the dog, in which (unlike in the cat) morphine is not an excitant, this drug also increases epineph- rine discharge, by central stimulation. However, the hyper- glycemia which follows morphine injections in the dog is not prevented by excluding the adrenals from the circulation. Histamine. The intravenous injection of 0.01 to 0.1 mgm. of histamine into a cat, after excision of the superior cer- vical ganglion causes dilatation of the pupils but not if the adrenals have been excluded from the circulation. 147 This effect is attributed to the discharge of epinephrine and may be sufficiently great to prevent the capillary damage caused by histamine. 457 OTHER FACTORS AFFECTING THE SECRETION OF EPINEPHRINE Besides the instances cited above, many other conditions and the injection of a variety of substances into the blood stream result in an increased output of epinephrine. The epinephrine store is thus a very labile and sensitive entity which responds to numerous stimulants. Shock induced in unanesthetized dogs by injections of peptone 657 is accompanied by an increased secretion of epineph- rine. In anaphylactic shock 118,547 this increased secretion is slight, for it does not result in a diminution of the epinephrine content of the adrenals nor is the hyperglycemia of shock absent in the adrenalectomized guinea pig. Many other substances when injected into the blood stream cause reactions which indicate an increased discharge of epineph- rine. Thus the hyperglycemia following injections of vari- ous salts, which is slight after section of the splanchnics, is attributed to epinephrine discharge. Mercury salts, arsenic, PHYSIOLOGY OF EPINEPHRINE 105 phosphorus, and similar poisons cause a diminution in the epinephrine content of the adrenals but it is not certain if this be due to an increased discharge or to injury of the mechanism responsible for epinephrine synthesis in the gland. Starvation may reduce the epinephrine of the adrenals to one-fourth to one-half of their normal content. After infec- tious and debilitating diseases, the epinephrine content may also be low but in these cases we must consider the effects of the accompanying cachexia, the agonal drop in body temperature, the asphyxia, etc. Diphtheria toxin, is particularly potent in reducing the epinephrine content of the adrenals, but in dogs poisoned by this toxin or by tetanus toxin there is no evidence of an increased epinephrine secretion. 590 Burns are accompanied by an increased secretion of epi- nephrine. Injury to the kidneys or excision of the kidneys also reduces the epinephrine content of the adrenals but there is no evidence that epinephrine discharge is responsible for the hypertension of renal disease. 637 Irradiation with X-rays causes an increased discharge of epinephrine. 639 The epinephrine content of the adrenals in persons dying of various diseases has been the subject of numerous investiga- tions. 181 Different observers have reported extremely variable results. The difficulty of obtaining the glands sufficiently soon after death to avoid post-mortem changes and the reliance upon analytical methods of doubtful accuracy account for the confusing results found in the literature. Schmorl and Ingier 329 , in their extensive study, did not find any note- worthy decrease in the epinephrine content of the adrenals of patients dead of various acute infections including diphtheria. In infectious fevers of man, Euler 187 found the epinephrine content of the peripheral venous blood to be 1 to 500 million to a billion which represents an increase over its normal content. Herring 294 found the epinephrine content of the adrenals to 106 MEDULLA be increased by thyroid feeding but Kuriyama 369 was unable to confirm this. Gley 223 found that thyroidectomy or pan- createctomy did not affect the epinephrine store of the adrenals. THE FUNCTION OF EPINEPHRINE Despite the extensive studies which have been carried out on epinephrine, we are still in ignorance of its function in the organism. Many theories have been advanced to explain the functional significance of the adrenal medulla and its secretion, but the validity of most of these theories is easily disproven and none of them will satisfactorily explain all our chemical, physiological, and anatomical knowledge concern- ing the medulla. That epinephrine serves an important function in the organ- ism is an assumption which can scarcely be denied when one considers the facts presented in the preceding sections. It would seem most reasonable, therefore, to adopt the view that we are ignorant of the function of epinephrine rather than omnisciently to disclaim any importance for this substance, and consider it as a waste product of the animal economy, as some have done. One conclusion is inescapable: viz., that the deprivation in the mammal of the epinephrine store (by adrenalectomy) does not result in any perceptible deficiency. Nor can it be satisfactorily argued that the loss of epinephrine is compensated for by the relatively small stores of epinephrine present in the extra-medullary chromaphil bodies. In the rat, such extra tissue has not been demonstrated and this animal can grow and flourish after adrenalectomy when furnished with an adequate supply of the cortical hormone. That the extra- medullary chromaphil tissue does not replace the normal secre- tion of the medulla is also demonstrated by its failure to hyper- trophy after adrenalectomy. We can thus safely say that the function of epinephrine is dispensable to the organism. One of the early theories of the function of epinephrine was PHYSIOLOGY OF EPINEPHRINE 107 that it exerts a continuous tonic influence on the structures under sympathetic control, particularly upon the blood vessels. That the vascular tone is not sustained by a steady discharge of epinephrine is demonstrated by the fact that ligation of the adrenal vessels, cutting the splanchnic nerves, or otherwise removing the supply of epinephrine has no effect upon the blood pressure. 307 Adrenalectomized animals may be main- tained in perfect health indefinitely without the administra- tion of epinephrine. Since small doses of epinephrine have a depressor effect one would, as a matter of fact, expect the minute quantity normally secreted into the blood stream to cause a drop in blood pressure rather than any rise. 222 The view advanced by Elliott 177 that epinephrine is neces- sary for maintaining normal sympathetic impulses has also been thoroughly disproven. The response to sympathetic impulses remains unimpaired in adrenalectomized animals, nor does the infusion of epinephrine facilitate the passage of such impulses. 269 Gley and Quinquaud 224 in a series of papers have also vigor- ously attacked the tonus theory of medullary function. They demonstrated that exclusion of the adrenals from the circula- tion did not influence the effects of vagal, depressor, or ac- celerator stimulation on the heart rate; nor did it influence the effects of splanchnic stimulation or asphyxia on the blood pressure. The view that epinephrine exerts a continuous effect on the heart and blood vessels has been more recently advocated by Tournade and Chabrol, 630 and Heymans. 297 The first men- tioned authors 634 found that the blood pressure of an adrenal- ectomized dog under choloralose anesthesia rose when its jugular vein was anastomosed with the right adrenal vein of a second dog whose adrenals were intact. If the left adrenal of the second dog was now excised and the right splanchnic nerve cut, thus cutting off the supply of epinephrine, the blood pressure of the first animal dropped from 160 to 100 mms. of Hg. 108 MEDULLA Heymans 297 also, on the basis of his experiments on the carotid sinus, considered the adrenals as playing an important role in regulating the cardiac rate and blood pressure. The carotid sinus according to Heymans reflexly regulates the vagal cardiac tone, the neuro-vascular tone, and the secretion of epinephrine from the adrenals. Changes in these functions take place in response to alterations in the blood pressure to which the carotid sinus is exceedingly sensitive. In Heymans' experiments the carotid artery of a dog, B, whose carotid sinus had been isolated, was anastomosed to the jugular vein of a dog, A. The lumbo-adrenal vein of B was in turn anastomosed with the jugular vein of a third dog, C, whose adrenals had been extirpated. Changes in the volume of the spleen of dog C served to detect epinephrine secreted by dog B in response to changes in the blood pressure of its carotid sinus. A drop in the arterial blood pressure of the sinus of B, called forth vasoconstriction and a reflex stimulation of epinephrine secre- tion in this animal, while a rise in pressure resulted in vaso- dilation and an inhibition of epinephrine secretion. As pointed out by Cannon, 103 the disturbed experimental conditions of the above quoted experiments deprive them of their validity. The abnormally excessive amounts of epineph- rine secreted under the experimental conditions cited undoub- tedly affect the circulation. The amounts secreted in the normal resting animal, however, could exert no such profound effects. Cannon and his collaborators in their studies of quiet unanesthetized cats, with hearts denervated for some time, could detect no difference between the basal pulse rate before and after exclusion of the secretion of the adrenal medulla by denervation or excision of these glands. Because of the remarkable pharmacological effects elicited by epinephrine when injected into the blood stream, numerous theories have been suggested to explain a variety of clinical conditions as being dependent on pathological changes in the medulla. The hyperglycemic action of epinephrine led PHYSIOLOGY OF EPINEPHRINE 109 Zuelzer 698 to assume the existence of an antagonism between the adrenal medulla and the pancreas. The idea that hyper- tension is due to overactivity of the medulla is not borne out by determinations of the epinephrine content of the blood. 637 Excision of one gland or denervation, as practiced surgically, 136 is not justified by the available physiological evidence. The operation is based on no sound evidence, is fraught with danger to the patient, and could, in any case, yield only transient effects since compensatory hypertrophy of the remaining gland readily ensues. The claims of a number of authors regarding the presence of an excess of epinephrine in the blood under various conditions, — Graves' disease, renal disease etc. — have also not been substantiated when carefully retested. 637 There is no evidence that epinephrine regulates urinary secretion, muscular activity, the development of fatigue, and the many other physiological actions for which it has been credited. 625 In emotional disturbances there is a discharge of nervous impulses via the sympathetic. Since epinephrine when in- jected induces the same action as the sympathetic, it would be logical to conclude that epinephrine is secreted in times of stress to cooperate with the nervous impulses. This is the crux of Cannon's theory of the ' 'Emergency Function" of the adrenals. 102 Cannon and de la Paz found that the dilatation of the pupils and upstanding of the fur which accompany sudden alarm or excitement are associated with an increased discharge of epinephrine. 103 Subsequently, Cannon and his collaborators claimed to show that fear, rage, pain, cold, asphyxia etc. caused a discharge of epinephrine from the adrenals. They attempted to show that epinephrine is serv- iceable in lessening muscular fatigue, in accelerating the coagulation of the blood, and in otherwise aiding the organism in an emergency. 104 - 105 The theory and experiments of Cannon and his collaborators have been the subject of an intense controversy. Stewart and 110 MEDULLA Rogoff 587 and Gley and Quinquaud 222 particularly have at- tacked the validity of the experimental evidence presented by Cannon and his co-workers as well as the interpretation of their experiments. It is unnecessary to repeat again the details of this controversy. In view of the results already quoted it must be admitted that Cannon and his collaborators are probably correct in assuming an increased output of epinephrine under the various conditions in which epinephrine by its pharmacodynamic reactions would be useful to the organism in an emergency. It is very doubtful, however, if the amounts of epinephrine secreted under these conditions would suffice to be of any significance to the organism as demanded by Cannon's theory. Moreover, adrenalectomized animals maintained on an adequate dose of cortical hormone are able to respond to emergencies as efficiently as normal animals do. Such animals respond to fright, become enraged, and fight as well as unoperated animals and hence any assumed emergency function of the epinephrine must, at best, be an easily dispensable one. Cannon's theory also fails to take into account the phylogenetic and ontogenetic facts in the develop- ment of the mammalian adrenal. As an emergency organ, one can see no teleological significance in the migration of the chromaphil into the interrenal tissue. All the ^physiological work on epinephrine secretion has been carried out on mammals. Any conclusion based on our present knowledge must be limited therefore to the mammalian body. We must admit our complete ignorance of the function of epi- nephrine in the lower animals. As suggested by Stewart, 587 epinephrine may be only a sur- vival which though of little significance in the higher animals is important in lower forms where hormonal control retains a more fundamental influence than nervous control. Epineph- rine may have assumed in the mammal an entirely different function than it has in the lower vertebrates. A number of facts speak for an intimate relation between the PHYSIOLOGY OF EPINEPHRINE 111 functions of the medullary and cortical tissues in the mammal. Ontogenetically and phylogenetically one finds an intimacy which can not be dismissed as a mere vagary of nature. The peculiar circulatory system of the adrenals by which, as we have seen (Chapter II), the vessels from the cortex continue into the medulla is further anatomical evidence for suspecting some relation between the medulla and the product of the cortex. The peculiar chemical properties of epinephrine in its oxidation-reduction potentialities would render it ideal as a protective agent for the vital and destructible cortical hormone. Has epinephrine, therefore, in the mammal some function which links it to the adrenal cortical hormone? Does our ignorance of the function of the latter shroud also that of epinephrine? The view that the function of epinephrine is to protect or otherwise act synergistically with the adrenal cortical hormone is supported by several other important facts. Sjostrand 578 found that those agents which cause an increased output of epinephrine from the adrenals also increase the blood flow through the cortex. This finding led him to suggest that epinephrine was linked functionally with the activity of the cortex. As we shall see later, the agents which stimulate epinephrine secretion are also those which stimulate the utilization and hence the demand for the cortical hormone. One would thus be justified in concluding that the observed stimulation of epinephrine which we have described as occurring under various conditions is in reality only secondary to the increased secretion of the cortical hormone which these con- ditions call forth. If the theory outlined above is valid one must conclude that in the mammal only the medulla is of functional sig- nificance. The extra-medullary tissue is of little or no use- fulness and merely a remnant of its occurrence in the lower animals. That the extra-adrenal chromaphil tissue is of little function in the organism as demanded by this hypothesis is 112 MEDULLA supported by the following facts. Non-fatal adrenalectomy in dogs, rats, or rabbits causes no hypertrophy of any extra- adrenal chromaphil tissue. 357, 685 If the medulla subserved an important function other than that involving the cortex, one certainly would expect some hypertrophy of this chromaphil tissue. On the other hand, after unilateral adrenalectomy, Stewart and Rogoff 588 found a compensatory hypertrophy of the medulla of the remaining gland. The major part of the chromaphil tissue of the mammal in embryonic life occurs outside of the adrenals. This tissue degenerates after birth while the adrenal medulla develops, which speaks for the assumption that the medulla is the func- tionally active part of the chromaphil tissue while the extra- adrenal chromaphil tissue is of little use to the adult organism. These observations indicate that the medulla takes over the function of the extra-medullary chromaphil tissues. The relative inactivity of the extra-medullary tissue is also indi- cated by Ingier and Schmorrs 329 observation that in persons dead of diphtheria, the adrenals may be free of epinephrine while the paraganglia still contain their normal store of this substance. Chapter VII THE PHARMACOLOGY OF EPINEPHRINE The pharmacology of epinephrine has been studied very thoroughly, the wide variety of its actions having invited at- tention from numerous investigators. Some of the discrepan- cies between the work of different authors may be attributed to their failure to appreciate that, not only quantitatively but qualitatively as well, the results obtained from epinephrine will depend upon the dosages employed. Most authors have been content to use commercially available epinephrine solu- tions instead of the pure crystalline material for their work, thus disregarding the effects of the acid and chloretone which these solutions contain. Chloretone exerts particularly poi- sonous effects on smooth muscle. 639 Almost without exception the effect of injecting epinephrine is the same as stimulating the sympathetic nerves and hence epinephrine is spoken of as a sympathomimetic substance. Epinephrine affects practically all tissues which are supplied with nerves of the sympathetic system. On the other hand, its action on tissues not innervated by the sympathetic is slight. Thus, contrasted to the marked activity which epinephrine exerts on blood vessels, it has no action on the placental vessels which are not under sympathetic control. In the embryo, tissues are not affected until they have become innervated by sympathetic fibers. However, epinephrine is said to affect the heart of the embryo fish and the blood vessels of the chick embryo before their innervation. 639 In the chick's amnion, likewise, although not known to contain any nerves, the rhyth- mic contractions of the unstriped muscle are inhibited by epi- nephrine. 379 The action of epinephrine, however, is not upon the nerves or their endings, for sectioning the nerves not only 113 114 MEDULLA does not prevent the action of epinephrine, but actually (after the fibers are degenerated) renders the tissue more easily ex- citable. Although most of its actions are sympathomimetic, epineph- rine exerts certain effects which indicate a parasympathetic- like action. Thus in the frog and turtle, epinephrine constricts the pulmonary blood vessels which are supposed to be under parasympathetic control. 405 The effects of epinephrine which follow its injection with neurine, acetylcholine, and related drugs or in the presence of a low calcium concentration, are also explained by assuming some parasympathomimetic action of epinephrine. 270 The action of epinephrine is characterized by the absence of any measurable latent period; by its dependence upon the epinephrine concentration, which if maintained constant, may elicit an unabated reaction for a long period of time; and by the rapid subsidence of its effects when the drug is removed from its site of action. 410 ■ 537 In general, the effects of epinephrine are dependent upon a number of conditions. The state of tone of the organ may determine the extent of the action. Thus a normally dilated bronchiole is scarcely affected by epinephrine while the con- stricted bronchiole is readily dilated. As Auer and Meltzer 451 first showed, interruption of the sympathetic pathways in- creases the effect exerted by epinephrine. Thus the denerv- ated iris is 10 to 40 times as sensitive to the drug as the intact organ. The ionic concentration of the inorganic constituents of the medium also affects the action of epinephrine. The calcium ion and the potassium ion act synergistically with epinephrine; other ions (hydrogen, hydroxyl, sodium, mag- nesium, etc.) also affect the action of epinephrine. 639 The alkaloids of ergot (ergotamine and ergotoxine) have the peculiar property of inhibiting the effects of epinephrine even in doses which in themselves induce no great functional changes. Although this is true of most actions of epinephrine, PHARMACOLOGY OF EPINEPHRINE 115 the dilatation of the pupil is a notable exception, for the my- driatic action of epinephrine is still elicited after ergotamine. Yohimbin, hydrastinin, quinine, and apocodeine share with the alkaloids of ergot the property of abolishing the stimulat- ing effects of epinephrine. They do not, however, paralyze the inhibiting effects of epinephrine nor the inhibiting effects of sympathetic excitation. Hence, when either contraction or inhibition can normally be induced under different circum- stances through the sympathetic nerves or by epinephrine, if the normal effect be stimulation, this will be abolished by ergotoxine or apocodeine, and the inhibiting effects alone will appear on subsequent injection of epinephrine. This is spoken of as a reversal action. If the normal effect be inhibition, this remains unaltered. Originally it was thought that the reversal effect of ergotox- ine was due to a double innervation from the sympathetic. The capillary dilatation observed by Dale and Richards 243 after epinephrine led them to believe that the reversal is due to the persistence of the capillary dilatation when the constricting effects on the arteries have been paralyzed by ergotoxine. Schafer 550 has, however, criticized this view. Where the parasympathetic acts as an antagonist to the sympathetic, paralysis of the former results in an augmented action by epinephrine. Thus the preliminary injection of atropine (by paralyzing the parsympathetics) results in an enhanced response to a subsequent injection of epinephrine. Epinephrine also acts as an antagonist to other parasympathe- tic drugs — pilocarpine, physostigmine, choline, etc. Nicotine, which paralyzes sympathetic ganglia, does not affect epineph- rine action for epinephrine does not act through any effect on the ganglia. 36, 270 Histamine, by its action in paralyzing smooth muscle, acts as an effective antagonist to epinephrine. Cocaine and novo- caine sensitize organs to the action of epinephrine. Thus the pupil is more widely dilated by epinephrine after a preliminary 116 MEDULLA application of cocaine. This action is due to the paralysis of the antagonistic fibers from the superior cervical ganglion by the cocaine, for the effect is not seen after extirpation of the ganglion. Caffeine is also an antagonist to the stimulating effects of epinephrine on the blood vessels, heart, and uterus. EFFECTS OF EPINEPHRINE ON THE CIRCULATION The stimulating effects of epinephrine on the mammalian heart may be demonstrated on the isolated organ or on strips of cardiac muscle. Addition of epinephrine to the perfusing fluid results in a marked acceleration of the pulse rate, an in- crease in the strength of beat, and an increased rate of conduc- tion when electrically stimulated. These stimulating effects are more pronounced in a heart poisoned by potassium chloride, chloroform, atropine, cyanide, etc. After chloral poisoning, on the other hand, epinephrine is ineffective in stimulating the cardiac contractions. When administered intravenously to mammals, the prelimi- nary acceleration of the pulse is followed by a marked slowing and often by an irregularity in rate. This slowing is brought about reflexly by impulses arising from the elevated blood pres- sure in the vagus center, for it can be abolished by previous ad- ministration of atropine. In chloroform poisoning, epineph- rine still reduces the pulse rate even after vagotomy. This is probably due to stimulation of the vagal endings. 292 This reflex slowing of the heart may even result in complete cessa- tion of the auricular beats due to inhibition by the cardio-in- hibitory center. If the vagi are cut or paralyzed by atropine the inhibitory effects are prevented, and the heart after epineph- rine injections maintains its more forceful and rapid rate of contraction. This cardiac activity still further increases the blood pressure. With large doses of epinephrine the heart becomes dilated to such an extent as to be fatal unless the pericardium be opened. 650 ■ 639 Epinephrine increases the irritability of the heart. This in- PHARMACOLOGY OF EPINEPHRINE 117 creased irritability manifests itself in the appearance of extra- systoles and is not prevented by vagotomy. 10 It is favored by chloroform narcosis. Under chloroform anesthesia ventric- ular fibrillation is easily induced. Barium salts and strophan- thin also sensitize the heart to these effects of epinephrine. The central vagal stimulation, which, as we have seen, arises reflexly as a result of the hypertension, also acts on the sinus and on the bundle of Tawara to give heart block or other de- rangements of rhythm. According to Stella, 586 the reflex bradycardia which follows the injection of epinephrine is due to the effects of the elevated arterial pressure acting on the sensitive regions of the carotid sinus and the territory of distribution of the depressor nerves. The degree of this action is conditioned by a state of increased reflex excitability of the cardiac vagus centers induced by the injected epinephrine. Oliver and Schafer 480 first demonstrated the immediate and marked rise of blood pressure produced by injecting an extract of the adrenal medulla. Contraction of the peripheral arteries is so marked as to cause a shrinkage of many organs, as re- corded by a plethysmograph. Several seconds after an intra- venous injection (subcutaneous administration is ineffective) of 0.05 mgm. per kilo of epinephrine into an animal, the arterial blood pressure rapidly rises, reaches a maximum in about 15 seconds, continues to rise slightly for the next \ to \\ minutes, and then gradually recedes. In the dog, the pulse rate may be increased to double its value at first but is slowed as the pressure rises and often becomes irregular. The reduced pulse rate continues for sometime after the blood pressure has re- turned to normal. The maximum pressor effect elicitable by epinephrine varies in different animals. In the rabbit the normal pressure is rarely doubled. In the cat and dog, on the other hand, pres- sures as high as 250 to 300 mms. are obtainable after vagotomy. The rise in pressure is proportional to the natural logarithm 118 MEDULLA of the amount injected; i.e., it follows the Weber-Fechner law. 410 Since repeated injections are reproducible one may- use the pressor response to assay epinephrine. 639 A good pres- sor response is obtained in the cat after an injection of 0.001 to 0.002 milligrams of epinephrine. The pressor effect of epinephrine is still elicited after cutting the sympathetics and allowing the nerve fibers to degenerate. Hence the pressor action is not mediated through the nervous system. Oliver and Schafer 480 in their original paper deduced this from their own experiments. Langley 379 postulated that the drug acts on the smooth muscle directly. However, Brodie and Dixon 93 showed that after the administration of apocodein (which blocks sympathetic fibers and in large doses causes vasodilation and a drop in blood pressure), epinephrine fails to give a pres- sor response. The smooth muscle is still reactive for the ap- plication of barium chloride elicits a reaction. Hence the point of stimulation lies between the sympathetic nerve termi- nals and the muscle cells; i.e., on the hypothetical "receptive substance" of Langley or, as it is more commonly denoted, the myo-neural junction. There is no support for the view that epinephrine exerts its pressor effects through action on the ganglia of the sympa- thetic vasomotors as has been claimed. When applied locally to the cervical ganglion, no sympathetic effects are elicited. 110 - 177 Subcutaneous injections (even in doses which if administered intravenously would be fatal) do not exert pressor effects on cats, dogs, or rabbits, although a very large dose (37 mgs. per kilo) raises the blood pressure in the dog. 13 In animals with intact centers, a drop in blood pressure fol- lows the return to normal. In rabbits, after the injection of \ mgm. of epinephrine, this drop persists for several days 639 due probably to reflex stimulation of the vasodilator center. This reflex is also held accountable for the notch observed in the ascending limb of the blood pressure curve for it is avoided by deep narcosis or by cutting the cord, and is accentuated PHARMACOLOGY OF EPINEPHRINE 119 by the preliminary injection of strychnine. This reflex ac- cording to Heymans 297 is initiated in the carotid sinus. In cats and dogs, small doses (.0001 mgm. per second) give a fall in blood pressure of 20 to 40 mms. of mercury. 270 This is due to vasodilatation in the extremities by stimulation of sym- pathetic vasodilator peripheral fibers. 243 Whether the arte- rioles or the capillaries are involved in this reaction is question- able. It does not occur in decerebrate unanesthetized or in normal unanesthetized animals. 639 The fact that very small doses of epinephrine cause a drop in blood pressure instead of a rise was first noted by Moore and Purinton 270 in 1900. Dale 36 showed that ergotoxin had the property of paralyzing those sympathetic fibers which have a stimulating function while unafTecting those having an inhibitory function. After poisoning with ergotoxin, epineph- rine in a dose which normally evokes a rise in blood pressure produces only a fall. The effects of epinephrine on the peripheral blood vessels have usually been determined by direct observation, by ple- thysmography measurements, by determining the rate of per- fusion, or the rate of venous outflow. If the blood pressure rises markedly, passive dilatation of the arteries may result with a consequent increase in the plethysmographic volume. This is, for example, taken to be the case in the kidney where the decrease in size of this organ which follows an injection of epinephrine is sometimes preceded or followed by an increase. The action of epinephrine differs as regards its effects on different vessels. Despite its general constricting action, cer- tain vessels, particularly the splanchnics, the arteries of the skeletal muscles, the coronary, and the pulmonary vessels are, under certain circumstances at least, dilated by moderate doses of epinephrine. 113 According to Orahovats and Gotsev, 484 epi- nephrine causes dilatation of the splanchnic vessels in two- thirds of all cases and constriction in the remainder. The arteries of the brain according to Dixon and Halliburton 159 are 120 MEDULLA only slightly affected or dilated by epinephrine but Wiggers 680 claims that they are constricted. Similarly divergent results have been obtained on isolated strips of cerebral arteries. It is difficult to ascertain the effect of epinephrine on the coronary circulation of the intact heart, since the acceleration of the pulse rate, the increased strength of ventricular contrac- tion, and the increased blood pressure would all tend mechani- cally to increase the blood flow through these vessels. Ac- cording to Barbour and Prince 32 the coronaries of man and the monkey are contracted by epinephrine while those of other animals are dilated. The results of numerous studies on the effect of epinephrine on various groups of vessels, have, as in the cases cited, in- variably given the most diverse and conflicting results. These discrepancies, as obtained in studies on the pulmonary vessels, have been reviewed by Daly, 149 who has pointed out the many factors which may lead to conflicting results: (1) the epineph- rine preparation used; (2) variations in dosage; (3) the per- fusion pressure and temperature; (4) the composition of the perfusion fluid; (5) the tone of the blood vessels; (6) the animal species experimented upon; (7) seasonal variations; (8) the interpretation of the observations. The same factors undoubt- edly have disturbed the experiments on other arteries. It must also be remembered that the results obtained on dismembered anesthetized animals or on isolated tissues are not indicative of the changes occuring in the normal animal in which numerous reflexes allow compensatory adjustments, which are absent in the anesthetized or operated animal, to occur. The marked increase in the cardiac output following epinephrine injections would speak for extensive dilatation of the splanchnic and pulmonary vessels in the intact organism. 243 The action of epinephrine is not limited to the arteries. Many capillaries are constricted as may be noted by direct observation. On the other hand, Dale and Richards 243 de- scribed a capillary dilatation. The action of epinephrine on PHARMACOLOGY OF EPINEPHRINE 121 the capillaries is manifested by its ability to counteract the swelling induced by application to the skin of mustard oil. The leakage through the capillaries caused by histamine and the cutaneous edema caused by paraphenylenediamine may also be prevented by the injection of epinephrine. 639 Epinephrine when applied directly causes constriction of veins similar to its action on arteries. It is particularly effec- tive in diminishing the calibre of the superficial cutaneous veins. Quiescent rings from the superior vena cava near the heart are stimulated to beat rhythmically when immersed in Ringer's solution containing epinephrine. 258 The pulse rate of certain invertebrates (Limulus, Daphnia, Peden, Maja, Aplysia, and Salpen) are increased by epineph- rine, while in others (the crab and the snail) the pulse rate is not affected. With large doses the pulse rate of the horse- shoe crab {Limulus), lobster, and snail is decreased. In fish an increased rate and strength of contraction as well as vaso- constriction are observed. In the frog the pressor effect is slight and the effect on the heart rather uncertain unless previ- ously damaged by drugs, in which case it is markedly stimu- lated. 639 In man the subcutaneous injection of 0.5 to 1 cc. of a 1 : 1000 solution of epinephrine causes a slight elevation of blood pres- sure, pallor of the face and extremities, and an accelerated pulse rate. The intracutaneous injection of one cubic centi- meter of a 1 to 10 million solution gives a detectable pallor. A 1 to 1 million solution gives an area of anemia surrounded by a zone of hyperaemia. The subcutaneous injection of 1 mgm. of epinephrine in man causes a rise in the systolic pres- sure of the brachial artery of 10 to 30 mms. of mercury. The maximum rise is reached after about one-half hour and ends after an hour or two. The pulse rate is increased 10 to 20 beats. Extrasystoles may occur. Euler and Liljestrand 243 found the cardiac output of man to increase from 4.3 liters per minute to 7.5 liters following the subcutaneous injection of 122 MEDULLA 0.7 mgm. of epinephrine. The pulse rate increased from 60 to 66 per minute; the systolic output from 71 to 120 cc. The blood pressure rose from 103/68 to 120/64. These results would indicate that in man the injection of epinephrine leads to marked stimulation of the cardiac activity and a diminished peripheral resistance. 243 RESPIRATION Epinephrine, as noted by Oliver and Schafer, 480 causes some diminution in the depth of respiration and at times a temporary apnea. This effect disappears before the pressor action has ceased to manifest itself. 383 That this apnea is not due to vascular constriction in the medulla oblongata was shown by Bouckaert 74 who found that it was not abolished in the cat by previous administration of ergotoxine which, as we have seen, abolishes the vascular constricting effect of epinephrine. Mellanby and Huggett, 450 however, could not confirm this result. In the dog, Langlois and Garrelon 383 found either a diminution or an increase of respiration after epinephrine, de- pending upon the state of the respiratory center, while Nice, Rock, and Courtwright 470 found the effect to depend upon the dose. Small doses stimulated, while large doses inhibited the respiratory center. Small doses of epinephrine cause an increase in the depth of respiration. In the cat a reduction is produced by 0.3 cc. of a 1 : 1000 solution. These effects are independent of the ac- companying blood pressure changes or vagotomy. Direct perfusion of the medulla has shown that epinephrine acts directly on the respiratory center. Small doses cause an increase in the depth and rate of respiration while large doses diminish the depth and rate. 687 In man Hartman 270 also ob- served an increase in rate from 24 to 42 per minute after the intravenous administration of 1 cc. of a 1 to 50,000 solution of epinephrine. It is now generally agreed that the apnoea which follows PHAEMACOLOGY OF EPINEPHRINE 123 an injection of epinephrine is not due to bulbar anemia. 687 That the apnoea is reflex in origin was demonstrated by Hey- mans and Heymans 298 who obtained a cessation of respiration in the head of a dog united to the body only by the vagi, after injection of epinephrine into the trunk of the animal. The apnoea is thus dependent upon afferent impulses transmitted by the vagus or the nerve of Hering. The apnoea may be abolished by cutting both vagi and denervating the carotid sinus. 297 The reflex which leads to apnea is set up by the ele- vation of blood pressure in the carotid sinus. When the bronchioles are in a state of tonic contraction, epinephrine causes their relaxation. 608 This action accounts for its therapeutic use in bronchial asthma. When the bronchi- oles were not fully relaxed Dixon and Ransom 160 obtained fur- ther dilatation after epinephrine injection, but Golla and Symes 639 obtained constriction except in cases where it had al- ready been established by the previous injection of some other drug. The results of various experimenters differ widely, due probably to differences in the state of tone of the bronchioles. After paralysis of the constrictors by ergotoxine, epinephrine produces dilatation of the bronchioles with greater ease than normally. STOMACH AND INTESTINES Not only the plain muscle of the vascular system but other involuntary muscle is also acted upon by epinephrine. Con- traction or relaxation occurs depending upon the effect of sympathetic stimulation under the same conditions. Epinephrine causes inhibition of the rhythmic movements and the tonus of the alimentary tract, an observation first made by Boruttau. 73 This is used as one of the most delicate physiological tests for detecting and assaying epinephrine (cf. Chapter VI). The relaxation of the stomach and intestines by epinephrine is in accord with their innervation, for stimula- tion of the splanchnic fibres arrests peristalsis and causes re- 124 MEDULLA laxation of the gut. Certain parts of the intestinal tract, however, receive motor fibres from the sympathetic and these (the pyloric, ileo-colic, and internal anal sphincters and the muscularis mucosae) are contracted by epinephrine. Pressor doses in man do not affect the intestinal movements. 165 Although inhibition is the typical reaction of the gut to epinephrine, excitatory effects are occasionally obtained. This is explained by assuming an occasional preponderance of motor over inhibitory sympathetic fibers. Hoskins 308 showed that doses below the threshold for inhibition will frequently cause an increased tone and rhythmical activity. In the rabbit epinephrine causes relaxation of the internal anal sphincter and the oesophagus as does also stimulation of the sympa- thetic nerves to these tissues. In birds and amphibia where the sympathetic nerves are mainly motor in function, epinephrine causes contraction. THE EYE The intravenous injection of epinephrine causes elevation of the lid, retraction of the nictitating membrane, and dilata- tion of the pupil. These effects are, however, much more pro- nounced after extirpation of the superior cervical ganglion with subsequent degeneration of the post-ganglionic fibers. Likewise the application of epinephrine to the conjunctiva 322 does not affect the pupil unless the superior cervical ganglion has been extirpated. The reaction of the enucleated frog's eye immersed in iso- tonic saline has been used as a test for epinephrine. 174 Al- though sensitive to epinephrine in a dilution of 1 to 20 million, the method is not specific. In rabbits after superior cervical ganglionectomy, dilata- tion of the pupil results from the subcutaneous injection of 0.6 cc. of a 1 : 1000 solution of epinephrine. Occurring within 15 minutes after the injection, the reaction lasts for over 2 hours. During its maximum dilatation, the pupil does not react to PHARMACOLOGY OF EPINEPHRINE 125 light or to eserin. 451 The reaction by which stimulation of the dilator pupillae and inhibition of the sphincter iridis occurs in response to epinephrine is ten times more sensitive in the cat than in the rabbit. In the dog, due to stimulation of the oculomotor center, one often obtains contraction of the pupil instead of dilatation. Muller's muscle is contracted by epinephrine making the globe of the eye more prominent and enlarging the palpebral fissure. UTERUS The action of epinephrine on the uterus is most striking. Uterine anemia and violent contractions are elicited in animals which, if pregnant, may be made to abort. The uterus is also rendered more excitable to physiological or artificial stimuli. The effect of epinephrine on the uterus varies with different animal species. The rabbit's uterus is stimulated whether pregnant or not. Inhibition is caused in the gravid or non- gravid uterus of the mouse, rat, or guinea pig. The uterus of the pregnant cat is contracted while the non-pregnant uterus is relaxed. In the dog, if pregnant, stimulation results; if non-pregnant, stimulation is followed by relaxation and inhibition. Similar results are obtained in the sow. The non-gravid uteri of the cow, ferret, and monkey are stimulated by epinephrine. According to Bourne and Burn, 76 the uterine movements of the intact pregnant human uterus are inhibited by tolerable doses of epinephrine. Most authors, on the other hand, re- ported stimulation of the human uterus whether gravid or non- gravid, but these results were based on experiments in which large doses of epinephrine were applied to strips of muscle re- moved at operation. As we have seen in Chapter VI, strips of uterine muscle are frequently used in the biological assay of epinephrine. The above described reactions of the uterus under different 12G MEDULLA conditions are in every case identical with those observed after stimulation of the hypogastric nerves. These nerves carry both motor and inhibitory fibers to the uterus and hence the relative strength of these two sets of fibers determines the re- action in any given case. EFFECTS OF EPINEPHRINE ON OTHER ABDOMINAL VISCERA The spleen is very sensitive to epinephrine, contracting even with minute doses. This contraction involves arteries, muscular capsule, and trabeculae. The gall bladder and sphincter of Oddi are relaxed by epi- nephrine; the bile ducts are contracted. Epinephrine causes little effect on the bladder of most ani- mals but in the cat and monkey relaxation (paralleling the effect of stimulating the hypogastric nerves) occurs, while con- traction follows epinephrine injections in the goat and ferret. Similar differences result from the action of epinephrine on the ureter. Contraction is observed in the cat, guinea pig, monkey, and man; contraction or relaxation in the dog; and no response in the ferret. Epinephrine causes relaxation of the tunica dartos, contrac- tion of the vas deferens, seminal vesicles and vagina, and in- creased tone of the prostate. PILOMOTOR MUSCLES Smooth muscle in general, if contracted by sympathetic stimulation, is readily made to contract by epinephrine. The pilomotor fibers, however, are an exception to this rule. Al- though readily affected by sympathetic stimulation their re- sponse to epinephrine in most animals is slight. The apparently discordant effects of epinephrine on the skin muscles and arrectores pilorum are harmonised, according to Elliott, 177 when one considers the varying functional use of these muscles in different animals. Thus epinephrine has little effect on the hairs of a cat's back, but causes marked action on PHARMACOLOGY OF EPINEPHRINE 127 the bristles on the scruff of the fox terrier's neck. The hair movement in the macaque is slight on the body but mani- fests itself well over the temples and forehead. The injection of 0.18 mgms. of epinephrine into the mongoose (Herpestes mungo), though insufficient to evoke a maximal dilation of the pupil, nevertheless, causes an extreme erection of the hairs on the animal's tail. The irritability of the arrectores pilorum thus varies directly with their normal functional use. According to Elliott 177 similar considerations are applicable to the varying reaction of other organs. The rise of "goose flesh" in the human subject after an in- jection of epinephrine is due to the contraction of the arrectores pilorum. MELANOPHORES Epinephrine causes contraction of the melanophores of the frog as may be noted by microscopic observation of the effect of painting epinephrine on the web of the foot. The retinal pigment cells migrate distally even in the light, which nor- mally causes their aggregation. In Fundulus heteroclitus, con- traction of the skin melanophores has also been observed in doses as small as 1 to 50 million. This effect is replaced by expansion after a previous injection of ergotoxine. 639 SECRETIONS Epinephrine stimulates the salivary, lachrymal, and other secretions. Since section of the chorda tympani and destruc- tion of the superior cervical ganglion do not interfere with this reaction, the point of stimulation must be peripheral. Other secretions (gastric and mucous secretions of the mouth, esopha- gus, and trachea) are also stimulated. The response of these glands to epinephrine is not marked, however, for the ischae- mia, simultaneously induced, reduces the secretory response to epinephrine. Although sweat secretion in the cat's paw is under sympathe- 128 MEDULLA tic control, epinephrine injections fail to produce sweating. 378 Likewise in man, Elliott 177 obtained a decrease in secretion from the skin of the hand, due probably to the accompanying vasoconstriction. However, injecting epinephrine directly into the pad of the cat's foot, after section of the sciatic nerve or under deep anesthesia, produces sweating. 639 Also in the horse, a localized area of sweating is induced by the subcutane- ous injection of epinephrine which lasts for several hours. 262 ' 462 Intravenous injections cause generalized sweating. Cow's 131 demonstration of a vascular connection between the adrenals and kidneys led him to suggest a functional rela- tion between these two organs. In the dog, Marshall and Kolls 438 found no such connection; nor does any apparently occur in man. Addis, Barnett, and Shevky 270 found that sub- cutaneous injections of epinephrine produced an increase in urea secretion by the rabbit. Relatively large doses gave a decrease. Intravenously injected epinephrine inhibits the urine flow temporarily. The injection of 1 mgm. of epi- nephrine diminishes diuresis and salt excretion in man. 639 In animals with vesical fistulae, Zunz and his collaborators 699 also observed a diminution in the diuresis which follows the ingestion of urea and in the proportion of chlorides in the urine of fasting dogs after an injection of epinephrine. These effects are probably to be attributed to the vascular effects induced by epinephrine. Contraction of the blood vessels of the glo- merular tuft would diminish the rate of urine flow while the subsequent contraction of the efferent vessels from the glomeru- lus would tend to increase the rate of filtration. Variable results have been obtained in studies of the effect of epinephrine on gastric secretion. The secretion of milk is not affected. Due to the ischaemia produced by epinephrine the secretion of bile and pancreatic juice are inhibited. 170 STRIATED MUSCLE Epinephrine (as does also stimulation of the sympathetic) decreases fatiguability and increases the work capacity of an PHAEMACOLOGY OF EPINEPHRINE 129 isolated muscle. If a gastrocnemius muscle of a frog be stimu- lated to fatigue, injection of epinephrine will give a good degree of recovery. The irritability of frog's muscle stimulated through its nerve is so much increased by epinephrine that this drug may act as an antagonizer of curare. 252 The claimed effects of epinephrine on skeletal muscle can be explained by its action on the circulation, the rate of which is increased, and its stimulation of the metabolic processes, by increasing the oxygen consumption. The increased ability of fatigued striated muscle to perform work in the presence of epinephrine has also been ascribed to an acceleration in the rate of formation of lactic acid. The phosphagen content of the muscle is not at first affected but when most of it has been decomposed, the accelerated formation of lactic acid furnishes the energy necessary for the resynthesis of the phosphagen. 463 BASAL METABOLISM Subcutaneous injection of epinephrine causes a rise of the basal metabolic rate, as measured by the oxygen consumption, which lasts for several hours. 544 In the rabbit, the injection of one milligram subcutaneously causes an elevation of 50 per cent or more in the basal metabolic rate which reaches its maxi- mum in the third hour after injection. Injection of 0.1 mgm. per kilo of body weight in the dog causes a rise from 350 cc. to 490, after 20 minutes; 580, after an hour and a quarter; 480, after 3 hours. 639 Since epinephrine does not affect the oxygen consumption of an animal paralyzed with curare or of a perfused limb, Born- stein 639 concluded that epinephrine exerts its metabolic effects by central action. However, epinephrine raises the metabo- lism of a rabbit after section of the spinal cord. It does not raise the metabolism of an eviscerated animal. Epinephrine injections stimulate the metabolism of hibernating hedgehogs to such an extent as to raise their body temperature and rouse them from their winter sleep. 639 Epinephrine still causes an increase in the oxygen consump- 130 MEDULLA tion in rabbits after thyroidectomy. The rise, however, is delayed somewhat in thyroidectomized animals and does not last as long as it does in normal animals. 436 The injection of epinephrine does not affect the protein metabolism during exercise by a fasting man. The carbohy- drate utilization, however, according to Dill and his collabora- tors, 158 is increased considerably. There is also a decreased excretion of acetone bodies indicative of the facilitating effect of epinephrine on the oxidation of carbohydrate. Epinephrine exerts the same effects on the blood sugar and lactic acid in work as it does during rest. The above described results of Dill and his collaborators on man are opposed to the earlier experiments on anesthetized animals which purported to show that epinephrine inhibited the utilization of carbohydrate in the body. This conclusion which is based on an observed decline in the respiratory quo- tient is open to serious objections. 419 BODY TEMPERATURE In man, therapeutic doses of epinephrine cause a rise of temperature of only a fraction of a degree. 544 In experimental animals, however, marked fever can be induced. This hyper- pyrexia is brought about by several factors. There is an in- creased heat production accompanying the increased metabo- lism, which is particularly striking in the liver. After removal of the liver, fever can not be induced. The increased work of the heart, under the influence of epinephrine, as well as the increased activity of other organs and tissues stimulated by epinephrine, all combine to give an increased heat production. This heat is not dissipated because of the marked cutaneous constriction which accompanies the reaction to epinephrine. Whether epinephrine causes hyperpyrexia by interference with the heat regulating center is still debatable. Against the assumption of such an interference is the fact that it raises the temperature of the dog rendered poikilothermal by section PHARMACOLOGY OF EPINEPHRINE 131 of the cervical cord and the hedgehog after removal of the heat regulating center. 639 CARBOHYDRATE METABOLISM Blum, 64 in 1901, first showed that an injection of epinephrine causes glycosuria. He suggested that the glycosuria observed by Claude Bernard after piqure of the floor of the fourth ven- tricle was due to liberation of epinephrine. The glycosuria is the result of hyperglycemia which in turn is brought about, in part at least, by glycogenolysis in the liver. After large doses of epinephrine, the liver may be depleted of its glycogen store. This glycogenolysis is not prevented by severing the nerves to the liver. The subcutaneous injection of 0.2 mgm. of epi- nephrine into a rabbit causes an hyperglycemia of several hours duration. Injected intravenously, on the other hand, the effect is very short due to the rapid destruction of the epi- nephrine. 128 Even in doses which do not elicit a rise in blood pressure, epinephrine still gives rise to hyperglycemia. Thus the con- tinuous intravenous infusion of 0.0001 mgm. per kilo per min- ute to a rabbit causes hyperglycemia, but is without effect on the blood pressure. The effect of epinephrine on the blood sugar varies in different animals, being greater, for example, in rabbits than in cats, dogs, rats, or men. The hyperglycemia which follows the injection of epinephrine no longer occurs, as Mann and Magath 425 have shown, after removal of the liver. However, the hyperglycemia may still be elicited in animals in which the glycogen store of the liver has been reduced to a minimum by prolonged fasting or by the injection of strych- nine. In such animals obviously the liver can not be the source of the glucose which appears in the blood stream. In such fasting animals, indeed, not only does hyperglycemia occur but there is also a concurrent storage of glycogen in the liver. Further evidence against the view that the effect of epinephrine upon the carbohydrate metabolism is due solely to 132 MEDULLA a conversion of pre-existent glycogen into glucose has been advanced by Cori and Cori. 128 These authors showed that the mobilization of all the glycogen present in the liver could only account for part of the glucose which appears in the cir- culation after an injection of epinephrine. In fasting rats, these authors found that epinephrine caused a decrease in the glycogen content of the muscles with a concurrent increase in the glycogen store of the liver. Cori and Cori considered the changes induced by epinephrine as consisting of a breakdown of glycogen in the muscles to lactic acid, a resynthesis of this lactic acid in the liver to glycogen, and a breakdown of the liver glycogen to the glucose which appeared in the blood. Corkill and Marks 129 demonstrated that in eviscerated cats, epinephrine causes a discharge of epinephrine from the resting muscles. None of this glycogen appears in the form of glucose and only a part of it as lactic acid. The remaining carbohy- drate may be in the same form as the so-called "lost carbo- hydrate" which disappears after the injection of insulin. Its appearance may be due to the action of the epinephrine liber- ated by insulin. MacCleod, 419 however, has cast doubt on the existence of this "lost carbohydrate." When the glycogen store of the liver is reduced by injections of phlorizin, hypoglycemia follows epinephrine injections. This depression of the blood sugar level is attributed by LaBarre and Houssa 371 to the stimulation of the secretion of insulin by the epinephrine. The failure of piqure after section of the splanchnic nerves to induce hyperglycemia is explained by the lack of epinephrine secretion in the denervated glands. Stewart and Rogoff 588 and MacLeod, 419 however, have concluded that the presence of the adrenals is not necessary for the development of the hyperglycemia which follows decerebration or piqure. The impulses transmitted along the sympathetic pathway from the diabetogenic center in the pons must therefore act independ- ently of the adrenal glands and influence the glycogenic func- PHARMACOLOGY OF EPINEPHRINE 133 tion of the liver directly. Epinephrine can thus not be held responsible for the hyperglycemia following decerebration, al- though it may play some part in bringing it about. OTHER PHARMACOLOGICAL EFFECTS OF EPINEPHRINE Epinephrine also causes other detectable changes in the animal economy but these are inconsiderable in their effects and for the most part are probably secondary to the influences described in preceding sections. Changes in acid-base balance, in salt metabolism, in blood concentration, et cetera have been described. 639 As first noted by Vosburgh and Richards, 651 the injection of epinephrine shortens the coagulation time of the blood. Can- non and Gray 104 found the intravenous injection of 0.001 mgm. per kilo to shorten the time to one-half to one-third of the normal. This action is due to the liberation from the liver of substances concerned in the process of coagulation. Large doses inhibit coagulability. These effects presumably result from the action of epinephrine on the liver for epinephrine when added to shed blood does not affect coagulation. The possible influence of epinephrine on protein metabolism is still debatable despite a number of investigations designed to determine this relationship. TOXICOLOGY OF EPINEPHRINE Large doses of epinephrine produce violent symptoms which may end in death. At first there is a period of excitement with rapid pulse and respiration. This reaction has occasionally been obtained in man where an intended subcutaneous injec- tion has been accidentally introduced intravenously. Follow- ing the period of excitement, depression supervenes. The ani- mal lies on its side, muscular movements are slowed, and paralysis of the limbs follows. The animal becomes dyspnoeic and finally dies in asphyxial convulsions. The paralysis is central, death being due to pulmonary edema. 134 MEDULLA The minimal lethal dose of epinephrine administered sub- cutaneously to man is from 10 to 20 mgms. per kilo of body- weight; intravenously it is 0.1 to 0.25 mg. per kilo. Alarming symptoms have followed the intravenous injection of 0.3 mgm. As little as 4 mgms. subcutaneously has proven fatal. 638 The lethal dose for the rabbit per kilo of body weight is 0.05 to 0.4 mgm. administered intravenously. For the dog or cat the lethal dose is 0.2 to 0.8 mgms. per kilo. 638 The paralysis and convulsions which follow lethal doses of epinephrine are results of changes in the central nervous sys- tem presumably caused by vascular constriction. At autopsy, one finds multiple hemorrhages throughout the body. The heart is dilated. The lungs are edematous and filled with blood. Hemorrhage is also found in the other serous cavities and in the kidney. The pupils are dilated and the eyeballs project due to sympathetic stimulation. The effects of sub-lethal doses of epinephrine is cumulative so that the injection of a lethal dose in two injections with an interval of some hours between the injections may still prove fatal. Atropine is a valuable antidote. 639 THERAPEUTIC USES OF EPINEPHRINE The versatile effects produced by the administration of epinephrine have given it wide usefulness in practical thera- peutics. Epinephrine receives wide application in conjunction with the use of local and spinal anesthetics. Here it acts by aiding the production of a bloodless field and, by preventing rapid absorption of the anesthetic, prolongs the period of anesthesia, maintains a high concentration of the anesthetic locally, and prevents toxicity due to its absorption. The stimulating effect of epinephrine on the heart renders it useful as an analeptic. When injected directly into the car- diac muscle, the heart which has stopped may resume its beat, particularly with the aid of massage. Epinephrine has been PHARMACOLOGY OF EPINEPHRINE 135 used as an analeptic particularly in cases of drowning and in asphyxia neonatorum. 112 Epinephrine is an antagonist to most cardiac depressants particularly to chloroform and chloral. It is therefore used in cases of failing circulation during anesthesia. In bronchial asthma, epinephrine relaxes the dilated bron- chioles and the relief obtained by an asthmatic is often strik- ing. The usefulness of epinephrine in asthma dates from be- fore our knowledge of the sympathetic bronchodilators and before the experimental demonstration of the dilating action of epinephrine on bronchiolar constrictors. It is administered subcutaneously in doses of ^ to 1 cc. of a 1:1000 solution. 112 One of the most important therapeutic applications of epinephrine is due to its local effects in constricting blood ves- sels. Local ischaemia induced by epinephrine permits blood- less operations on the eye and on the nasal and oral mucosae. Epinephrine is also useful for stopping epistaxis. In the use of epinephrine surgically as a hemostatic, it is necessary to remember that small vessels subsequently bleed when the effect of the epinephrine has disappeared. 520 The ischaemia due to epinephrine may also cause delayed healing and even necrosis. Although advocated for internal hemorrhage, it would seem to be contraindicated in this condition. The application of the drug to a congested mucous membrane is followed by contraction of the swollen mucosa and constric- tion of the dilated blood vessels. The congestion of hay fever is temporarily relieved by such applications. In urticaria, angioneurotic edema, serum sickness, and the nitroid crises following the injection of arsphenamine, epi- nephrine injections often give spectacular relief when adminis- tered subcutaneously in doses of ^ to 1 cc. of the standard 1 : 1000 solution. 112 In cases of acute traumatic shock in which there is a dilata- tion of the capillary bed with an increase in capillary permea- bility, it is doubtful if the transient cardiac stimulation and 136 MEDULLA vasoconstriction following epinephrine can be of any thera- peutic effectiveness. On the other hand, where there exists, as a result of a weakened cardiac action, a low blood pressure, epinephrine acts as an efficient analeptic. This is the case, for example, in the collapse following excessive anesthesia 257 or in the use of a spinal anesthetic. 520 Due to the frequency with which epinephrine induces ventricular fibrillation in the presence of chloroform anesthesia, its use is contraindicated during or im- mediately after chloroform anesthesia. Epinephrine may be used in averting the symptoms of hy- poglycemia {e.g., after an overdose of insulin) providing there is an adequate store of glycogen in the liver. If no such store exists, epinephrine obviously can only have a deleterious effect. Epinephrine has also been advocated for use in poisoning (to prevent absorption), in diptheria, heart block, Addison's disease, osteomalacia, rodent ulcer, tobacco amblyopia, and osseous repair. It is doubtful if it has any therapeutic value in these conditions. Epinephrine injections have been advocated as a diagnostic aid in thyroid disease, 117 hypertension, angina pectoris, irrit- able heart, and other conditions but its use for this purpose has not met with success. The use of epinephrine in angina pectoris is to be deprecated because of the strain it puts upon the heart. 243 MODES OF ADMINISTRATION Epinephrine is administered clinically by subcutaneous, in- tramuscular, intravenous, or intracardial injection, or by local application to mucous membranes. Its oral use has at times been advocated but it is doubtful, in view of the rapid destruc- tion of epinephrine by the gastric and intestinal secretions and the extremely slow rate of its absorption by mucous linings, if such oral therapy can be of any significance. Such effects as have been claimed to result from oral therapy may in part be due to the oxidation products of epinephrine. These deriva- PHARMACOLOGY OF EPINEPHRINE 137 tives of epinephrine are extremely toxic and in large doses may prove harmful even when administered orally. Severe gastric and intestinal cramps are the commonest symptoms following the oral administration of epinephrine. Doses of 4 cc. of a one per cent solution have been advocated 83 for the oral treatment of several conditions but in view of what we have stated above, the oral use of epinephrine must be dep- recated. That some epinephrine is absorbed after oral administra- tion is manifested by the hyperglycemia resulting from the administration of 4 milligrams of epinephrine to man 83 and by the effects of an oral dose on the iris of the cat, after removal of the superior cervical ganglion. The epinephrine which is absorbed from the gastro-intestinal tract is carried first to the liver where it exerts its glycogenolytic action and is destroyed before it can exert any cardio-vascular effect. Rectal adminis- tration which results in absorption into the general circula- tion before reaching the liver is more effective than oral ad- ministration. The pharmacological effects of epinephrine are rapidly elici- ted after injection but very transient if directly introduced into the blood stream. 661 When injected subcutaneously, epineph- rine is absorbed along the lymph channels. The local vaso- constriction occurring at the point of injection retards the rate of absorption of the epinephrine and thus prolongs its action. The subcutaneous route of administration is always preferable except in emergency treatments where the circula- tion is too much retarded or the heart has stopped, in which cases intravenous and intracardiac injections, respectively, are required. 328 As an analeptic, in cases where the heart has stopped, as in shock, anesthesia, electrocution, drowning, suffocation, et cet- era, epinephrine must be injected intracardially to produce the desired effect. An injection into the heart muscle is much more effective than an injection into the cardiac cavity, for 138 MEDULLA absorption from the blood stream is relatively slow compared to the rapid distribution of the epinephrine by way of the lym- phatics when injected into the myocardium. The intracardiac injection is best made through a fine needle, 8 cms. long, which is inserted above the fifth rib in the fourth, left, intercostal space. To avoid injury to the internal mammary artery, the injection should be made at a point about a finger's breath from the left sternal margin. 328 Hyman 320 reports that of 250 intracardial injections in mori- bund individuals, 25 per cent were followed by successful stimu- lation of the heart. Successful results have been reported in cases where the heart had stopped for over ten minutes. 328 FATE OF EPINEPHRINE AFTER ITS ADMINISTRATION The fate of epinephrine in the body is still unknown. It is not excreted in the urine but after large oral doses, catechol derivatives of epinephrine have been detected. The destruc- tion of epinephrine does not occur in the blood stream for the blood has a protective action against the oxidation of epi- nephrine as do also the tissues in general. Nor do the lungs, capillaries, or arterial walls play a part in the destruction. It is most likely that the liver is the chief agent for the removal and destruction of epinephrine. An injection into the portal vein or absorption from the stomach gives only minimal effects since the epinephrine under these conditions reaches the liver before entering the general circulation. On the other hand, in animals with an Eck fistula, epinephrine has a very pro- longed action. PART III. THE CORTEX With the failure of investigators to demonstrate the function of the adrenal medulla, interest was gradually shifted to the cortex as the important part of the adrenal. During the last two decades, numerous studies have been made on the function of the cortical tissue and the product of its secretion. The importance of the cortex for the maintenance of the functional integrity of the organism has been demonstrated most con- clusively. There remains little doubt that the cortical cells of the adrenal elaborate a hormone of vital importance to the organism, and that death rapidly follows the exclusion of this hormone from the body. By what mechanism this hormone exerts its effects is still unknown. The various theories advocated thus far are, for the most part, unworthy of serious consideration since they are based on some specific manifesta- tion of adrenal insufficiency and ignore all other aspects of the problem. It has been suggested that the cortical hormone is essential for the well-being of all the tissues of the body. If this be true one should be able to demonstrate striking effects of the hormone on in vitro preparations of tissue cultures. A great advance in the study of the cortex has been made by the preparation of the cortical hormone in sufficiently pure and potent form to permit its application to clinical and experimental problems. The isolation of the hormone and its chemical study with a view toward its ultimate synthesis still remain as problems for the future, although some progress in these directions has already been made. 139 Chapter VIII ADRENALECTOMY Extirpation of the adrenals of experimental animals has been performed by a host of workers since Brown-Sequard's 96 pioneer researches in this field in 1856. Until recently, ob- servation of adrenalectomized animals was the chief approach to an experimental study of adrenal function. The operation is essential for most studies on the glands and we shall, there- fore, describe in some detail the general features of the opera- tion as performed on various classes of vertebrate animals. Inspired by Addison's 7 description of a disease involving the adrenal glands, Brown-Sequard 97 undertook to reproduce the disease in the lower animals by extirpating the glands in rab- bits, dogs, cats, guinea pigs, and rats. The fatal outcome of his operations (within a few hours to two days) led him to con- clude that the adrenals were indispensable for fife. Gratiolet 238 repeating these experiments found that even unilateral ad- renalectomy in the guinea pig was fatal due to post-operative peritonitis and he therefore concluded that the outcome was primarily induced by injury to the viscera and only secondarily by the deprivation of the adrenals. Philipeaux and Harley 198 also reported that adrenalectomy was not fatal to the rat if the operation were performed in stages. In 1891 Abelous and Langlois 3 verified Brown-S6quard's conclusion as to the vital importance of the adrenals for life. Hultgren and Anderson 323 found that unilateral adrenalectomy was tolerated by the cat but that bilateral operation was fatal in 5 days when the glands were removed in two stages, but in only three days if removed at one operation. In rabbits, too, adrenalectomy was followed by death in 5 or 6 days, survival being prolonged by previous castration. 141 142 CORTEX Strehl and Weiss 600 carried out a series of operations on cats, guinea pigs, rabbits, rats, mice, and frogs and showed the fatal outcome in all of these animals. To avoid the deleterious effects of trauma, Biedl 56 devised the following operative technique: He first dislocated the glands from their normal position and, with their blood vessels intact, attached them subcutaneously. Several days later, he removed the glands through a skin incision. His results confirmed his predecessors' views regarding the indispensability of the glands for life. The earlier work cited above indicated that adrenalectomy was rapidly fatal in most animals. Subsequent work during the last two decades has shown, however, that, with a more refined technique and certain precautions, one can adrenalec- tomize cats, dogs, monkeys, and other mammals and have them survive for a few days to a few weeks in good condition. The rapidity with which death followed the operation in the hands of the earlier workers is attributable to the operative shock, hemorrhage, and general manhandling to which the animals were subjected. However, even in recent years expert surgeons have reported results little better, as regards the survival period of their animals, than those of the early part of the century. It is only with the development of some degree of skill and observation of certain precautions involved in the operative technique that the more prolonged survivals are attainable. Until recent years, the rat, mouse, and rabbit were con- sidered as exceptional in that adrenalectomy was supposed to be fatal in only a small fraction of these animals. 198 As shall be shown later, this view is erroneous being based on the results of an incomplete extirpation. With proper technique adrenalectomy in all the common laboratory animals can be carried out with recovery of the animals from the immediate effects of the operation and the ultimate development of a fatal adrenal insufficiency. ADRENALECTOMY 143 FACTORS DETERMINING THE SURVIVAL PERIOD AFTER ADRENALECTOMY Adrenalectomized animals are extremely sensitive to trau- matic injury or hemorrhage and hence a finesse of surgical technique will be a factor in determining survival after ad- renalectomy. The shock of trauma and hemorrhage involved in prolonged and clumsy handling of the viscera will obviously shorten the life of an already doomed animal. In addition to surgical technique, however, a number of other factors will determine the survival period, chief among which are the following : 1) the animal species 2) the age of the animal 3) the pre-operative treatment 4) the anesthetic and the duration of its administration 5) the completeness of the extirpation 6) the post operative treatment 7) the season of the year S) the state of the reproductive system Some animals (e.g., the rat, goat, and frog) survive adrenalec- tomy much longer than others (e.g., the dog or guinea pig) which is in accord with their comparative hardiness and ability to withstand other forms of injury. Age. Age is an important factor in determining the sur- vival of a given animal species. Young animals survive for much shorter periods than adults. It is probable that the active metabolism and growth processes of the young individual induce a rapid depletion and more urgent demand for the cortical hormone than the relatively inactive tissues of the adult. In accord with this view is the fact that adrenalec- tomized young animals require relatively more of the cortical hormone than adults to maintain them in good condition. The effect of age in determining the survival of animals after adrenalectomy has been demonstrated in rats by Firor and the 144 CORTEX author 198 and by Sisson and March. 577 The latter authors found the following survival periods: Age in days 20 30 40 50 60 70 5.6 6.2 8.3 14.9 14.4 17.0 Immature animals survive for a period of time which is only about one-half as long as the survival time of adult animals. Pre-operative care. The pre-operative care is of utmost im- portance in determining the survival period after adrenalec- tomy. Animals obtained from sources in which temperature conditions, food, etc., are not optimal succumb much more quickly than those maintained under good conditions and in a good state of health and nutrition. This is illustrated by the following experiment : A series of six cats were subjected to a room temperature of 10°C. for several days before the removal of the right adrenal. Such animals normally survive unilateral adrenalectomy without manifesting any signs of insufficiency. The cats of this series, however, all showed signs of adrenal insufficiency, and four of them died within ten days following the unilateral adrenalectomy. 198 Anesthetic. The anesthetic used and the duration of the anesthesia have an important bearing on the survival period of animals after adrenalectomy. Some of the long survivals reported by earlier workers are perhaps to be attributed to their avoidance of any anesthetic. That the duration of the period of anesthesia is of great importance is demonstrated by the following experiment: The average survival of five rats receiving ether for five minutes was fourteen days, while in five animals receiving ether for ten minutes the average survival period was only seven days or only half as long as in the first group. 198 In general, the use of ether as an anesthetic results in sur- vival periods which are much shorter than those obtained when certain other anesthetics are used. Thus in dogs, Firor and ADRENALECTOMY 145 Grollman 198 found the survival period to be markedly pro- longed by the use of spinal anesthesia instead of the usual anesthetization with ether. In rats survival is markedly prolonged by the use of intraperitoneally injected barbiturates as compared with the use of ether. One may obtain a measure of the effect of the operative interference (including the action of the anesthetic) in reducing the survival period of an animal in the following manner: By efficacious therapeutic treatment the animal may be restored to normal and allowed to recover from the operative wound and resume its normal growth and activity. If treatment of such an animal now be suddenly stopped, it will be found that sur- vival extends for a longer period than would have been observed had the animal not been treated. We may consider the difference between the observed survival period after cessation of therapy of a series of treated animals and a similar series allowed to die untreated as representing the period of life shortened by the operation. The advantage of performing adrenalectomy in two stages in order to prolong life beyond the period observed in a one- stage operation, was first indicated by Langlois 380 in 1893 and has been confirmed repeatedly by numerous workers. The explanation for this phenomenon is quite obvious from our preceding discussions. The extirpation of the more difficultly removable gland in a preliminary operation and the allowance of a sufficient time (a week or more) for recovery of the animal permits the extirpation of the remaining gland with a minimum of trauma and anesthesia. Dogs which survive adrenalectomy for an average of only 3 or 4 days by the one-stage operation will survive twice as long when the operation is performed in two stages with an interval of a week or more between opera- tions. Completeness of the extirpation. The completeness of the extirpation is obviously important in determining the period of survival. Fragments of the main gland or the microscopic 146 CORTEX nests of accessory cortical tissue which lie in the vicinity of the main glands may hypertrophy to a sufficient degree to permit indefinite survival of the animal in good health after a pre- liminary period of mild insufficiency. In such cases macro- scopic examination will reveal the presence of the hypertrophied glandular material. The occurrence of such hypertrophy has long been recognized. However, it has not been generally recognized that, although such remnants may be undetectable by the usual macroscopic necropsy, they may suffice to prolong life for some time. Microscopic examination of the connective tissue of the space occupied by the adrenals will often reveal in animals that have survived an unusually long time after adrenalectomy the existence of exhausted cortical cells. These cells apparently functioned for a time but eventually, due perhaps to poor vascularization or other factors preventing their multiplication, were unable to maintain the fife of the animal. The existence of such exhausted adrenal tissue must be borne in mind in testing the therapeutic efficacy of any preparation. Failure to examine microscopically the adrenal sites at autopsy may explain some of the claims for the therapeutic value of extracts which later work has shown to be utterly worthless. Mere macroscopic search for accessories as performed by most recent workers in proving the completeness of their adrenal- ectomies is no valid proof of a complete extirpation. Micro- scopic search must also be made for the exhausted nests of cells described above. Post-operative care. The post-operative care of adrenalec- tomized animals is important in determining the length of their survival. They should be maintained at an equable temperature, free of all excitement. Excessive exercise should be avoided. A relished diet high in salts and carbohydrate is desirable. The ingestion of high protein diets reduces the sur- vival period. 31 ' 267 ADRENALECTOMY 147 Season. The survival of adrenalectomized animals is depend- ent upon their state of activity at the time of operation. Hibernating animals survive for extended periods while the same animals during their summer activity survive adrenalec- tomy for a much shorter time. 86 Pregnancy. H. A. Stewart 593 first noted the prolongation of the survival of adrenalectomized pregnant cats as compared to non-gravid females. G. N. Stewart and Rogoff 529 found a mean survival period of 7 days for male and 6^ days for non- pregnant female dogs as compared to 22 days for pregnant animals. Similarly in rats, Firor and the author 198 observed a prolongation of life in pregnant as compared to non-pregnant animals. Other authors 125 have failed to note any prolongation in the survival of pregnant animals. Their results might be explained by the fact that during pregnancy (particularly when advanced) the glands are less easily accessible for operative removal. Since pregnant animals are more susceptible to injury by any operative manhandling, the survival after adrenalectomy may be unaffected or even shortened (as com- pared to non-pregnant animals) unless the operation is carried out with great technical skill and celerity. The prolonged survival of pregnant animals may be ex- plained by assuming that the cortical hormone produced by the embryo is transported through the placenta to the maternal tissues. Estrus. As demonstrated by Rogoff and Stewart, 533 dogs adrenalectomized during or shortly after estrus survive for a much longer period than animals in diestrus. The explanation for this phenomenon probably lies in the fact that the increased body activity during natural estrus stimulates the adrenals to the production of a greater store of the hormone in the body than is normally present. There is no reason to believe, as has been suggested, that the corpus luteum (whose cells resemble superficially those of the adrenal cortex) takes over the func- 148 CORTEX tion of the adrenal. Nor has the author been able to find an appreciable supply of the cortical hormone in the corpora lutea of pigs or cattle which might act as a store for the hormone. Firor and the author were unable to prolong the life of adrenalectomized dogs by inducing in them pre-operatively an artificial estrus by injection of theelin or the gonadotropic substances of pregnancy urine or of the hypophysis. Appar- ently such artificially induced estrus does not duplicate all the physiological changes occurring in natural estrus as is also indicated by other experimental work. Castration. Castration according to some authors prolongs the survival of animals after adrenalectomy. One might an- ticipate that the reduced metabolic activity of the castrated animal would enable it to survive the extirpation of the adrenals for a longer period as compared to the survival of the more active normal animal. On the other hand, the increased adrenal activity of the female in estrus, described in the pre- ceding paragraph, would tend to prolong its survival beyond that of a castrated female. The diversity of results obtained by different authors as to the effect of castration on survival after adrenalectomy may result from the extent to which the factors just outlined have affected their results. Sex. Except for the effects of estrus and pregnancy, no appreciable difference has been demonstrated between the survival periods of male and female animals. In dogs Rogoff and Stewart 628 found a mean survival of 7 days for 34 male dogs as compared to 6| days for 39 non-pregnant females. The observed difference is of no significance in view of the marked variation of the individual results from the mean. Sisson and March 577 report that female rats survive longer than males, but their conclusion is based on the results obtained on only 11 animals. In a series of 100 consecutive operations on immature rats selected at random from the data of Firor and the author the average survival for male animals was 6.0 days as compared to 6.1 days for the females. It is possible that the ADRENALECTOMY 149 survival of rats adrenalectomized during estrus is longer than those operated during diestrus but this has not been proven. ADRENALECTOMY IN VARIOUS ANIMAL SPECIES Fishes. Adrenalectomy in fishes has a particular interest because of the separation of the interrenal and chromaphil tissues as distinct organs. They thus offer a natural separation of the compound organ of the higher animals. Pettit 498 performed the first operations on eels but his extirpations were only partial and were intended to demon- strate hypertrophy in the remaining fragments. Biedl 86 ex- tirpated the interrenal bodies of the torpedo. He observed expansion of the melanophores, a gradually increasing muscular weakness which progressed until the animals could no longer turn, muscular convulsions, opisthotonus, a decrease in the respiratory rate, and death in 3 to 7 days. These experi- ments demonstrated the indispensability for life of the in- terrenal bodies in this species. In the eel, on the other hand, Vincent 647 found that the extirpation of the interrenal bodies did not result in death but Giacomini's 218 demonstration of accessory interrenal tissue in this species explains Vincent's results. Recent observations 353 have confirmed the earlier work of Biedl. The difficulties involved in performing interrenalec- tomy in fishes render the observed results open to the objection that they are to be attributed to operative shock. Main- tenance of the adrenalectomized fish with a supply of the cortical hormone until it has recovered from the operation would remove the basis for this objection. Frog. Adrenalectomy in frogs is difficult to perform due to the close attachment of the adrenals to the kidneys (Figure 1). Complete removal of the glands, which is best accomplished by the thermo-cautery, necessarily involves renal injury. The operation, first performed by Abelous and Langlois 3 in 1891, has been carried out by many subsequent observers. The 150 CORTEX animals do not survive the operation well during the summer, when they die within one to three days, but during the winter months the animals survive for one to three weeks if maintained at a low temperature. 300 This seasonal variation is also ob- served in other cold blooded animals. One might expect that the depressed metabolism of hibernating periods would lead to less rapid deterioration of the organism than during the period of bodily activity. The survival period is markedly shortened if the poikilothermic animal is subjected to an ele- vated external temperature. Adrenalectomy in frogs leads to a train of symptoms similar to those observed in the mammal. The animals in in- sufficiency are easily fatigued. There is incoordination and weakness of the hind legs and paresis involving first the flexor and adductor and finally the extensor muscles. Eventually the fore limbs are also affected. Death is preceded by marked edema, which is to be attributed probably to renal injury since the close apposition of the adrenals to the kidneys renders adrenalectomy without serious renal injury virtually im- possible. Abelous and Langlois 3 noted that the length of survival of their frogs was inversely proportional to the intensity of their metabolism. Exercise, for example, hastened the onset of the final stages of insufficiency. These authors also experi- mented with some success on the prolongation of life by the use of grafts 4 and by the use of saline extracts of adrenal glands. They found the blood of their animals dying of insufficiency to manifest toxicity when injected into normal animals. 6 Adrenalectomy in frogs is best performed through a lumbo- dorsal incision. A fine cautery is used to destroy the glands. Since no capsule separates the adrenal from the kidney one can not avoid injuring the latter organ. Birds. Adrenalectomy in birds was first performed by Gourfein 235 in 1896. He found the operation in pigeons to be fatal within 4 to 24 hours. If one-eighth to one-tenth of one ADRENALECTOMY 151 of the organs was allowed to remain, the birds survived for 15 days. The adrenals in birds are so situated as to make the operative approach exceedingly difficult. Subsequent workers have consequently avoided the use of birds although much of interest might be learned by studying the effects of adrenalec- tomy in this species. Gourfein extirpated the glands through an incision ex- tending obliquely from the caudal tip of the sternum to the ischium. His birds recovered from the operation but soon began to manifest muscular weakness and died usually within a few hours. Rat and mouse. The advantages and ready availability of the rat (Mus norvegicus) as an experimental animal have made it the subject of many studies on the effects of adrenalec- tomy. The older view that the rat differs from other mammals in being able to withstand the effects of adrenalectomy due to the presence of widespread accessory tissue has been thor- oughly disproven in recent years. Jaffe 332 showed that of 90 adrenalectomized rats, 35 per cent died within 30 days of the operation, the majority dying before the 13th day, with the typical symptoms of acute adrenal insufficiency. Forty-six per cent showed chronic insufficiency and died within seven months without the presence of gross accessories being mani- fested at autopsy. In the remaining 19 per cent, which were unaffected by the operation, large accessory cortical bodies were found at autopsy. Pencharz, Olmsted, and Giragos- sintz 491 proceeded further in their analysis and concluded that the rat is no exception to the rule that insufficiency and death invariably follow a complete adrenalectomy. In 62 rats death occurred in from two to eighteen days with no survivals. If only 5 per cent of the gland were left at operation, rapid regeneration occurred and the animal survived. Subsequent workers 198 have confirmed these results and demonstrated that the rat is no exception to the general rule that adrenalectomy is fatal. Survival is due to incomplete extirpation, which 152 CORTEX consists either in allowing cortical remnants of the main glands to be left or in failing to remove the scattered accessory nests of cells present in the peritoneal tissue in the neighborhood of the glands. In every case of indefinite or prolonged survival, microscopic examination has revealed the presence of hyper- trophied cortical tissue in this region. The assumption of the existence of widespread accessory tissue in other parts of the body is entirely unnecessary (cf. Chapter II). The description of the operative procedure for adrenalectomy in the rat shall be deferred to Chapter XVII where it shall be described in connection with the assay of the cortical hormone. Adrenalectomy in the mouse and its consequences do not differ from those observed in the rat and require no special description. 198 The mouse is a useful experimental animal involving studies on the androgenic zone which it possesses (Chapter IV). Rabbit. The rabbit, like the rat, has been the subject of much experimentation and controversy regarding the outcome of adrenalectomy. Until recently it has been the general opinion that a large percentage of rabbits survive the operation due to the widespread occurrence of accessory bodies. This view, however, as in the case of the rat, is erroneous and ex- plicable by the great difficulty of performing a complete ex- tirpation without so much manipulation and hemorrhage as to kill the animal by operative shock. The rabbit's adrenals are very delicate and may be easily torn. Such detached fragments may hypertrophy and explain some of the survivals by "accessory bodies" reported in the literature. 198 The left gland lies about a half of a centimeter above the upper pole and about one centimeter medial to the inner border of the kidney. It lies in a hollow between the psoas and quadratus lumborum muscles, in the angle formed by the vena cava and the large vein which drains the lumbar muscles. The right gland lies two to three centimeters cephalward of the ADRENALECTOMY 153 left in an angle between the vena cava and the right renal vein. It is partially covered by the vena cava. The above description makes it evident why adrenalectomy is so unsatisfactory in the rabbit. Many of the animals die within 24 hours due undoubtedly to the shock of the opera- tion. Many never recover from the anesthetic. In a series of rabbits which recovered from the operation the following survival periods were noted by Firor and Grollman 198 after a one-stage operation under ether: 13 8 2 1 1 2 3 1 1 1 1 1 1 Survival period in days — Less than 1 1 2 3 4 6 7 9 11 IS 65 68 Over 120 Ninety per cent of the animals survived 11 days or less. In these, there were the usual manifestations of adrenal in- sufficiency, — progressive loss of weight, subnormal tempera- ture, anorexia, and a liability to suffer death from apparently minor causes. The act of catching the rabbit would often throw it into convulsions similar to those which follow an overdose of insulin. All the rabbits were autopsied and serial sections made of suspicious residues in the vicinity of the normal site of the adrenal glands. In the rabbits sur- viving 9 days or less no adrenal tissue was demonstrable. In the rabbit surviving 11 days no adrenal tissue was seen at autopsy, but microscopic examination revealed a small piece of typical adrenal cortex. The rabbit surviving 18 days had a small bit of adrenal tissue in the peritoneal fascia. In the rabbits surviving 65 and 68 days a glandular mass the size of a normal adrenal gland was found. These had not been present at the first operation and represented, therefore, an active regeneration of tissue left at operation. In the rabbit surviving 120 days a well formed cylindrical mass of cortical tissue about 3 mm. in diameter and 6 mm. long was found at autopsy in the 154 CORTEX interior of the abdominal vena cava. Whether this was its original site or whether it developed from cellular masses accidentally implanted during resection of the vessel is de- batable. 198 The above described results indicate that the generally accepted view regarding the frequency of the existence of scattered cortical tissue in the rabbit is erroneous. Complete removal is difficult ; but it is unnecessary to assume that tissue capable of supporting life exists along the vena cava and is diffusely scattered throughout the dorsal peritoneal spaces or in the reproductive organs, as claimed by a number of in- vestigators. Guinea pig. The guinea pig is ill-suited for adrenalectomy. It is extremely sensitive to any surgical manipulation and hemorrhage, and hence in the hands of most experimenters death has followed adrenalectomy in this species within a few hours to a day following operation. To add to the difficulty, the right gland is intimately connected to the vena cava. As in the rabbit, one risks a fatal hemorrhage or the possibility of leaving glandular tissue behind, which, in surviving animals, hypertrophies and allows extended survival. The guinea pig like the rabbit should be avoided for experiments involving a complete adrenalectomy. Dog. The dog, because of the many advantages it offers as an experimental animal, has been the subject of numerous studies on the effects of adrenalectomy. It is comparatively easy to perform the operation so as to remove all the gland. Accessory tissues are rarely present or, at least, are removed with the connective tissue surrounding the main glands, for rarely do the animals survive for extended periods as in the case of the rabbit or rat. Adrenalectomy in dogs is best performed by the lumbar approach. The smaller species are more easily adrenalec- tomized than large fat animals in which one has to penetrate ADRENALECTOMY 155 a thick layer of muscle and fat before reaching the glands. As already pointed out, the use of spinal anesthesia leads to a more prolonged survival than the use of ether. The objec- tion to the use of spinal anesthesia is the fact that pain im- pulses are still elicited on manipulation of the splanchnics and their associated ganglia. Some authors have recommended the use of nembutal as an anesthetic. 267 Judging from the experimental data on rats the barbiturates should be preferred to ether in adrenalectomy. Strict aseptic technique is necessary in adrenalectomy on dogs, cats, and other animals susceptible to infection. The increased susceptibility of the adrenalectomized animal to infection renders strict asepsis more imperative in this opera- tion than in other experimental surgical work. The adrenals are extirpated through an incision, 2 to 3 inches long, extending slightly ventrally and distally from the angle of the last rib. The lumbar muscle is retracted and the ventral layer of the dorsal fascia exposed and slit, exposing the retroperitoneal tissue behind the kidney. The large vein which runs outward from the midline over the adrenal is dis- sected free, clamped, and followed to the gland. Since the adrenals are fragile, care must be exercised not to grasp the gland. After the gland has been dissected free, the pedicle is ligated and the adrenal removed. Any point of hemorrhage must be carefully ligatured. The wound is closed in the usual manner. The most complete study of the survival period of adrenalec- tomized dogs is that of Rogoff and Stewart. 528 In a two-stage operation under ether anesthesia, they found that about two- thirds of their 74 animals lived from 4 to 9 days after the second adrenalectomy. About 10 per cent of the animals lived 10 to 12 days while 2 animals survived until the fifteenth day. About one-sixth of the dogs survived less than 5 days. The average survival of all their animals was about 7 days. 156 COKTEX The survival of dogs after a single-stage adrenalectomy under spinal anesthesia is indicated in the following table of Firor and his collaborators: 251 Days following operation 1 2 3 4 5 6 7 8 Number of animals dying on day 4 6 5 4 3 5 2 1 Cat. The ready availability of the cat and the relative ease with which its adrenals can be extirpated have made it a favorite animal for this type of experiment. The classic study of adrenalectomy and its effects in the cat is that of Elliott. 180 He removed the glands of 25 animals in stages with an interval of 3 to 9 months between the two operations and observed a survival which ranged from 6 to 23 days. Elliott avoided the splanchnic nerves in his operation. Cats withstand the effects of adrenalectomy well and their survival period is usually much longer than it is in dogs. The glands are situated in less intimate contact with the large vessels than they are in the dog and hence are more easily removed. Extraperitoneal excision through a lumbar incision as in the dog is to be preferred, for much less trauma is in- flicted by this approach than when the glands are removed through an abdominal incision. Even after extirpation under ether anesthesia and by a one- stage operation, most cats survive 3 to 7 days when the opera- tion is properly performed. The use of a more satisfactory anesthetic and extirpation in two stages should give much longer survivals. The average survival of cats after a two- stage operation was found to be 11 days by Rogoff and Stewart. 634 Swingle and Pfiffner 613 found an average survival of 7.7 days while Britton in the single stage operation reports an average survival of 7.5 days. 86 Other mammals. Adrenalectomy has been performed in a few cases in monkeys. In these animals, the adrenals are ADRENALECTOMY 157 easily accessible through a posterior extra-peritoneal approach and may be readily extirpated. Kahn 345 first performed this operation in a monkey and found that the course of the result- ing insufficiency was similar to that observed in other mammals. Recent investigators have confirmed Kahn's results. 198 The reported development of pigmentation in a monkey maintained on an apparently inadequate dose of the cortical hormone 267 would indicate that this species may be useful in studying this phenomenon which is so striking a symptom in the adrenal insufficiency of man. Moore and Purinton 459 performed adrenalectomy in several goats. Their results indicate an exceptionally long survival in this animal. Since the goat is unusually well adapted for studies of the metabolism, blood chemistry, circulation, etc., it should prove superior to the more common laboratory animals for many experimental studies on adrenal insufficiency. The results of adrenalectomy in the opossum (Didelphys virginiana), the squirrel (Sciurus carolinensis) and the marmot (Arctomys monax) do not differ materially from those ob- served in the cat or dog. 86 THE r6lE OF ACCESSORY BODIES Death may often occur following adrenal insufficiency even in the presence of accessory tissue. Examination of such tissue at autopsy will show interstitial fibrosis, vacuolization, in- filtration of giant cells, and, in general, a picture indicative of "exhaustion atrophy." 335 Apparently under certain conditions the accessory tissue or remnants of the main gland are unable, due to inadequate blood supply, perhaps, to undergo hyper- trophy. Consequently they function for a short while but eventually become exhausted. Such exhausted tissue is often encountered in rats dying of chronic insufficiency several months after adrenalectomy. Accessory tissue in cats or dogs is often incapable of maintaining life after adrenalectomy. How- ever, maintenance of such animals for a week or more on the 158 CORTEX cortical hormone will permit the hypertrophy of these acces- sories or fragments of the main gland left at operation and sub- sequent survival of the animal. Failure to appreciate this fact has undoubtedly led to many of the erroneous claims of successful replacement therapy. Only by careful micro- scopic observation of the tissues at the adrenal sites can one determine the completeness of a given operation. The oft-quoted claims of Wiesel, 676 regarding the occurrence of accessory bodies in the rat in the region of the epididymis, has never been confirmed by subsequent investigators. 198 ' 335 Wiesel claimed to have proven functional capacity of the epididymal accessory bodies by performing left-sided adrenal- ectomy in 10 young male rats which were killed 3 to 12 weeks later. The normally microscopic accessories in the region of the epididymus were found to be hypertrophied to the huge size of 5 mms. As pointed out by Jaffe, 335 it is doubtful if such hypertrophy ever occurs in accessories after unilateral ad- renalectomy because compensation is rapidly effected by en- largement of the remaining gland. Moreover, in several hundred rats of different ages, Jaffe 332 was unable to demon- strate by careful microscopic section any accessories in the region of the testes, vas, or epididymis, in either normal or adrenalectomized rats. Firor and the author have confirmed Jaffe's findings. 198 According to Jaffe gross accessory bodies are found in about 8 per cent of normal rats and in 20 to 25 per cent of doubly adrenalectomized rats, but these are always situated near the main glands. By adopting the technique described in Chapter XVII, one can ensure the extirpation of these accessories together with the main glands. RELATIVE IMPORTANCE OF CORTEX AND MEDULLA That it is the cortex and not the medulla which is indis- pensable for life has been demonstrated by a number of in- vestigators. Biedl, 66 Wheeler and Vincent, 670 and Crowe and ADRENALECTOMY 159 Wislocki 141 excised the left adrenal of cats, rabbits, and dogs, removed half of the right gland, and cauterized the medullary substance in the remaining half of the gland. Subsequent histological examination of the adrenal tissue revealed in some cases complete absence of any medullary tissue. Neverthe- less the animals survived for long periods in good health. Pende 493 and Stewart and Rogoff 587 excised one adrenal and denervated the remaining gland. Although no epinephrine could be detected in the blood draining the remaining gland, the animals remained in good condition indicating that lack of epinephrine was not the cause of the deficiences observed after adrenalectomy. Houssay and Lewis 311 split the left adrenals of dogs, scooped out the medulla, and ten days later excised the right gland. Their animals remained entirely normal. At autopsy, histological examination of the adrenals revealed complete absence of the medullary tissue. The extirpation of the interrenal bodies of the elasmobranch fishes leads, as we have seen, to an insufficiency resembling that which follows adrenalectomy in mammals. The fact that extracts prepared from this purely cortical tissue serves as a replacement therapy in the insufficiency of mammals which follows adrenalectomy is further evidence that it is the absence of the cortex which is responsible for these manifestations. 250 It requires only a small remnant of the adrenal cortex to support life. As was first shown by Langlois, 380 one-sixth to one-eleventh of the total cortex suffices to preserve life. Ac- cording to Biedl, 56 about one-eighth is necessary; according to Wislocki and Crowe, 685 about one-fifth; and according to Bornstein and Gremels, 70 one-fourth. From our previous considerations it is evident that the fraction necessary will depend upon the conditions observed in performing the opera- tion. In fact in rats, as we have seen, even an invisible group of cortical cells may suffice after their hypertrophy to maintain normal life. That it is the cortical tissue and not the medullary which is 160 CORTEX responsible for the fatal outcome which follows adrenalectomy is now generally accepted as an incontrovertible fact. Many lines of evidence might be cited to support this conclusion. The fact that cortical extracts free of epinephrine even when ad- ministered orally maintain adrenalectomized animals in normal physiological condition is the most direct proof that absence of the cortical secretion alone is responsible for all of the manifestations which follow adrenalectomy. The possible im- portance of the medullary secretion has already been discussed in Chapter VI. Chapter IX PATHOLOGICAL PHYSIOLOGY OF ADRENAL INSUF- FICIENCY The normal physiological functions of animals in adrenal in- sufficiency are disturbed in many ways. Some of these path- ological manifestations are the results of the anatomical and blood chemistry changes described in Chapters X and XI while the basis for others is still a matter of uncertainty. In general, the physiological changes observed in experi- mental adrenal insufficiency are rather characteristic but cer- tain minor differences occur depending upon the animal species investigated and upon the rapidity with which the in- sufficiency develops. Many of the phenomena to be described are not observed in animals surviving adrenalectomy for only a brief time. One must avoid confusion with the manifesta- tions due to the surgical shock attendant upon adrenalectomy. The dysfunctions due specifically to absence of the adrenal cortex are best brought out by withdrawing the administration of the cortical hormone from adrenalectomized animals main- tained on adequate doses of the hormone until the original operative wounds have healed. In this way the onset of in- sufficiency is delayed and one has the opportunity of observing the symptomatology and physiological variations occurring in uncomplicated cortical insufficiency. In dogs surviving less than fifty hours, Banting and Gairns 31 observed the following symptoms before the onset of the coma which precedes death: Rapid pulse Loss of appetite Elevated temperature Terminal fall in blood sugar Thirst Anuria Restlessness Vomiting Salivation Diarrhea Weakness Convulsions 161 162 COETEX Some of these symptoms (e.g., the elevated temperature, thirst, and restlessness) are probably due to operative shock and are not observed in animals surviving for longer periods except for the first day following operation. In completely adrenalectomized animals, after recovery from the anesthetic, one notes no obvious abnormal manifestations. The animals are alert, eat and drink, and are apparently in perfect condition. The blood pressure is normal; the constituents of the blood undergo no noteworthy change. Gradually, however, symptoms of insufficiency supervene. The animal becomes apathetic, refuses food, and may vomit. Muscular movements become slow and uncertain. Weakness of the hind legs develops which may cause the animal's gait to become unsteady. Eventually the animal lies prostrate. As insufficiency progresses, the body temperature falls in warm-blooded animals. The skin becomes cold; the mucosae turn pale. Pus may appear in the eyes and the pupils become dilated. Muscular twitches and convulsions may occur. The respiration is first rapid, then slow. There may be anuria. Death occurs in coma, with respiratory paralysis while the heart is still beating. The delay in the appearance of the symptoms of insufficiency following adrenalectomy may be attributed to two factors: 1, A store of the vital cortical hormone may be present in the body and it is only after the exhaustion of this store that dis- ability ensues; 2, The tissues are able to function normally for a time without the hormone. Extraction of various tissues, such as liver, pituitary, corpora lutea, etc. demonstrates the presence of small amounts of a substance capable of maintain- ing life in the adrenalectomized animal. It is likely therefore that a store of the hormone is left in the organism after adrenal- ectomy. The effect of adverse physical conditions, toxins, trauma, etc. in precipitating an adrenalectomized animal into insufficiency indicates, however, that the second of the above listed possibilities is also a factor in explaining the survival of animals in good health for some time after adrenalectomy. PHYSIOLOGY OF CORTICAL INSUFFICIENCY 163 G ASTRO-INTESTINAL DISTURBANCES Anorexia is one of the earliest clinical symptoms of adrenal insufficiency in dogs, cats, rabbits, and man. In the rodents some food may be ingested shortly before death but the food and fluid intake is markedly reduced with the advent of in- sufficiency. Usually at the first sign of disinclination to take food, an animal may be tempted by offering it some delicacy. As the insufficiency progresses there is finally a complete aversion to all food. If the animal survives for some time, it may become very thin due to inanition. The immediate cause of the anorexia of adrenal insufficiency is still undecided. It may be due perhaps to the inflamma- tion, congestion, or ulceration of the gastro-intestinal tract or it may be secondary to the disturbances in the composition of the blood and the accumulation of the nitrogenous waste products of metabolism. Harrop and his co-workers 268 suggest that the anorexia may be due to the absence of free hydrochloric acid from the stomach. Vomiting is a very common symptom in adrenal insufficiency, particularly in dogs. The animal may be unable to retain any food and the introduction of small amounts of fluid through a stomach tube may be followed in a few minutes by its ejection. The vomitus usually contains bile and may be blood stained. Watery or bloody diarrhea is a frequent symptom of adrenal insufficiency, particularly in dogs and rabbits, less commonly in cats or rats. ASTHENIA AND MUSCULAR WEAKNESS As insufficiency develops animals become more and more apathetic. They ultimately refuse to move or take an interest in the surroundings. Animals which preoperatively were ac- tive or ferocious may appear gentle after adrenalectomy due to their disinclination to indulge in any activity. A characteristic gait results from the weakness of the hind legs when the insufficiency has progressed to a moderate degree. 164 CORTEX At first there is a spasticity of the legs. The animal walks un- steadily, lurches from side to side, and may fall. Weakness of the hind legs may progress until they can no longer be moved and the animal drags itself on the floor. It finally lies feebly on its side with limp legs and its head hanging low. The muscular weakness of adrenal insufficiency is not due to lack of intrinsic muscular power, for even in moribund ani- mals the muscles can be stimulated to normal activity. 180 However, after incomplete adrenalectomy in rats, one observes a marked asthenia and diminution in the body activity. 167 The isolated muscles of animals in insufficiency have been shown to be more easily fatigued than those of normal animals. This may possibly be due to an abnormal accumulation of lactic acid in the stimulated muscle of adrenalectomized animals or to their carbohydrate impoverishment. 377 Intravenous injec- tion of epinephrine, by raising the blood pressure in moribund animals, will often cause a disappearance of the extensor rigidity which characterises the late stage of insufficiency. There is thus no interference with the control of the skeletal muscles by the central nervous system in adrenal insufficiency and the observed prostration and muscular weakness are not attributable to a paralysis of the skeletal muscles or their nerves. 180 BODY TEMPERATURE In adrenal insufficiency the body temperature gradually drops 440 reaching values which may be lower than 32°C. at death (Figure 10). During the first hours after adrenalectomy or after a sub-lethal injury to the adrenals there may be an eleva- tion of the body temperature (cf. Chapter XIII). These changes in the body temperature are reflections of correspond- ing alterations in the basal metabolic rate which shall be dis- cussed in greater detail in Chapter XIII. RESPIRATION Hyperpnoea is a common symptom in the early stages of adrenal insufficiency. Some authors 71 have attributed to this PHYSIOLOGY OF CORTICAL INSUFFICIENCY 165 hyperpnoea a particular importance in producing the manifes- tations of insufficiency. However, this view is not tenable for it is only in animals dying soon after adrenalectomy that one observes any unusual hyperpnoea. Thus in one of Bornstein and Holm's 71 experiments the basal respiratory minute volume of a dog rose from 2.53 liters per minute to 7.19 liters, with a drop in the C0 2 tension of the alveolar air from 4.27 per cent y 5 "Hi •*« ■X40 USO I §3? // 40 30/030 - Si/s6o//c J!/ood 'Pressure / 1 J - ReJJS/ooi£££^J j>„h?_Rate ^^^$^ - OjTJ/Oe/9 CortSUMD^r, - — ■ — ^^"^^^S^t^ 1 1 I 1 1 Days sifter /jafrenateciomj/ 80 SO 60 -I ^ 7 \k Fig. 10. Changes in Various Physiological Functions in Adrenal Insufficiency Composite records of results obtained on dogs adrenalectomized in stages. The animals received no therapy during the period of observation and died seven days following the removal of the second gland. to 1.18 per cent; the body temperature fell from 38.2° to 35.7°; the oxygen consumption fell from 109.6 cc. to 82.5 cc; and death occurred 7f hours after the operation. The changes observed in this case must be attributed in great part to opera- tive shock. In animals which have survived for some time and then gone into insufficiency, the respiration is usually slow and not easily 166 CORTEX stimulated by factors such as an increase in room temperature or an injection of epinephrine. The respiratory rate in dogs may drop to 5 or 6 per minute. Respiratory paralysis is the immediate cause of death, for the heart continues to beat after the cessation of respiration. CIRCULATION The circulatory system manifests no signs of dysfunction in the early stages of adrenal insufficiency. The blood pressure remains normal and there is no sign of cardiac decompensation. When the first clinical signs of insufficiency are evident, the pulse rate becomes rapid and may be irregular. Later, when the clinical symptoms of insufficiency become pronounced, the pulse rate becomes slowed and often assumes an idioventricular regular rhythm or an irregular rhythm with the manifestations of some degree of heart block. Electrocardiographic studies by Nicholson and Soffer 471 demonstrated the existence in adrenalectomized dogs of a slow auricular fibrillation. This would be expected to lead first to a partial heart block and eventually to a complete block with the assumption by the ventricle of its idiopathic rhythm. This disturbance in cardiac function may be due to the eleva- tion of the potassium content of the blood and the disturb- ance in the normal potassium-calcium ionic ratio. Such a disturbance would explain also the earlier observations of Loewi and Gettwert 401 on the hearts of frogs dying of adrenal insufficiency. The blood pressure does not fall appreciably until a short time before death. The cardiac output, on the other hand, according to Harrop et alii, 268 diminishes progressively after the initiation of the first symptoms of insufficiency. This drop in cardiac output may be looked upon as a reflection of the decreased metabolic activity of the organism and not neces- sarily indicative of cardiac insufficiency. 243 Two chief factors are probably responsible for the circula- PHYSIOLOGY OF CORTICAL INSUFFICIENCY 167 tory disturbances in adrenal insufficiency. The abnormal com- position of the blood will affect the nutrition and rhythmicity of the heart and thus lead to its inefficiency, while the decrease in the blood volume will vitiate the hemodynamic relationships which make possible normal circulatory activity. The latter factor is undoubtedly of greatest importance and is probably responsible for the ultimate drop in blood pressure. THE BLOOD Changes in the blood are an important and frequent observa- tion in animals in adrenal insufficiency. There is a loss of fluid from the blood stream which results in a concentration of the formed elements so that the relative volume of the red blood corpuscles as determined by the hematocrite may rise considerably. That this represents an actual loss of fluid from the blood stream and not merely its transferral from plasma to corpuscles is shown by the concomitant increase in the number of red blood corpuscles, which is approximately propor- tional to the observed increase in their volume as determined by the hematocrite and by the increase in the total solids of the plasma (Figure 10). The differential leucocyte count in adrenal insufficiency is also altered from the normal. 126 Thus in cats, Zwemer and Lyons 703 found a decrease in the relative number of polymor- phonuclear neutrophiles with a corresponding increase in the number of small mononuclear lymphocytes, similar to that ob- served clinically in chronic wasting diseases. The above de- scribed blood picture many be obscured by shock or infection. Several investigators have attempted to measure the de- crease in blood volume during adrenal insufficiency. Unfor- tunately the dye methods utilized for this purpose give entirely unreliable results, as might be anticipated from a simple con- sideration of the basis for the application of these methods. In normal animals one allows a given length of time (empirically determined) to elapse before drawing the blood sample in 168 CORTEX which the concentration of the injected dye is determined. If the period of time is too long, the dye will be lost from the circulation; if too short, it will not mix properly with the blood. In adrenal insufficiency, the circulation is slowed and hence one is not justified in using the same period of time as one does in normal animals. We must therefore disregard the extant data on the blood volume in adrenal insufficiency and rely on the other findings which indicate a decrease in this function. ALTERED SENSITIVITY Animals in adrenal insufficiency are hypersensitive to many extraneous influences. This abnormal sensitivity to toxins and infections will be considered in detail in Chapter XVII. Insufficiency also renders animals hypersensitive to such in- fluences as heat or cold, muscular exercise, emotional dis- turbances, and the like. Adrenalectomized animals are unable to maintain their body temperature when cooled. Thus de Marval 442 found that on subjecting rats to an external temperature of 10°C. their rectal temperature dropped 5.9° as compared to 2.5° for normal ani- mals. The metabolic rise, which normally follows subjection to cold, does not occur in adrenal insufficiency. 219 One can markedly reduce the survival period of adrenalec- tomized animals by subjecting them to extremes of tempera- tures. Animals which normally survive for a week can be thrown into an, acute and fatal insufficiency by subjecting them for a few hours to temperatures which the normal ani- mal can endure with impunity. 279 Adrenalectomized animals are unable to withstand severe muscular exercise and are easily precipitated into insufficiency by exertion. A brief period of struggling may bring on the final stages of insufficiency. The adrenal cortical hormone is essential for the normal activities of the organism and hence an excessive manifesta- PHYSIOLOGY OF CORTICAL INSUFFICIENCY 169 tion of these activities probably depletes the residual supply of hormone still present in the body of the adrenalectomized animal. The fact that animals survive for sometime after adrenalectomy indicates either that their life is maintained during this period by the supply of hormone left in the tissues at operation, or that these tissues can carry on their activities for some time without the hormone. In either case, excessive activity of any kind will either deplete the store of available hormone or hasten the ultimate collapse of the organism. We should expect therefore that all influences tending to stimulate the activity of the organism should hasten the onset and ag- gravate the insufficiency of the adrenalectomized animal. Although hypersensitive to many extraneous and toxic agen- cies, animals in adrenal insufficiency react sluggishly or not at all to many stimulants. In the moribund cat, as Elliott 177 showed, there is an apparent paralysis of the vaso-motor and cardio-accelerator nerves. Other nerves react in an ap- proximately normal manner. Thus nicotine has no pressor action in cats dying of cortical insufficiency even after pre- liminary atropinization. 180 This apparent paralysis of the vaso-motor nerves is actually due to a change in the non- striated muscle for pituitary extract and barium chloride have little or no effect on the blood pressure. Epinephrine, how- ever, still causes pressor and cardio-accelerator effects. The vaso-motor nerves thus appear to be paralysed because the muscle cannot respond to their excitatory impulses. Hence stimulation of the splanchnics or injection of nicotine cause little rise in blood pressure. As Elliott pointed out, the paraly- sis of the vaso-motor nerves is not due to shock for in moderate shock there is little paralysis. It is not surprising that the physiological response of animals in adrenal insufficiency should be less pronounced than it is in normal animals. In insufficiency we are dealing with an ani- mal, the vital processes of whose organs and tissues are at a 170 CORTEX low ebb. Severe infectious processes, malnutrition, avitamino- sis, and similar debilitating agencies also render an animal less reactive to many forms of stimulation. REPRODUCTIVE SYSTEM The reproductive function of animals in adrenal insufficiency is in abeyance. 439 - 689 Although manifesting normal sexual ac- tivity soon after adrenalectomy, this ceases when the symp- toms of insufficiency are manifest. Male animals become im- potent and females remain in a state of permanent diestrus. These changes have been studied in detail in rats but similar changes occur in the larger mammals. This dysfunction of the reproductive system shall be described in greater detail in Chapter XIV. LIVER AND KIDNEY Aside from the pathological manifestations described in the preceding sections, functional tests will reveal dysfunction of other visceral organs. Thus the liver is probably affected judging from the abnormalities in the carbohydrate metabolism described in Chapter XII. Whipple and Christman 269 found the excretory power of the liver for the excretion of phthalein dyes to be reduced by the removal of three-fourths or more of the adrenal tissue. The kidney 549 likewise manifests an inability to excrete in- jected urea or creatinine 438 and, as we shall see in Chapter XI, the changes in the inorganic constituents of the blood in adre- nal insufficiency are most likely due to renal dysfunction. It must be emphasized that all the physiological dysfunc- tions described in the preceding sections do not manifest them- selves immediately following adrenalectomy. For some time the animal may be entirely normal. It is only when the supply of cortical hormone present in the body has been exhausted that insufficiency sets in with its attendant manifestations. PHYSIOLOGY OF CORTICAL INSUFFICIENCY 171 It may rightfully be argued that many of these manifestations are merely terminal events which are encountered before death from many causes. Thus a pre-mortem drop in blood pressure is commonly seen in many conditions. The same may be true of some of the other symptoms which develop late in insuf- ficiency and which may be secondary to the primary disturb- ance caused by removal of the vital hormone of the adrenal cortex. Until we know definitely how the hormone acts in the body it is impossible to form a clear concept of the sequence of events which in their totality give the picture of adrenal in- sufficiency. This picture will vary in individual cases depend- ing upon the particular organs most affected in any given ani- mal. Thus, whereas the immediate cause of death in a given dog may be due to circulatory failure attributable to a dimin- ished blood volume, hypoglycemia due to hepatic injury may be the chief factor terminating life in a given rat. In both cases other deficiencies contribute to the final fatality. Chapter X ANATOMICAL PATHOLOGY OF ADRENAL CORTICAL INSUFFICIENCY Considering the marked and diverse symptoms manifested during life in adrenal cortical insufficiency, one is surprised at autopsy to find relatively little in the nature of gross pathologi- cal changes. A radical dysfunction of an organ may appar- ently be undetected anatomically, particularly when the dis- ability is acute in its onset. In acute adrenal insufficiency, too short a time elapses for the development of gross changes which are evident by the methods of anatomical pathology. Pigmentation of the skin which is a striking (although not an essential) symptom of adrenal insufficiency in man, has not been reproduced with certainty in the experimental animals. Some of the earlier investigators (Brown-Sequard, 97 Noth- nagel, 474 Tizzoni, 628 and others) described the deposition of pigment in the skin or blood of animals the adrenals of which had been injured, but subsequent workers have failed to sub- stantiate these claims. Harrop and Weinstein 267 have recently reported some slight pigmentation in an adrenalectomized monkey maintained for some weeks with the cortical hormone. To attain conditions comparable to those obtaining in Ad- dison's disease it is necessary to maintain animals in a state of chronic insufficiency for a long period of time and subject their shaved skin to the sunlight. Thus far such attempts have been futile (c/. Chapter XXI). It is possible that man (and possibly the ape) is unique in that some property of his epidermis permits the deposition of pigment. The blood in animals dead of adrenal insufficiency is often thick and dark due to loss of fluid from the blood stream and incomplete oxygenation during the last moments of life. The 172 PATHOLOGY OF CORTICAL INSUFFICIENCY 173 hemoconcentration, as we shall see in Chapter XI, is probably due to loss of fluid through the kidneys due to tubular injury which prevents reabsorption of water and threshold substances. The tissues also appear to be dehydrated showing that there has also been a loss of fluid from the tissue spaces. Obviously the loss of fluid from the circulation can not have been due to damage of the capillary endothelia with a consequent inability to retain fluid, as has been claimed; for if such were the case one would observe an edematous swelling rather than dehy- dration of the tissues in adrenal insufficiency. In animals which have been maintained for sometime in a state of cortical insufficiency, one notes at autopsy an almost complete disappearance of the body fat. The anorexia seen in insufficiency leads to starvation with the depletion of the reserve stores of fat and carbohydrate of the body. GASTRO-LNTESTINAL TRACT The outstanding pathological finding at autopsy of animals dying of acute adrenal insufficiency is a marked hyperaemia of the visceral organs — stomach, intestines, liver, spleen, kid- ney, pancreas, thymus, and hypophysis. Frequently, hemor- rhages into the gastro-intestinal canal are prominent and ulceration may be visible. There may be submucosal ecchymo- ses in the intestinal tract. The gum margins are often con- gested and bluish and ulcers may be found under the tongue. 31 Lesions of the gastric mucosa are found in a large percentage of rats, mice, cats, and dogs dying of adrenal insufficiency. There may be an injection of the mucosa, widespread super- ficial erosions, or true punched-out ulcers. 197 The ulcers de- velop at the site of local hemorrhages in the gastric mucosa and penetrate to the muscular coat of the stomach with complete destruction of the mucosa. The ulcers as observed in the dog 423 are round or oval, 2 to 20 mms. in diameter, and are usually multiple although at times a single ulcer may be en- countered. They are cone-shaped with the base at the sur- 174 CORTEX face. The gastric lesions develop, as Mann 423 showed, in the absence of pancreatic secretion and bile and hence are not due to regurgitation of these fluids. Although at times the entire gastro-intestinal may be con- gested, the chief sites of congestion are the stomach, duodenum, and rectum. Hemorrhages from the inflamed rectal mucosa give rise to the bloody diarrhea observed in insufficiency, par- ticularly in the dog. At autopsy one often finds bile in the stomach. The intes- tines are sometimes filled with a brownish watery fluid which may contain blood. 528 LIVER Banting and Gairns 31 found much degeneration in the liver cords of dogs dying of adrenal insufficiency. This degenera- tion varied in degree from slight changes to actual necrosis of the cells. There was also great vascular congestion and hemor- rhage which was more marked in areas about the central vein with pressure changes in the liver cords and fatty degeneration. This degeneration had proceeded in the longer surviving ani- mals to a point where little normal tissue remained. The above described changes in the liver would explain the results of the liver function tests observed in adrenal insuffi- ciency and account in part perhaps for the observed abnormali- ties in carbohydrate metabolism (Chapter XII). KIDNEY Although many authors have failed to note any obvious pathology of the kidneys in animals dying of acute adrenal in- sufficiency, some have described definite changes — particu- larly an increased lipid content of the renal cortex. Such an increase in the lipoidal content of the cortex of the kidney with congestion of the pyramids was found by Hartman and his collaborators. 280 There was a high-grade, general hyperemia involving chiefly the cortex with swelling and vacuolization of the epithelium of the tubuli cortorti. In frozen sections stained PATHOLOGY OF CORTICAL INSUFFICIENCY 175 with Sudan III large quantities of lipoidal substances were found. These lipids were in the form of droplets in the tubu- lar epithelium and corresponded to the vacuoles which were observed in paraffin sections. Banting and Gairns 31 also de- scribed hyperemia of the kidney, swelling of the tubules, and albuminous casts containing blood cells in the lumina of the tubules in dogs which had died of adrenal insufficiency.* LYMPHATIC SYSTEM Hypertrophic changes in the lymphatic system associated with loss of adrenal cortical function due to disease or experi- mental ablation have been frequently observed. 335 These changes in the lymphatic tissues were first noted in Addison's disease. During life one may observe enlargement of the lymphatic nodules at the base of the tongue and of the tonsils and other palpable lymphatic tissues. At autopsy there is marked enlargement of Peyer's patches and isolated follicles in the gastro-intestinal tract and mesentery. Star 585 first noted the persistence of the thymus in patients dying of Ad- dison's disease. The spleen often shows a moderate enlarge- ment with hyperplasia of the follicles. Indeed, the general lymphatic enlargement sometimes seen in Addison's patients resembles that of the so-called "status lymphaticus." 335 Animals dying of chronic adrenal insufficiency also show a striking hypertrophy and regeneration of the thymus and lymphatic tissues generally. The changes in the thymus of the rat after adrenalectomy have been studied in detail by Jaffe. 331 In young animals adrenalectomy stimulates the growth of the thymus while in mature animals active regener- ation of the thymic tissue occurs. At autopsy, huge thymic glands are encountered. In larger mammals the short period of survival which follows adrenalectomy does not allow time for any regeneration of the thymus. In cats and dogs main- tained for long periods on minimal doses of the cortical hor- mone, this hypertrophy is, however, very prominent. The lymph nodes of animals in adrenal insufficiency are also * Cf. also Jour. Path, and Bact. vol. 40, p. 483. 176 CORTEX markedly enlarged. The immediate cause of this hyperplasia, like that of the thymus, is unknown. Banting and Gairns 31 described an enlargement of the lymph nodes in dogs accom- panied by a proliferation of plasma cells, endothelial leucocytes, enlarged macrocytes, and a great increase in the reticular tissue, with obliteration of the germinal centers. McMahon and Zwemer, 420 on the other hand, describe the change in cats as consisting of an enlargement of the germinal centers which are filled with young lymphocytes and lymphoblasts showing ac- tive mitosis. As to the significance of the status lymphaticus observed in adrenal insufficiency several possible explanations may be pre- sented. Kahn 343 suggested that it is a compensatory mechanism to counteract a primary injury to the myelo-erythroblastic system. Marine and Jaffe 335 suggested that the hyperplasia of the thymus is a response to hyperthyroidism induced by adrenal insufficiency. It is true that in hyperthyroidism (as well as in hypothyroidism) one observes hyperplasia of the lymphatic tissues. However, as shall be shown in Chapter XIII, adrenalectomized animals maintained on an inadequate dose of cortical hormone show no signs of hyperthyroidism. In fact, they manifest the symptoms of a depressed thyroid function. It is consequently difficult to accept the hypothesis that the hyperplasia of the thymus is a response to hyperthy- roidism induced by adrenal insufficiency. It would be more logical to ascribe the observed hyperplasia to the thyroid in- sufficiency which is secondary to chronic cortical insufficiency (Chapter XIII). However, until our knowledge of the exact function of the thymus and other lymphatic tissues is eluci- dated, it is futile to speculate concerning the significance of their hyperplasia in adrenal insufficiency. PANCREAS Congestion of the pancreas is one of the commonest findings at autopsy of animals dead of adrenal cortical insufficiency. PATHOLOGY OF CORTICAL INSUFFICIENCY 177 It is practically always found in dogs and rats. Its signifi- cance, however, has not been determined. It is questionable if the observed changes are of the nature of a true pancreatitis to which one might attribute some of the symptoms of adrenal insufficiency. Rogoff and Stewart 528 describe the pancreatic changes as consisting of dilatation of the small vessels in the islets with marked congestion of the veins in the trabeculae. CIRCULATORY SYSTEM The heart shows no abnormality in most cases. In frogs dying of adrenal insufficiency Loewi and Gettwert 401 found the heart markedly dilated. In cats, Moore and Purinton 459 ob- served the heart to be filled with clots formed during life. The increased coagulability of the blood in adrenal insufficiency may account for their occurrence, although in dogs or cats dead of insufficiency one often observes that the blood does not clot when shed. 31 The blood vessels also manifest no obvious pathological changes. During life they are so markedly collapsed in the agonal stages of insufficiency that it is difficult to draw blood from them. This collapse is probably secondary to a combina- tion of effects due to loss of blood volume, the weakened cardiac action, the hypotension, and possibly the stagnation of blood in the congested visceral organs. CENTRAL NERVOUS SYSTEM Although earlier observers described vacuolization of nerve cells particularly in the medulla oblongata and cerebral cortex, their animals died several hours after adrenalectomy and hence their observations can not be ascribed to uncomplicated adrenal insufficiency. There has been no recent work on the nervous system in insufficiency, and further studies in this field are in- dicated. It is questionable if the mental symptoms observed in adrenal insufficiency in animals or in man (Chapter XXI) are due to anatomical changes in the cerebrum or whether these 178 CORTEX symptoms result from functional changes induced by the de- ranged blood chemistry which accompanies cortical insuf- ficiency. The changes found in the endocrine organs of animals dead of adrenal insufficiency shall be considered in Chapter XIV. Despite the relative paucity of detailed studies of the ana- tomical changes occurring in adrenal insufficiency, it is evident that a number of tissues and organs manifest definite injury. The manifold nature of the symptomatology of adrenal insuf- ficiency is indicative of a widespread involvement of many organs. The available experimental data is still too meager, however, to permit one to define accurately the relation of the various clinical symptoms to the different organs responsible for them and further work along these lines is indicated. It is desirable, however, in making such studies to maintain the experimental animals on an adequate dose of the cortical hor- mone after adrenalectomy until all effects of the operation have disappeared. In this way one avoids the effects of trauma and anesthesia and allows the animal to survive for a longer period during which the changes due to insufficiency can develop. Chapter XI THE BLOOD CHEMISTRY IN ADRENAL CORTICAL INSUFFICIENCY The composition of the blood is characteristically altered in adrenal cortical insufficiency as experimentally produced in animals or as it occurs in Addison's disease. The chief altera- tions occur in the water, sodium, potassium, magnesium, glucose, chloride, non-protein nitrogen, and cholesterol con- tent. There is thus a profound upset in the normal com- position of the blood which will be reflected in the tissues and will produce marked physiological effects in the organism. A consideration of the changes in the glucose concentration of the blood will be deferred to the next chapter. CHOLESTEROL The normally high cholesterol content of the adrenals and the fact that changes in the cholesterol content of the adrenals are often associated with corresponding changes in the blood led earlier observers to consider the adrenals as regulators of the cholesterol metabolism. Feeding cholesterol results in an enlargement of the adrenals with an increase in their cholesterol content. Adrenalectomy, as Grigaut, Rothschild, Chauffard, and Landau 376 first demonstrated, is followed by an increase in the cholesterol content of the blood. Abnormal conditions not involving the adrenals primarily are however, also, at- tended by changes in the level of the blood cholesterol. For example, in infections, uremia, hypothyroidism, and cachexia, the blood cholesterol is reduced while in biliary obstruction, diabetes, nephrosis, and hyperthyroidism it is elevated. The disturbances in cholesterol metabolism which occur in adrenal insufficiency are not caused by the absence of the 179 180 CORTEX adrenal tissue per se, for by treatment of an adrenalectomized animal with an adequate supply of the cortical hormone, the blood cholesterol may be maintained at its normal level. The most probable explanation of the observed hypercholesteremia observed in adrenal insufficiency is that it is a result of hepatic dysfunction induced by the absence of the adrenal cortical hormone. This hypercholesteremia is usually not manifested until after other changes due to cortical insufficiency (such as the increased non-protein nitrogen and the changes in the inorganic constituents of the blood) have already occurred. As we shall see later, the earliest changes evident in the blood chemistry in insufficiency are probably due to renal dysfunc- tion. The hypercholesteremia and hypoglycemia, both of which are of later occurrence, are attributable, in the author's opinion, to liver injury. The liver normally secretes choles- terol and its esters into the bile and any interference with its normal activity would tend to result in an elevation of the cholesterol content of the blood. The claim, first made by Stewart 593 and by Landau, 376 that the injection of cholesterol prolongs the life of adrenalecto- mized animals, is based on too inadequate data to merit its acceptance. In rats, Firor and the author were unable to demonstrate a prolongation of life after the injection or oral administration of either cholesterol or lecithin. NON-PROTEIN NITROGEN Marshall and Davis 438 demonstrated the rise in the non- protein-nitrogen (particularly the urea) concentration of the blood which follows adrenalectomy in cats. After the injec- tion of urea or creatinine, much less of these substances was excreted than in normal animals. These authors also observed a diminution in the excretion of phenolsulphonephthalein and concluded that normal kidney function is dependent upon the integrity of the adrenals or upon the product of their se- cretion. Subsequent writers have amply confirmed these results. 264, 404, 630, 693, 704 BLOOD CHEMISTRY 181 The rise in the non-protein-nitrogen of the blood is one of the earliest manifestations of adrenal insufficiency and is evi- dent before many of the other characteristics of adrenal in- sufficiency such as weakness, anorexia, etc. become prominent. The non-protein-nitrogen content of the blood may reach 73 30 70 Daj/s FolloH//np Adrenalectomy Fig. 11. Changes in the Blood Chemistry in Adrenal Insufficiency Composite records of results obtained on dogs adrenalectomized in stages. The animals received no therapy during the period of observation and died seven days following the removal of the second gland. With the exception of the pH, the values are expressed in terms of milligrams per 100 cc. values as high as five to six times the normal (c/. Figure 11) but often animals die of typical insufficiency with a non-protein nitrogen which is only twice the normal. Death can not be due to the accumulation of this catabolite for experimentally one can produce much higher values than occur in adrenal in- sufficiency (e.g., by ligature of the ureters) without fatal result. 182 CORTEX The accumulation of the waste products of metabolism must, however, exert deleterious effects which add to the other defi- ciences of the organism. The increased non-protein-nitrogen observed in adrenal cor- tical insufficiency consists for the most part of urea, the chief end-product of protein catabolism. Other non-protein-nitro- gen constituents such as creatinine and uric acid are also in- creased, the former attaining values several times those ob- served in normal animals. WATER The water content of the blood and tissues is characteristi- cally altered in adrenal insufficiency. During the early stages of insufficiency a diuresis may occur. This loss of water from the body together with that normally lost through the lungs and skin is not replaced by the ingestion of additional quanti- ties of water. In fact, the animal in adrenal insufficiency manifests no thirst despite the abnormal loss of fluid from its body. Similarly, patients suffering from Addison's disease will not manifest a degree of thirst consonant with the state of dehydration of their tissues. The existence of an actual negative water balance in adrenal insufficiency has been experimentally demonstrated 265 • 398 in dogs by the excess volume of the water present in the excreta over the total water intake. The actual loss of water from the body is greater than is indicated in these studies which do not take into account the appreciable loss of water through the lungs. There can be no doubt, therefore, that adrenal insufficiency is accompanied by a loss of water from the body and that there is no attempt to replace this loss by an increased ingestion of fluids. Gradinescu 236 in 1913 showed that the concentration of the blood in adrenalectomized animals was accompanied by no change in the electrical conductivity, the freezing point, the viscosity, or the refractive index. He, therefore, concluded BLOOD CHEMISTRY 183 that the hemoconcentration was due to loss of fluid through the capillary endothelium. This view which has recently been revived by Swingle and his collaborators 614 is entirely un- tenable, for such endothelial leakage would necessarily result in an obvious anasarca and edema of the tissues. The reverse of these conditions is actually found. The tissues of animals dying of insufficiency manifest a dehydration but never an abnormal hydration as was claimed by Gradinescu. In adrenalectomized cats, Baumann and Kurland 44 found the plasma to constitute 57 per cent of the total blood volume as compared to 65 per cent in normal animals. This decrease in the plasma volume was attended by an increase of 8 to 10 per cent in the plasma solids. Similar changes have been found in dogs 268 and other experimental animals. There is thus a decrease in the relative water content of the blood plasma which may be brought about in one of three ways: by a loss of an excessive amount of water through the kidneys, by a shift of the water from the plasma into the blood corpuscles and tissue cells, or by an increase in the content of solids of the blood. From the obvious dehydration and negative water balance which occur in adrenal insufficiency, it may be concluded that the observed hemoconcentration is a result pri- marily of the loss of water from the body. The state of dehy- dration of the tissues speaks against the view that any con- siderable amount of water could have been lost from the blood to the tissues. Nor is there any reason for supposing that the observed anhydremia is only relative and the result of an increase in the absolute solid content of the blood. That there is an actual loss of fluid from the circulation and not merely a transfer from the plasma to the red corpuscles is in- dicated by the increase in the number of red corpuscles which roughly parallels the hematocrite readings. Thus in an experi- ment of Harrop et alii, 2 ™ in which the plasma volume decreased from 72 to 57.5 per cent, the red blood corpuscles increased from 4.2 to 6.1 millions per cu. nun. There is, however, no in- 184 CORTEX creased concentration of the erythrocytes in the peripheral blood as contrasted with the venous blood such as occurs in surgical or traumatic shock in which the loss of fluid presum- ably occurs by leakage through the capillary endothelium. Before attempting to explain the changes in the water metab- olism observed during adrenal insufficiency, it is necessary to consider the changes in the concentration of the osmotically active constituents (sodium, potassium, chloride, etc.) which accompany the changes occurring in the water metabolism. SODIUM The inorganic constituents of the blood undergo marked changes in their concentration during adrenal insufficiency. These changes are most pronounced in the case of sodium, chloride, and potassium, as shown in Figure 11, in which are reproduced typical curves of the blood chemistry changes oc- curring in the dog following adrenalectomy. The sodium con- tent of the blood plasma is usually decreased about 15 per cent below its normal level in experimental cortical insuf- ficiency while the chloride content is diminished to a some- what lesser extent. The drop in the sodium and chloride contents of the blood in adrenal insufficiency is due to a loss of these substances in the urine. During the early stages of adrenal insufficiency, as Loeb, 398 Harrop, 265 and their coworkers have shown, there is a negative balance of sodium and chloride due to an excre- tion of these substances in the urine in an amount which ex- ceeds their intake by the organism. As shown in Chapter XI, anatomical evidence indicates injury of the renal tubules in adrenal insufficiency, and one can adequately explain all the observed changes in the blood chemistry which occur in adrenal insufficiency on the basis of this tubular injury. According to our present theories of renal function, the blood plasma is filtered through the glo- meruli to give a protein-free ultrafiltrate in which the filterable BLOOD CHEMISTRY 185 constituents of the blood are present in the same concentra- tion as they are in the plasma. From this protein-free ultra- filtrate, the renal tubules reabsorb water and the so-called threshold bodies including sodium and chloride, and return these constituents to the blood stream. On the other hand, the non-threshold substances, such as urea, are not reabsorbed but appear in the urine in relatively concentrated solution due to the reabsorption of water and other threshold substances. Injury to the tubules might therefore be expected to result in an increased excretion of water, sodium, and chloride due to the inability of the kidney to reabsorb these substances. The injury to the tubules may also result in the back diffusion of non-threshold substances, such as urea, from the tubular lumina to the blood and thus result in a faulty excretion of the non-protein-nitrogen catabolites and their accumulation in the body. As we have seen, these changes in the sodium, chloride, and non-protein-nitrogen constituents of the blood are pre- cisely those which occur in adrenal insufficiency. POTASSIUM AND OTHER CATIONS Simultaneously with the decrease in the sodium and chloride contents of the blood plasma, one observes in adrenal insuffi- ciency an increase in the concentration of potassium and mag- nesium. Baumann and Kurland 44 found an increase of 42 and 23 per cent of these ions, respectively, above their normal values in adrenalectomized cats. Hastings and Compere 285 observed potassium values as high as 20 millimoles per liter, compared to 3 for normal animals. Changes in the blood calcium are not noteworthy and rather irregular in their occurrence. 625 The large amounts of potassium which appear in the blood in adrenal insufficiency may originate either from the ingested food or from the tissues. Normally the potassium ingested in the food is excreted in the urine. In adrenal insufficiency where the loss of sodium and chloride through the kidney 186 CORTEX threatens to disturb the normal osmotic pressure of the organ- ism, one might expect the ingested potassium to be retained to compensate for the loss of other electrolytes. Should the amount of potassium ingested not suffice, this ion might also diffuse from the muscles and other tissues into the blood in order to maintain an osmotic balance. Whether or not the loss of potassium from the muscles is responsible for the muscu- lar asthenia and weakness observed in adrenal insufficiency is problematical. It is also possible, of course, that a loss of the normal impermeability of the muscle cells results in the diffu- sion of potassium into the blood. The evidence available, at present, which purports to show that the permeability of the muscles is abnormal in adrenal insufficiency is, however, not valid. The fact that the potassium content of the blood rises during the late stages of insufficiency when little or no food is being ingested would indicate that it, in part, originates from the tissues. In any case, it is plausible to assume that the same tubular injury which makes it impossible for the kidney to re- absorb sodium and chloride efficiently also fails to prevent the diffusion of potassium from the tubules back into the blood. The presence of an abnormal concentration of potassium in the blood will, as we have seen, help to maintain the normal osmotic pressure of the blood. The ratio of the sodium to the potassium content of the blood plasma drops to about half of its normal value in adrenal insufficiency. Similarly the ratio of potassium to calcium is increased about one-third. The maintenance of a proper ratio between the above-mentioned electrolytes is of fundamental importance to the organism for any disturbance in these ratios alters appreciably the physicochemical properties of proto- plasmic systems. The alteration of these ratios in adrenal insufficiency is probably secondary to the loss of sodium and chloride through the kidney and a consequence of the main- tenance of an approximately normal osmotic pressure. The resulting disturbed ratios will undoubtedly act deleteriously BLOOD CHEMISTRY 187 on many organs and may be responsible for their dysfunction in adrenal insufficiency. For example, the cardiac arrhythmias often observed in terminal stages of adrenal insufficiency may be attributed to the high potassium content of the blood and the low potassium-calcium ratio. ANIONS Of the blood anions, the concentration of chloride is most markedly affected as might be anticipated from the changes occurring in the sodium concentration already described. However, the loss of blood chloride is not quantitatively so great as that of the sodium loss (cf. Figure 11). The relative preponderance of the loss of sodium over that of the chloride results in a decrease in the bicarbonate concentration of the blood and a disturbance in the normal acid-base equilibrium. The inorganic phosphate and sulphate are also increased but this increase is usually not prominent except in the later stages of insufficiency. The kidney normally maintains the hydrogen ion concen- tration of the blood at a constant value. When its function is disturbed in adrenal insufficiency, this control is inadequate and we find a marked disturbance of the acid-base equilibrium of the blood. This disturbance is marked by a fall in the pH of the blood (cf. Figure 11) accompanied by a decrease in the bicarbonate content and carbon-dioxide combining power of the blood. There is thus an acidosis in adrenal insufficiency which is probably responsible in part for the hyperpnoea observed in the late stages of insufficiency. THE MECHANISM OF THE OBSERVED CHANGES IN THE BLOOD CHEMISTRY The osmotic pressure of the blood and tissues of mammals is maintained with a high degree of constancy thus affording the organism a "milieu interieure" of constant colligative com- position. The osmotic pressure readily adjusts itself, by rapid 188 COETEX shift of salt and water, to any change threatening its deviation from the normal. To speak of an abeyance of the osmotic forces, as assumed by some authors in discussing adrenal in- sufficiency, is obviously as absurd as it would be to speak of an abeyance of the law of gravity in explaining some terrestial phenomenon. Gradinescu 236 first demonstrated that the osmotic pressure of the blood was normal in adrenal insufficiency. Howard and the author have also found that blood removed from dogs dying from adrenal insufficiency has a normal freezing point thus indicating that despite the profound changes occurring in the composition of the blood, this physico-chemical property remains constant. Stewart and Rogoff 588 found a decrease in the conductivity of the blood and serum which would indicate an absolute decrease in the total ionic concentrations. This decrease in the concentration of the ionic constituents of the blood is com- pensated for by the elevated non-protein-nitrogen of the blood in maintaining the osmotic pressure at its normal value. We can picture the chain of events which bring about the changes in the composition of the blood and tissues in adrenal insufficiency as consisting essentially of the following events: Renal injury causes in the early stages of insufficiency an abnormal loss of sodium chloride, water, and certain other threshold substances. This loss reduces the blood volume which imperils the efficiency of the circulation. To overcome this loss of blood volume, there is a passage of water from the tissues into the blood stream, accompanied by a passage of salts, to maintain a constant osmotic pressure. The changes in the inorganic constituents of the blood plasma observed in adrenal insufficiency are reflected in corresponding changes in the whole blood so that there is a shift of these elec- trolytes between plasma and corpuscles to maintain the normal equilibria existing across the corpuscular membrane. Attempts have recently been made to simulate the loss of BLOOD CHEMISTRY 189 sodium in adrenal insufficiency by injecting isotonic glucose into the peritoneal cavity and later withdrawing the fluid after ionic equilibration has occurred. In this way one obtains a marked fall in the concentration of the serum sodium and a slight drop in the osmotic pressure of the serum. A shift of water into the blood cells depletes the extracellular fluid. This procedure, as utilized by Gilman, 221 does not reproduce exactly the conditions obtaining in adrenal insufficiency for it does not involve a loss of fluid from the circulation. The rapidity with which the depletion of sodium occurs is not com- parable to the more slowly progressive changes occurring in adrenalectomized animals. In the latter, the accumulation of non-protein nitrogen constituents in the blood will counteract the development of any drop in osmotic pressure such as follows the intraperitoneal injection of glucose. Gilman demonstrated an analogy between the sensitivity of his animals to hemorrhage with that observed in adrenal insufficiency. His conclusion that a shift of water into the cells occurs in adrenal insufficiency as it does in his procedure does not, how- ever, follow. In adrenal insufficiency the loss of fluid through the kidneys with a consequently diminished blood volume accounts for the sensitivity to hemorrhage, without necessitat- ing the assumption of a passage of water into the cells and tissues such as occurs after the intraperitoneal injection of glucose. Harrop, 266 Loeb, 398 and their coworkers have reported studies on the water, sodium and chloride balances in animals during cortical insufficiency as well as during periods of recovery fol- lowing the injection of the cortical hormone. They have demonstrated that the loss of sodium and chloride through the urine in excess of the amounts ingested is greater than can be accounted for by the loss of these constituents from the plasma. Part of the excreted sodium and chloride must be derived, therefore, from the tissues. The injection of cortical extract into animals in adrenal in- 190 CORTEX sufficiency results in a period of diuresis in which the accumu- lated nitrogenous and other catabolites are excreted. This diuresis differs, however, from the initial diuresis which ushers in cortical insufficiency by a diminished excretion of sodium. The restored kidney is now able to excrete the waste products of the blood while retaining the essential constituents. As the kidney resumes its normal activity, the excessive concentra- tions of potassium and magnesium in the blood are excreted or restored to the tissues; the water, sodium, and chloride of the blood are replenished from ingested food and fluid; and the normal distribution of the various inorganic constituents in the body is restored. The argument has been advanced that the loss of sodium chloride in adrenal insufficiency can not be attributed to damaged renal function because the loss of this substance is notably greater than the loss of water. This view ignores our modern concept of the role of filtration and reabsorption in the elaboration of urine. The assumption of an interference with reabsorption as outlined above not only explains the facts but is in accord with modern views of renal function. The view that the adrenal cortical hormone in some way controls "os- motic pressure" is too fantastic to require comment. The assumption that the hormone controls the electrolyte level of the blood by some mysterious hormonal regulation is equally unnecessary if we accept the view (for which there exists both anatomical and physiological evidence) that the renal tubules are injured and are unable to perform their normal reabsorp- tive and secretory functions. The view that the accumulation of non-protein nitrogen is secondary to the fall in blood pressure is contrary to the avail- able facts. The blood pressure is still normal at a time when the non-protein-nitrogen blood level is markedly elevated. The increased non-protein-nitrogen of the blood must be looked upon either as a further consequence of the renal injury or as a mechanism to maintain a normal osmotic pressure of BLOOD CHEMISTRY 191 the blood. In the elasmobranch fishes, urea serves this func- tion of maintaining the osmotic pressure at the level of the sea-water. An injury to the tubules which would prevent reabsorption of sodium chloride might also be expected to allow the diffusion back into the blood stream of the non-pro- tein-nitrogen from the glomerular filtrate. The osmotic pressure of the blood would be a factor in determining the extent of this reabsorption and thus incidentally serve to main- tain the osmotic pressure of the blood at its normal level. THE ROLE OF THE ELECTROLYTE DISTURBANCE IN THE CAUSATION OF THE SYMPTOMS OF ADRENAL INSUFFICIENCY The question arises as to what part the disturbance in the electrolyte balance plays in causing the symptoms and ultimate death in adrenal insufficiency. Other pathological conditions are also attended by a loss of inorganic base from the body; e.g., diabetic acidosis, severe diarrhea, high intestinal obstruc- tion, cholera, etc. These conditions are accompanied by pro- found weakness, prostration, anorexia, nausea, vomiting, a fall in blood pressure, retention of non-protein nitrogen, acido- sis, and anuria — conditions which resemble those of the "shock" observed in the terminal stages of cortical insufficiency. In some instances, particularly as observed in man, the acute onset of the symptoms of adrenal insufficiency are attributable to the disturbed electrolyte balance of the organism, for the administration of sodium chloride will bring about in these cases a striking relief and recovery from imminent death. 399 However, adrenal insufficiency can not be considered as the result solely of a disordered metabolism of the body electro- lytes. Animals can not be kept alive indefinitely by the ad- ministration of salts in amounts which maintain an approxi- mately normal blood composition. Such animals die of the typical symptoms of insufficiency even when the sodium, chloride, and other blood constituents are sufficiently close to normal to preclude the possibility that death is due to a de- 192 CORTEX ficiency of these ions. According to Britton and Silvette, 91 adrenal insufficiency in the opossum {Didelphys virginiana) and marmot (Arctomys monax) is accompanied by blood serum sodium and chloride levels which are greater than normal. Apparently, in these animals, the renal injury is not a pre- dominant factor in producing the effects of adrenal insuffi- ciency. If one assumes that the adrenal cortical hormone is essential for the normal function of several organs, or perhaps even for all of the tissues, one would expect different species or different animals of the same species to manifest symptoms which are attributable to different deficiencies. Thus, whereas a given dog may die of an acute disturbance of the electro- lyte and water balance due to renal injury, a marmot might die of carbohydrate deficiency due to hepatic injury. Remedying either of these deficiencies may temporarily postpone death, but ultimately some more fundamental disturbance, the nature of which we are still ignorant, will result in death from adrenal cortical insufficiency. THE ELECTROLYTE DISTURBANCE IN MAN In Addison's disease one also finds the same disturbances in blood chemistry as are observed in the experimental animals. Hypoglycemia may reach convulsive levels in moribund pa- tients. Rowntree 538 observed an increase in the blood urea in patients which was in proportion to the degree of adrenal insufficiency. MarafLon and Collazo 428 in seven patients dying of Addison's disease found the water content of muscle (obtained by biopsy) to be 75 per cent as compared to 80 per cent in normal individ- uals. The water content of the blood of 24 patients with this disease averaged 76.8 per cent compared to 82 per cent for normal individuals. The potassium content of the blood serum was 31.1 mgms. per cent as compared to 20 for the normal. On the other hand the sodium and chloride concen- trations were not markedly deranged. BLOOD CHEMISTRY 193 Other observers have, however, demonstrated marked abnor- malities of the sodium and chloride concentrations of the blood of patients in adrenal insufficiency. Thus Loeb 399 found the sodium content of two patients to be 108 and 109 millimoles per liter as compared to 138 for normal individuals. The serum potassium in these patients was 8.7 and 8.1 millimoles per liter compared to 4.8 for the normal. The chloride was reduced from its normal value of 105 to 70 and 73 millimoles, respectively. These observations led Loeb to suggest the use of sodium chloride in the treatment of Addison's disease, with dramatic improvement in some cases. SALT THERAPY IN ADRENAL INSUFFICIENCY The derangement of the salt metabolism in adrenal insuffi- ciency will obviously exert a deleterious effect on the organism and any method tending to restore the normal balance will have a beneficent effect in mitigating such symptoms as are attributable to this deficiency. The fact that injection of saline or of Ringer's solution is capable of extending the life of adrenalectomized animals was first demonstrated by Soddu 580 and independently proven by Marine and Baumann, 435 Stewart and Rogoff, 531 and many recent observers. In figure 16 is shown the beneficent effects of administering 1.0 gram of sodium chloride plus 0.5 gram of sodium bicar- bonate daily (mixed in their regular food) to six adrenalecto- mized rats. Such adjuvant therapy, as seen in figure 16, results in a material prolongation of life, but it does not permit normal growth in young animals nor does it avert ultimate death from adrenal insufficiency. The claim 541 that adminis- tration of salts or Ringer's solution, admixed with the food or in lieu of the animals' supply of drinking water, permits the indefinite survival of adrenalectomized rats has not been con- firmed by the author nor by other observers. The apparent indefinite survival and normal growth of animals on a replace- ment therapy consisting solely of inorganic salts must be 194 CORTEX attributed to incomplete adrenalectomy. Animals which would normally succumb to the effects of an adrenalectomy may in the presence of microscopic nests of interrenal tissue manifest no signs of adrenal insufficiency when supplied with adequate doses of inorganic salts. The withdrawal of the salt may even throw the animals into adrenal insufficiency and lead to death. However, in these cases, some adrenal cortical tissue is present and it is only by microscopic section of the adrenal sites that this tissue is demonstrable. It is preposter- ous to claim that gross post-mortem examination revealed no accessory cortical tissue, for in the rat, at least, the small nests necessary for maintaining life in the presence of salts are not detectable by the naked eye among the connective tissue which abounds at the site of the adrenals. The deficiencies in the organism brought about by a loss of sodium chloride from the body are pronounced in their effects, but are readily remedied by the administration of an excess of salt. This fact has led investigators to misinterpret certain of their observations, and conclude that the adminis- tration of salts to an adrenalectomized animal 266 - 541 or to pa- tients suffering from Addison's disease 351 offers a complete replacement therapy. This view is entirely misleading. Al- though useful in mitigating the symptoms due to loss of elec- trolyte from the body, the administration of salts does not serve as a replacement therapy for the cortical hormone. Neither adrenalectomized animals nor man can be maintained on such therapy beyond a reasonable period of time. Another current misconception is based on the view that the administration of both an excess of salt and of the cortical hormone is necessary to supply a complete replacement therapy in adrenal insufficiency. Adrenalectomized animals or pa- tients with Addison's disease maintained on inadequate doses of the cortical hormone will react much more favorably when an excess of salt is simultaneously administered with the hormone, than when they receive an insufficient amount of BLOOD CHEMISTRY 195 the hormone alone. However, with an adequate dose of the hormone, the addition of this extra salt is unnecessary, and one can relieve all the symptoms of adrenal insufficiency by the use of the cortical hormone alone plus the normal salt requirement of the individual. It is quite conceivable that in certain cases the loss of elec- trolyte has proceeded so far that a resumption of the normal salt balance is impossible without an adequate exogenous source of electrolyte. In any case, the administration of salt will aid in mitigating the serious symptoms due to electrolyte loss, and thus aid in the recovery of the organism. Conse- quently, the use of salt in adrenal insufficiency is to be highly recommended in all acute cases and in chronic conditions where the cost of the adrenal cortical hormone makes it nec- essary to economize on its use. The beneficent effects of salt therapy as well as its limita- tions are well illustrated by experiments on adrenalectomized month-old rats. If one maintains such animals on the cortical hormone for about a week and then replaces the hormone with 0.2 gram sodium chloride plus 0.1 gram sodium bicarbonate per rat per day, one finds that the animals will grow and ap- pear normal for a period of a week or ten days. Their subse- quent reactions to salt therapy will depend upon the complete- ness of the adrenalectomy. If completely adrenalectomized, growth ceases on the salt therapy and death of the animal follows in the course of about a week. If rests of cortical tissue are present, due to an incomplete operation (cf. Chapter XVI), the animals will continue to live when maintained on the adjuvant salt treatment. If these rests hypertrophy, the salt therapy may be discontinued and the animal which would have died had it remained untreated with salt or hormone following operation, now survives and grows normally on its regular diet. If the cortical rests fail to hypertrophy, the animal may be maintained alive for several weeks, but it will grow at a subnormal rate, and eventually die of adrenal in- 196 CORTEX sufficiency. Salt therapy in the experiments just cited pre- vents the impoverishment of the body of its vitally important electrolyte, and aids in overcoming adrenal insufficiency, but the salt does not replace the cortical hormone nor does it prevent the fatal outcome of the adrenalectomy unless suffi- cient cortical tissue remains to furnish, after its hypertrophy, an adequate supply of the vital hormone. Results, similar to those described in the preceding para- graph are obtained in experiments on adult dogs or other experimental animals. Failure to appreciate the effects of administering large amounts of salt on the survival of adrenal- ectomized animals, has undoubtedly led to many of the falla- cious conclusions regarding the alleged potency of various cortical extracts reported by earlier workers. On the other hand, failure to appreciate the effect of the presence of micro- scopic nests of cortical tissue on the survival of adrenalec- tomized animals has led to the false conclusion that salt is able to serve as a complete replacement therapy for the cortical hormone. Chapter XII THE RELATION OF THE ADRENALS TO CARBO- HYDRATE METABOLISM Considerable confusion exists in the earlier literature con- cerning the role of the adrenals in carbohydrate metabolism. Following Blum's 64 demonstration that epinephrine injections elicit glycosuria, numerous workers attributed importance to epinephrine secretion as a regulator of glucose metabolism. Aside from numerous technical sources of error and misinter- pretation of observed findings, confusion resulted from a failure to dissociate the hypoglycemic effects of adrenal cortical in- sufficiency from the hyperglycemic effects of epinephrine. In the normal organism the glucose content of the blood is maintained at a relatively constant level. The utilization of glucose by the muscles and tissues is accompanied by glyco- genosis (the breakdown of glycogen) in the liver and muscles which process furnishes a supply of glucose to replace that consumed in metabolic processes. The mechanism of this carbohydrate control involves a number of physiological reac- tions. Stimulation of the splanchnic nerves or the injection of epinephrine, as we have seen (Chapter VII), cause a libera- tion of glucose from the liver. Stimulation of the brain stem in the region of the pons (the piqure of Claude Bernard) causes a reflex stimulation of glycogenolysis which is mediated through the splanchnic nerves but fails to occur (if these nerves are cut or the adrenals are removed) only when the glycogen store of the liver is reduced. If large stores of glycogen are present in the liver, adrenalectomy or severance of the splanchnics does not prevent the appearance of hyperglycemia. Moreover, atropine, which paralyzes the parasympathetic nerves, pre- vents the development of hyperglycemia following pontine 197 198 CORTEX decerebration. Hence the adrenals are not the only organs involved in the changes in carbohydrate metabolism which follow the operations described above. The parasympathetic nerves by influencing the secretion of insulin from the pancreas also play a part. The liver is also affected directly for if the hepatic nerves are cut, stimulation of the splanchnics produces a lesser degree of hyperglycemia than normally. In considering the relation of the adrenal glands to carbo- hydrate metabolism, it is necessary to dissociate the effects due to epinephrine and those due to the cortical hormone. As we have seen in Chapter VII, epinephrine exerts a striking hyperglycemic activity. The hyperglycemia which follows the injection of many drugs and accompanies various physio- logical procedures is due to the liberation of epinephrine from the medulla. Hyperglycemia can be elicited, however, in the absence of the adrenals, as Stewart and Rogoff 588 and others have shown, so that epinephrine is not the sole agency re- sponsible for a rise in the blood sugar. For example, Sund- berg 606 has shown that operative interference, pain, etc. give rise to an hyperglycemia in adrenalectomized animals, but the hyperglycemic response is less marked than it is in animals with intact glands. In the adrenalectomized animal, not only is there an absence of the medullary secretion, but, unless the cortical hormone is administered, the results are complicated by the partial corti- cal insufficiency which may be simultaneously produced. The variation in the degree of this cortical insufficiency accounts for. the divergence in the results obtained by different authors on the reaction of the blood sugar to stimuli after excision of the adrenals. EFFECTS OF CORTICAL INSUFFICIENCY Bierry and Malloizel 58 in 1908 first demonstrated the exist- ence of hypoglycemia in dogs after adrenalectomy. This result was confirmed by Porges 611 who also showed that the hypogly- CARBOHYDRATE METABOLISM 199 cemia was accompanied by a reduction of the glycogen content of the liver, the glycogen content of the gastrocnemius muscle remaining normal. Porges also demonstrated the occurrence of hypoglycemia in some patients suffering from Addison's disease. Schwartz 559 showed that after adrenalectomy the glycogen of the liver of rats might vanish. Other authors have repeatedly confirmed the above results which indicate a tend- ency to hypoglycemia and a reduction in the glycogen store of the liver and muscles in animals in adrenal cortical insuffi- ciency. The results of Stewart and Rogoff, 588 who found nor- mal values in adrenalectomized rabbits, are obviously due to the absence of any cortical insufficiency in their animals. The completeness of the operation and the time allowed to elapse before making the observations will determine the result obtained. As hypertrophy of accessory bodies and unextir- pated remnants of the main gland proceeds, the degree of cortical insufficiency diminishes and the signs of an abnormal carbohydrate metabolism disappear. There always remains, however, any abnormal sensitivity which may be due to absence of the medullary tissue. The hypoglycemia of adrenal insufficiency is in no way the result of failure of the medullary secretion but is entirely the result of absence of the hormone elaborated by the cortex. This is shown by the experiments of Houssay and Lewis 311 who extirpated the medulla from dogs leaving the cortical tissue intact. In such animals in which no medullary tissue was demonstrable, the blood sugar was normal. B0ggild 65 has also demonstrated that it is the cortex which is responsible for the hypoglycemia which follows adrenalectomy. In depancrea- tized animals the blood sugar level was not affected by removal of the medulla in severe diabetes, but a slight reduction fol- lowed in mild cases. Nor as Leloir 386 has shown does unilateral adrenalectomy with denervation of the remaining adrenal, modify the intensity of pancreatic diabetes. This operation does not affect the blood sugar level of normal animals. Extir- 200 CORTEX pation of one adrenal and denervation or removal of the medulla of the remaining gland might be expected to cause a temporary slight degree of cortical insufficiency. Hence the demonstration of hypoglycemia soon after such operations is no evidence that the medullary deficiency is responsible for the observed effects. It is only after sufficient time has elapsed for the normal secretion of the cortical hormone to adjust itself by hypertrophy of the remaining cortex that one is justified in interpreting the observed effects as due to medul- lary deficiency. Under these conditions it has been repeatedly demonstrated that no abnormalities of the carbohydrate con- tent of the blood, liver or muscles occur under normal condi- tions. We can, therefore, conclude that the hypoglycemia and reduced glycogen content of the tissues observed in adrenalec- tomized animals is due to cortical insufficiency. In Addison's disease the hypoglycemia which occurs in some cases is like- wise attributable to the cortical insufficiency. There is some evidence that the mobilization of glycogen from glucose is interfered with in the absence of an adequate supply of the cortical hormone. Thus in dogs, 48 hours after adrenalectomy, injected glucose disappears slowly; and muscu- lar glycogen is not increased unless one injects the adrenal cortical hormone or insulin. 386 Although the muscle glycogen may be normal a day or two following adrenalectomy in the dog, it rapidly disappears after muscular fatigue and its re- synthesis proceeds very slowly. Normally the muscle glyco- gen is rapidly restored after its diminution by severe exercise. After adrenalectomy, however, this restoration is greatly de- layed. Intravenous injection of glucose does not appreciably hasten the resynthesis of glycogen, while the administration of the cortical hormone results in a rapid restoration of the normal glycogen content. 160 The cortical hormone is thus essential either for the normal synthesis of glycogen by the muscle or for maintaining the normal balance between the blood sugar and the glycogen of the various tissues. 3S6 CARBOHYDRATE METABOLISM 201 ROLE OF THE MEDULLA Although the adrenal cortex is responsible for the hypogly- cemia which accompanies adrenal insufficiency, the medulla may play a part in counteracting the hypoglycemic reaction which follows the injection of certain drugs, as for example, insulin. Thus cats in which the adrenal medullae are excised or in which the right gland is removed while the left is denervated are said to be hypersensitive to insulin. 88 This hypersensitivity is not due to deficiency of the hepatic store of glycogen which may be normal. Since insulin (c/. Chapter VII) stimulates the secretion of epinephrine, one might antici- pate a more pronounced hyperglycemia to follow the injection of insulin in animals in which the medulla has been inactivated. This stimulation of epinephrine secretion by insulin was dem- onstrated in the anastomosis experiments of Houssay, Lewis, and Molinelli. 312 In rats and in rabbits, on the other hand, in which an incomplete adrenalectomy has been performed, the increased sensitivity to insulin which follows the excision of the glands disappears with time according to some authors. 588 It is possible that in these animals the discharge of epinephrine which follows insulin injection is of minor importance (as com- pared to the cat or dog) in compensating for the hypoglycemic action of insulin. Sundberg, 606 however, observed a greater sensitivity in rabbits in which cortical tissue only was present and in which there was no evidence of cortical insufficiency. Takats and Cathbert 619 have also found that denervation of the adrenals raises the sugar tolerance of normal dogs, in- creases their responsiveness to insulin, and decreases their responsiveness to the hyperglycemic action of epinephrine. The theory, that the hyperglycemia following epinephrine injections is caused by an inhibition of insulin secretion from the pancreatic islet cells, is refuted by the occurrence of this hyperglycemia in depancreatized animals. The hypoglycemia which follows the primary hyperglycemia induced by epineph- rine has been attributed to stimulation of the vagus which causes an increased secretion of insulin. 202 CORTEX Insulin and epinephrine are antagonists. The mobilization of sugar induced by epinephrine is counteracted by the stimula- tion of sugar utilization and the inhibition of glycogenolysis in the liver which insulin induces. However, this antagonism between epinephrine and insulin is limited to their effects on carbohydrate metabolism. Epinephrine is capable of causing glycogenolysis after insulin poisoning and hence may be used as an antidote to overdosage of insulin, when the liver store of glycogen is not depleted. That hyperglycemia, induced by insulin injections and probably also by other methods, causes an increased epinephrine secretion, is shown by the depletion of the epinephrine stores of the adrenals after insulin poisoning and by the reaction of the denervated heart and iris of the cat. These reactions are absent in adrenalectomized animals and may be prevented by injections of glucose. The injection of large doses of insulin causes a depletion of the liver glycogen and a considerable diminution of the muscle glycogen. After removal of the adrenals, however, there is little effect on the muscle glycogen. 151 Since epinephrine also depletes the liver of its glycogen and diminishes the glyco- gen content of the muscles, the latter effect when following in- sulin injections has been attributed to epinephrine. In hypophysectomized rabbits, insulin hypoglycemia still liberates epinephrine into the blood stream, but this epineph- rine fails to restore the blood sugar to the normal level in spite of the presence of ample reserves of liver glycogen. There is also a diminution in the hyperglycemic response to injected epinephrine. 124 The question of whether or not emotional hyperglycemia is due to increased epinephrine secretion should be settled by noting the blood sugar changes occurring in adrenalectomized animals, maintained on adequate quantities of cortical hor- mone following emotional disturbances. CARBOHYDRATE METABOLISM 203 EFFECTS OF THE CORTICAL HORMONE The claim of earlier workers that the adrenal cortical hor- mone causes a rise in the blood sugar of normal animals has not been confirmed by subsequent workers. 267 Hypergly- cemia is caused by a number of substances and the presence of impurities in the extracts accounts most likely for the earlier results. Silvette's 569 claims of an in vitro effect of the cortical hormone on the blood sugar are not borne out by an examina- tion of the probable errors of his observations as calculated from his data. There is ample evidence accumulated by numerous authors since 1908 that adrenal cortical insufficiency is accompanied by abnormalities in the carbohydrate metabolism. The claim, however, that this breakdown in normal carbohydrate metab- olism constitutes "the first critical contingency in adrenal insufficiency" or is the pre-eminently "potent" factor in adrenal insufficiency, as claimed by Britton and his co-work- ers, 89 is untenable. Many animals (dogs in particular) may show marked symptoms of adrenal insufficiency without an appreciable hypoglycemia or reduction in the glycogen stores of the body below their normal fasting levels. It is very true that in a few cases (both in experimental animals and in man) hyperglycemia is a predominant symp- tom of adrenal insufficiency. 17 - 473 In animals, particularly those which have been subjected to a chronic insufficiency of several months duration, the convulsions characteristic of hypoglycemia may develop and are relieved by an injection of glucose. In the vast majority of cases, however, this is not the case and injection of glucose does not cause any striking alleviation of the symptoms of insufficiency. As Banting and Gairns, 31 Stewart and Rogoff, 588 and others have shown, the hypoglycemia of dogs may be only a terminal finding and hence not to be seriously considered as involved in the primary manifestations of adrenal insufficiency. Moreover, the blood sugar of dogs dying of adrenal insufficiency may often be 204 CORTEX normal or even slightly above normal. It is thus unjustifiable to lay too much stress on the relation of the adrenal cortex to carbohydrate metabolism. We must consider the observed changes in the carbohydrate metabolism as only one of the many abnormalities associated with cortical insufficiency. The exact mechanism responsible for the changes in the carbohydrate metabolism observed in adrenal insufficiency are still unknown. Part of the deficiency may be due to the star- vation which results from the anorexia of adrenal insufficiency. The chief factor is most probably the inability of the liver and muscles to function properly without an adequate supply of the cortical hormone. The synthesis of glycogen in the liver and muscles may be deficient in the absence of this vital hor- mone. The exact role which other glands — the pancreas, pitui- tary, etc. — play is also unknown. Pancreatectomy does not pre- vent the usual fatal outcome or mitigate the symptoms of cortical insufficiency. 402 Further work is indicated before we can authoritatively discuss the exact nature of the relationship between the adrenal cortex and carbohydrate metabolism. Chapter XIII THE ADRENALS AND THE RESPIRATORY METABOLISM The basal metabolic rate of an organism, measured usually by the rate of oxygen consumption in the fasting, resting con- dition, is constant and predictable from a knowledge of the animal's size. This metabolism representing as it does the intensity of the metabolic processes is easily altered by any factor which modifies the activity of one or more organs. The thyroid gland is preeminently important in regulating the metabolic rate, but other organs, including the adrenals, may also alter the metabolism either through their effects on the thyroid or on the anterior lobe of the hypophysis (which in turn affects the thyroid) or by their direct effects on the metab- olic processes of the tissues. The exclusion from the animal economy of a hormone necessary for the normal activities of a tissue or organ will result in a change in the respiratory metab- olism. The observation of such a change does not imply, however, that the hormone in question controls the metab- olism in the same sense as one is justified in speaking of the control of the metabolism by the thyroid. Epinephrine, as we have already seen (Chapter VII), in- creases the metabolic rate by direct action on the tissues. It is very doubtful, however, if the medullary secretion normally controls or affects to any great extent the metabolic rate, al- though, to be sure, some effect will secondarily result from any stimulus which affects the secretion of epinephrine. Ad- renalectomized animals maintained on adequate doses of cortical hormone, or rats, in which the medullary tissue has been removed leaving only cortical tissue, have a normal metabolic rate. These experiments indicate the dispensability 205 206 CORTEX of the medullary tissue for the maintenance of the normal metabolic processes as reflected in the oxygen consumption. The adrenal cortical hormone, on the other hand, is either itself necessary for the maintenance of the normal oxidative processes in the tissues, or at least its absence makes impossible the normal utilization of oxygen by the tissues. This depend- ence of the metabolism on the adrenal cortical hormone has been repeatedly demonstrated by the fall in the basal metabolic rate which follows adrenalectomy. This fall in the metabolic rate is proportional to, and is the primary cause of the fall in body temperature which accompanies adrenal insufficiency. 268 The observed diminution in the oxygen consumption and body temperature are directly proportional to the degree of adrenal insufficiency. 23 ' 568 Extremely low values may be obtained in the terminal stages of insufficiency (cf. Figure 10). A severe but non-fatal injury to the adrenals, on the other hand, causes a significant and prolonged increase in the metab- olism. This has been demonstrated by Marine and Bau- mann 434 in rabbits and confirmed by Scott 561 in cats. This temporary increase in basal metabolism is also reflected in an increased body temperature and has been observed by the author many times in rats, cats, and dogs immediately follow- ing double adrenalectomy. Marine and Baumann found that the rise in the metabolic rate after adrenalectomy is followed by a fall to or below the normal. This occurred whether the rabbits died of adrenal insufficiency or lived indefinitely due to the presence of acces- sory or hypertrophied remnants of tissue left at operation. The average maximum rise of metabolism following the opera- tion was 23 per cent of the basal value. The rise in metabolism just described is produced by thyroid activity for it is absent if a preliminary thyroidectomy has been performed, and is reflected in a thyroid hyperplasia noted after partial adrenal destruction in the cat or rabbit. This hyperplasia and hyperfunction of the thyroid are probably METABOLISM 207 secondary effects of trauma to the nerve plexuses near the adrenal, for adrenal insufficiency tends to cause hypo- rather than hyper-plasia of the thyroid. The rats in Tsuji's 641 experi- ments, in which he found thyroid hyperplasia after adrenalec- tomy, died within a few days following operation. The short period of survival of his animals indicates the degree of trau- matization to which they must have been subjected and render his conclusions regaring an adrenal-thyroid relationship of no significance. Marine and Baumann were 434 impressed by the similarity in the clinical course of acute adrenal insufficiency and the unusual form of Graves' disease which runs a rapidly fatal course with severe asthenia, prostration, and coma. They also considered the increased appetite, sleekness of the fur, rapid healing of the operative wound, and the diarrhea which fol- lowed sublethal injury to the adrenals to be suggestive of hyperthyroidism. These experiments led Marine 433 to suggest that the adrenals were involved in the etiology of exophthalmic goitre, a view which shall be discussed in Chapter XIV. A satisfactory explanation of the rise in metabolic activity following sub-lethal injury to the adrenals has not been pre- sented. This rise is also frequently seen for some hours follow- ing a complete bilateral adrenalectomy and hence might be attributed to a moderate degree of adrenal insufficiency as suggested by Marine and Baumann. However, this explana- tion is improbable if we consider the fact that slight or moderate degrees of insufficiency induced by methods other than those involving direct physical injury to the adrenals and its con- tiguous structures do not cause a rise in the metabolic rate. Such an insufficiency when produced, for example, by with- drawing from an adrenalectomized animal the adequate supply of the cortical hormone upon which it had previously been maintained does not cause any temporary hyperpyrexia. It would seem, therefore, most logical to attribute the rise in metabolism observed after sub-lethal injuries of the adrenal 208 CORTEX to an effect other than the temporary reduction in the secretion of the cortical hormone. Were the increased metabolism attributable to cortical insufficiency, one would expect it to occur some time after adrenalectomy as one of the first symp- toms of failure of the hormone. The adrenals are supplied with such a rich network of nerves that injury to these struc- tures may perhaps reflexly cause the observed increase in metabolic rate. Webster and his collaborators 663 found that the injection of the adrenal cortical hormone into adrenalectomized cats re- stored the respiratory metabolism to its normal value in from 24 to 48 hours. This restoration was also obtained in thy- roidectomized animals. The injection of the adrenal cortical hormone did not affect the oxygen consumption of normal cats or rabbits but did cause an increase in metabolism in thyroid- ectomized cats in most animals. Webster et alii concluded that the adrenal cortical hormone can exert an influence on the mechanism controlling the respiratory metabolism and that this effect can occur independently of the thyroid gland. As regards the diminished respiratory metabolism in adrenal insufficiency, it is unnecessary to assume that this implies any direct control by the cortical hormone. So many of the organs and tissues of the body in adrenal insufficiency are manifesting a dysfunction that a decrease in their oxygen consumption would be anticipated. Until further evidence to the contrary is available, it suffices to attribute the reduced oxygen con- sumption and heat production to the general morbid state of the animal in adrenal insufficiency. It is unnecessary to assume any more fundamental control of the metabolism by the adrenal cortex. As stated in Chapter VII the requirements of the organism for the cortical hormone are determined by the general metab- olism. This does not, however, indicate any direct control of the metabolic rate by the hormone, for with increased activity one might expect the tissues to require a proportionately larger amount of any hormone vital to their normal function. Chapter XIV THE RELATION OF THE ADRENALS TO THE OTHER ENDOCRINE ORGANS The various endocrine organs are intimately related to one another and mutually interdependent for their normal ac- tivities. Ablation of one endocrine gland will usually be re- flected by obvious alterations in the structure and functional activity of the others. The alterations in activity of one gland will affect the general activity of many parts of the organism and these changes in turn will be reflected in the activities of the endocrine organs. It is, therefore, erroneous to suppose, as many endocrinologists do, that changes occurring in any endo- crine gland as a result of a modification in the activity of another gland indicate that the latter "controls" or produces a "hormone" which activates the former. Such loose reasoning is responsible for the prolific multiplication of "hormones" which are in many cases only hypothetical entities invented to cover ignorance of the nature of some change occurring in the body. The adrenal has often been pictured as controlling many other glands and being responsible for their dysfunctions or suffering from their "miscontrol." It cannot be denied that the other endocrine glands reflect disturbances in adrenal activity and vice versa, and we shall, in the present chapter, describe these changes and attempt to evaluate their signifi- cance. HYPOPHYSIS The adrenal glands and the hypophysis are mutually depend- ent upon the integrity of one another, for extirpation of either of these organs results in anatomically demonstrable changes 209 '/J* o* * 210 COHTEX in the other. Hypophysectomy causes a very marked atrophy of the adrenal cortex which may reduce the cor- tex to one-fifth of its normal size, the medulla remaining unaffected. Implants of the pituitary into hypophysecto- mized rats prevents this adrenal atrophy. Evans 309 first demonstrated the hypertrophy of the cortex which follows the administration of alkaline extracts of the anterior pituitary. Houssay et alii 310 showed that such extracts caused hyper- trophy of the adrenal cortex in the absence of the hypophysis, thyroid, or sex glands and after section of the splanchnic nerves. Clinically, likewise, one observes changes in the pituitary in diseases involving the adrenal cortex and changes in the adrenal in acromegaly, hypophyseal cachexia, and other patho- logical involvements of the hypophysis. In acromegaly, the cortex is hypertrophied whereas the hypophyseal atrophy of Simmonds' disease is accompanied by atrophy of the adrenals. In Addison's disease Kraus 366 found a marked diminution in the number of normal basophilic cells of the pituitary in some cases. In extreme cases normal basophilic cells are entirely absent from the gland. The eosinophiles are also diminished in number and may be abnormal. Experimentally, changes in the hypophysis may be induced in animals maintained for long periods in a state of chronic adrenal insufficiency. Thus in dogs maintained on minimal doses of adrenal cortical hormone for periods of 100 days and then allowed to die of adrenal insufficiency, Grollman and Firor 248 found changes in the pituitary which resembled those reported in patients dying of Addison's disease. There was an increase in vascularity of the hypophysis, dilatation of the capillaries, and a marked diminution in the number of baso- philic cells which, in one dog, had completely disappeared. In the rat, the increased vascularity was less striking than in the dog. Nor was there as marked a diminution or disappearance of the basophilic cells. However, the staining of these baso- philic cells was very abnormal. As in Addison's disease, the RELATION TO OTHER ENDOCRINES 211 changes in the eosinophilic and chromophobic cells were not as striking as the changes observed in the basophilic cells. In determining the relative roles played by the adrenal cor- tex and the pituitary in the symptomatology of a primary adrenal or pituitary dysfunction, it is necessary to differentiate between the effects of acute and chronic insufficiency. The stunted growth, subnormal body temperature, and reduced reproductive and body activity of hypophysectomized animals cannot be remedied by treatment with large amounts of the adrenal cortical hormone. This would indicate that the symptoms of hypophyseal insufficiency are not due to a sec- ondarily induced adrenal cortical insufficiency. Nor can the stunted growth, sub-normal body temperature, and reduced body activity of adrenalectomized animals be remedied by the injection of the anterior pituitary hormone. Hence we must conclude that these symptoms of acute adrenal insufficiency are not attributable to a secondarily induced hypophyseal insufficiency. It is true that in animals in diestrus as a result of adrenal insufficiency, estrus can be induced by the injection of large doses of estrogenic or gonadotropic hormones. 567 This is not, however, an indisputable proof that the initial reproduc- tive dysfunction resulting from adrenal insufficiency is hypo- physeal in origin. The pituitary gland of hypophysectomized rats has, however, been shown to be deficient in gonad-stimu- lating power, which is presumptive evidence for the view that pituitary dysfunction may be responsible for the abeyance of the estrus cycle in adrenalectomized rats. The general de- bility and cachexia of animals in adrenal insufficiency, how- ever, can also be held responsible for the abeyance of reproduc- tive activity. Although no good evidence exists for attributing the symp- toms observed in acute adrenal insufficiency to pituitary dys- function and vice versa, the anatomical findings already cited would indicate that chronic adrenal insufficiency does result in pituitary injury. Such injury, as one would anticipate, will 212 CORTEX manifest itself clinically by causing changes in physiological functions normally under hypophyseal control. As demon- strated by Grollman and Firor, 248 animals maintained for some time in a state of chronic adrenal insufficiency assume a clini- cal picture which is essentially that of hypophyseal cachexia. The physiological deficiencies manifested by such animals are not remedied by treatment with the adrenal cortical hormone but respond to treatment with extracts derived from the pituitary. Grollman and Firor concluded, therefore, that the hypophyseal insufficiency induced by interference with normal adrenal activity is primarily responsible for producing an essen- tial part of the syndrome observed in animals suffering from chronic adrenal insufficiency. Several methods were utilized in the production of a chronic adrenal insufficiency. Completely adrenalectomized animals (rats, cats, or dogs) were treated for extended periods with a minimal amount of the adrenal cortical hormone sufficient to maintain life but insufficient to maintain growth in young animals or to maintain a normal body temperature, respiratory metabolism, and reproductive and general activities in adult animals. It is extremely difficult to maintain such a state of insufficiency in young animals for an extended period of time but in full-grown animals it may be done with ease. A second method of inducing a chronic adrenal insufficiency consisted in performing an incomplete adrenalectomy. The operation being incomplete, cellular residues remained which eventually gave rise to sufficient gland to maintain life after treatment of these animals for a week to ten days with an active preparation of the adrenal cortical hormone. A third procedure for pro- ducing a chronic insufficiency consisted in ligating the blood supply to the adrenals. Although a large percentage of the animals on which this operation is performed succumb to the effects of an ensuing acute adrenal insufficiency, some survive and develop the symptoms of chronic insufficiency. The general symptomatology of animals in a state of chronic RELATION TO OTHER ENDOCRINES 213 adrenal insufficiency induced by the methods just described differs from that observed in acute adrenal insufficiency in several important respects. Acute adrenal insufficiency re- sponds readily to treatment with the adrenal cortical hormone, is rapidly fatal in untreated animals, and is accompanied by a rapid loss of weight and other symptoms characteristic of adrenal insufficiency. Animals brought into the state of what we have called a chronic adrenal insufficiency live for long periods of time without treatment, do not respond to adrenal cortical therapy, maintain a constant body weight, and are free of many of the symptoms characteristic of acute adrenal insufficiency. Such animals show a slight degree of asthenia, fail to gain weight under a luxus diet, maintain a slightly lowered body temperature, and show a diminished capacity for reproduction. At autopsy evidence of pathological changes are noted chiefly in the degree of inanition and loss of general body fat, marked atrophy of the reproductive system, atrophy of the thyroid gland, and a generalized hyperplasia of the lymphatic system with regenerative enlargement of the thymus. The growth of rats may be stunted by interference with normal hypophyseal or adrenal function. Adrenalectomy results in a permanent cessation of growth which can be en- tirely prevented by adequate replacement therapy with the adrenal cortical hormone. However, should the adrenal cortical hormone be administered in small doses one is able to prolong the life of adrenalectomized young animals without supplying sufficient hormone to permit growth. Incomplete removal of the adrenals, leaving only a minute portion of the glomerulosa of the gland, suffices for regeneration of the gland and prolonged survival. In many cases such animals assume their normal adult size and manifest no symptoms of adrenal insufficiency. In some cases, however, one observes that such animals after a preliminary period of growth ultimately cease to grow and maintain a constant weight for long periods of time. The preliminary normal growth observed in these 214 CORTEX 240 7?rne /n Daj/s Fig. 12. The Effect of Adrenal Cortical and Pituitary Extracts on Growth Adrenal cortical and anterior pituitary growth hormone were administered to female rats after the following experimental procedures: Curve 1, normal unoperated control; 2, ligation of the adrenal pedicles; 3, incomplete adrenal- ectomy; 4, hypophysectomy. The animals were given no treatment during the twenty-day periods indicated on the abscissae as to 20, 40 to 60, 80 to 100, 120 to 140, and 160 to 180 days. Each animal received 3 rat units of the adrenal cortical hormone daily during the periods of 20 to 40, and 100 to 120 days. They received 1 cc. of anterior pituitary growth hormone extract daily during the periods of 60 to 80 and 140 to 160 days. (Reproduced through the courtesy of the American Journal of Physiology. 2 ™) RELATION TO OTHER ENDOCRINES 215 animals is similar to that noted in hypophysectomized young rats in which growth does not cease until sometime after opera- tion. In Figure 12 are reproduced typical curves which show the effects of administering the adrenal cortical hormone or the growth hormone of the anterior pituitary body to rats whose growth had been stunted by various procedures. The periods of treatment extended for 20 successive days, each period of treatment alternating with periods of an equal length of time during which no treatment was administered. As shown in Figure 12, administration of the adrenal cortical hormone is without the least effect on the growth of rats stunted by chronic adrenal insufficiency or by hypophysectomy. On the other hand, the administration of extracts of the anterior lobe of the pituitary is accompanied by a remarkable growth approximating or exceeding that observed in normal animals. It may be concluded, therefore, that the cessation of growth in animals maintained for long periods in chronic adrenal in- sufficiency is not due to lack of the adrenal secretion but is due to pituitary insufficiency induced secondarily by the adrenal insufficiency. The reproductive function of animals in adrenal insufficiency is in abeyance, as described in Chapter IX. In the rat, the periods of diestrus may extend for months during chronic adrenal insufficiency. However, in animals in which growth has ceased for several months, spontaneous oestrus may still occur at intervals of several months, compared to 4 to 7 days for normal rats. The animals conceive and may rear a normal litter. About half the animals die during either pregnancy or lactation. In such animals there is no evidence of failure of mammary function and the young are normally nourished. Undoubtedly, the strain of pregnancy like other strains upon the organism (excessive heat, cold, drugs such as histamine, etc.) which are innocuous to normal animals cannot be borne by animals in chronic insufficiency. In animals surviving the 216 CORTEX period of lactation, the body weight is found to be the same as before pregnancy. Any growth hormone in the foetuses is apparently not transmitted to the mother. 248 Male animals in chronic adrenal insufficiency show impo- tence with atrophy of the reproductive system similar to that observed in hypophysectomized animals. Repair of the reproductive system in neither male nor female animals occurs when adrenal cortical hormone is administered in doses of two to three rat units daily. On the other hand, a ready response, similar to that obtained in hypophysectomized animals, is elicited by injections of extracts of the pituitary. These observations indicate that the hypophysis is probably respon- sible for the observed failure of the reproductive system in long continued chronic adrenal insufficiency. Certain metabolic changes are common to both hypophysec- tomized animals and those maintained in a state of chronic adrenal insufficiency. Thus, the body temperature is reduced about equally in both cases. In neither hypophysectomized animals nor those maintained in a state of chronic adrenal in- sufficiency for long periods can the body temperature be ele- vated to normal by administration of the adrenal cortical hormone. On the other hand, administration of either desic- cated thyroid, orally, or the injection of thyroxine or anterior pituitary extracts containing the thyrotropic principle results in an elevation of the body temperature to normal. In Table 1 are summarized the results obtained on a series of rats and dogs after hypophysectomy or in chronic adrenal insufficiency. The results of Table 1 may be interpreted as due to successive changes in the adrenal-pituitary-thyroid complex. The primary adrenal insufficiency causes an irreversible injury of the ante- rior pituitary. This pituitary dysfunction, in turn, results in a thyroid insufficiency which gives rise to the observed symp- toms. The results cited in the above paragraphs point strongly to an intimate relation between the adrenal cortex and the ante- RELATION TO OTHER ENDOCRINES 217 rior lobe of the hypophysis. Besides the pathological findings in acromegaly, Addison's disease, etc., other clinical conditions present even more striking indications of a close pituitary- adrenal relation. Thus Cushing's syndrome, in which one finds basophilic adenomata of the hypophysis, and the adreno- genital syndrome (to be described in Chapter XXIII) which accompanies certain adrenal tumors, are often clinically in- distinguishable due to their almost identical symptomatology. TABLE 1 The body temperature of animals in a state of chronic adrenal insufficiency The data in the table represent averages of daily temperatures obtained during the course of one week. The average deviation of the individual readings from the mean values recorded in the table was less than 0.3° (Groll- man and Firor 248 ). ANIMAL SPECIES OPERATIVE PROCEDURE RECTAL TEMPERATURES OP ANIMALS IN SERIES Untreated During thyro- tropic therapy During thyroid medica- tion "C. °C. °C. 4 Dogs Normal controls 39.6 2 2 8 Dogs Dogs Rats Hypophysectomized Chronic adrenal insufficiency Normal controls 38.7 38.6 39.1 39.8 39.7 39.5 39.8 4 4 Rats Rats Hypophysectomized Chronic adrenal insufficiency 36.5 36.6 39.2 39.3 38.7 39.0 Similarly the differential diagnosis of Simmond's disease (pitui- tary cachexia) from Addison's disease is sometimes extremely difficult. Both diseases share the common symptoms of asthenia, anorexia, loss of weight, dizziness, and hypotension. The question arises as to the extent to which adrenal insuffi- ciency is responsible for these manifestations of a primary pituitary disease and whether some of these symptoms as observed in Addison's disease are not due to secondary effects on the pituitary. The answer to these questions must be sought in the effects of therapy with the adrenal cortical and 218 CORTEX anterior pituitary hormones in the two diseases. The few pre- liminary reports which have been made on the results of such studies may be ignored since they were based on the use of extracts the hormone content of which was negligible and in- volved only a short period of clinical observation with no subsequent verification of the diagnosis or the effect of with- drawing the extracts. It should be emphasized, however, that although secondary pituitary insufficiency may be expected to occur in Addison's disease (as is borne out by anatomical findings) the chief symp- toms are certainly not attributable to hypophyseal dysfunction but resemble those observed in acute experimental adrenal insufficiency. The infantilism observed in Addison's disease when it occurs in children and the progeria which has been found to accompany sclerosis of the adrenals are probably due to pituitary insufficiency. As stated above, the injection of alkaline extracts of the pituitary causes hypertrophy of the adrenals and prevents the atrophy which follows hypophysectomy. The tendency to as- cribe all effects which follow injections of pituitary extracts to an hypothetical new "hormone" has resulted in the assumption that the above described effects on the adrenal cortex are due to an "adrenotropic hormone" 185 which normally regulates the adrenal. Scrutiny of the experimental data, upon which the assumed existence of this hormone is based, does not, however, inspire confidence. The available extracts derived from the hypophysis are at their best relatively crude concoctions. The adrenals, moreover, are extremely sensitive and readily respond by hypertrophy to the injection of foreign materials into the organism. Hence one might justifiably doubt that the adrenal hypertrophy observed after injection of the so-called adreno- tropic hormone is the result of specific stimulation by a hor- monal entity. The so-called thyrotropic hormone of the pitui- tary also causes hypertrophy of the adrenals. This action is mediated by the thyroids for it fails to occur in thyroidecto- RELATION TO OTHER ENDOCRINES 219 mized animals. 400 However, preparations free of the thyro- tropic hormone have been prepared which still cause hyper- trophy of the adrenals. 121 One can explain all the available facts without assuming the existence of a specific pituitary hormone which controls the adrenal. Nor need one assume that the adrenal elaborates a separate hormone which is necessary for normal hypophyseal activity; for the most highly purified cortical extracts, which fail to remedy certain symptoms of chronic adrenal insufficiency, are still capable of maintaining in adrenalectomized animals all the physiological functions attributed to pituitary activity. The above considerations have dealt exclusively with the relation of the anterior lobe of the pituitary to the adrenal cortex. Theories have also been elaborated involving an assumed physiological relation between epinephrine and the posterior lobe of the pituitary as well as between the latter and the adrenal cortex. No valid evidence exists to substantiate these assumed interrelationships and hence we need not discuss them here. THE THYROID The existence of an antagonistic relationship between the thyroid gland and the adrenal cortex is suggested by a number of well-established observations and was clearly stated over a decade ago by Marine and his collaborators. 433 Their views were based chiefly on the observation that sublethal injury to the suprarenal glands caused marked chronic hyperthermia provided the thyroid were intact. As we have already seen in Chapter XIII, this hyperactivity of the thyroid resulting from adrenal injury may more reasonably be attributed to operative effects, for true adrenal insufficiency is characterized by a reduction in the metabolism. Thyroidectomy does not result in any constant change in the adrenal cortex 605 nor does it always greatly affect the survival period of adrenalectomized animals. The administration of 220 CORTEX thyroid substance causes an enlargement of the adrenals 513 which may be looked upon as secondary to the increased metabolic activity. Reactions in general which cause an in- creased metabolic activity are accompanied by hypertrophy of the adrenal cortex. Feeding thyroid extracts to adrenalec- tomized animals markedly reduces their survival period which is also a specific example of the effect caused generally by an increase in metabolism. A number of experiments have been carried out on the effects of feeding or implanting adrenal tissue on the thyroid or upon the metamorphosis of amphibia. 186 Such experiments have no significance in determining the relation of the thyroid and adrenal glands for it is doubtful if any cortical hormone was being administered by the methods utilized in these inves- tigations. Any observed changes are to be attributed to the toxic effects of the administered tissue. The etiology of hyperthyroidism has been attributed to some unbalance between the adrenal and thyroid glands. Ma- rine's 433 demonstration of an increased thyroid activity in sublethal injury to the adrenals led him to hypothecate that hyperthyroidism is due to dysfunction of the adrenals. He attempted, therefore, to alleviate the symptoms of Grave's disease by administration of fresh and dried adrenal substance. The reputed beneficent effect of this therapy is open to criti- cism and more recent work has shown that administration of neither cortical extracts nor fresh raw cortical tissue results in any clinical improvement 664 in patients suffering from hy- perthyroidism. Normal metabolic activity in the higher organism is depend- ent upon both the thyroid and the adrenal gland. The extir- pation of either gland leads to a reduced metabolic activity. The effects of thyroidectomy are chronic and are not incom- patible with life while the decreased metabolism which follows adrenalectomy is perhaps only a reflection of the general dys- function of the tissues generally. Too great emphasis should RELATION TO OTHER ENDOCRINES 221 not, therefore, be placed on the superficially analogous effects of extirpating the two glands on the metabolic rate. Adminis- tration of thyroxin increases the metabolism far above its normal, while administration of excessive amounts of the adrenal cortical hormone does not influence the metabolic rate. This speaks against the view that the adrenal directly controls the metabolism, in the sense that the thyroid does, or that it exerts a control over the thyroid as claimed by Marine's theory. The metabolic activity of thyroxin is not dependent on the integrity of the adrenals for a rise in metabolism can still be elicited in the adrenalectomized animal by injection of thyroxin. It may justifiably be argued that in such cases a sufficient amount of the cortical hormone is still present in the body, for in the late stages of adrenal insufficiency, thyroxin no longer causes an elevation in the metabolism. It would seem logical to conclude, therefore, that no intimate thyroid-adrenal relation exists. Injury to the adrenals or their extirpation may lead to a temporary overactivity of the thyroid. However, this need not be due to dysfunction of the adrenals but is probably a reflex effect of trauma. Over- activity of the thyroid by increasing the metabolism of the organism incidentally increases the demand for the adrenal cortical hormone. There is no evidence, however, that either hypo- or hyperactivity of the adrenals affects thyroid activity. The results of Tsuji 641 indicating hyperplastic changes in the thyroid of adrenalectomized rats are of no significance since his animals died so soon after operation. Mahorner 421 failed to confirm Tsuji's results, in dogs. The relation between the adrenal medulla and its secretion product, epinephrine, and the thyroid has been the subject of numerous researches. Attempts have been made to ascribe a close interrelation between these two organs but the results are inconclusive. The increase in oxygen consumption which follows epinephrine injections (Chapter VII) is elicited and, in fact, accentuated after thyroidectomy. 436 The effects of 222 CORTEX thyroidectomy and feeding of desiccated thyroid substance on the epinephrine content of the adrenals has given conflicting results. 294 The results following injections of thyroid extracts have been equally inconclusive. The older experiments in which it was claimed that such injections sensitized the organs innervated by the sympathetic nervous system to a subsequent injection of epinephrine have been shown to be non-specific reactions to foreign protein. Thyroxin induces no such sensitization. 639 Koehlsche and Kendall 364 have recently studied the effect of administering adrenal cortical extracts on the nitrogen excre- tion of dogs after injection of thyroxin. They consider their re- sults as indicating the existence of a thyroid-adrenal interrelation. PARATHYROIDS Injection of epinephrine modifies the calcium content of the blood and attempts have, therefore been made to link para- thyroid and adrenal medullary activities. The assumption of such a relationship has not, however, been substantiated. With the transferral of emphasis from the medulla to the cor- tex as the important part of the adrenals, attempts have been made to demonstrate an intimate relation between the adrenal cortex and the parathyroid glands. Thus the fact that both the administration of parathyroid extracts and adrenalectomy increase the cholesterol content of the blood suggested that parathyroid hyperactivity depresses the activity of the cortex. The hyperplasia of the adrenals noted in a case of osteitis fibrosa suggested, on the other hand, that over-activity of the parathyroids stimulates the adrenals. The relative ease with which the cholesterol content of the blood can be affected and the many factors which cause an hypertrophy of the adrenals renders the evidence just cited for the existence of an adrenal- parathyroid relationship exceedingly flimsy. Rogoff 624 has suggested that some of the symptoms of adrenal RELATION TO OTHER ENDOCRINES 223 insufficiency are due to parathyroid overactivity which causes a disturbance in the calcium metabolism, because changes in calcification of the dentin of rat's teeth after adrenalectomy resembled that caused by administration of parathyroid hor- mone. The muscular twitchings, spasms, and tetanic convul- sions often occurring in animals in insufficiency may be due to a disturbance in calcium metabolism. Although Rogoff and Stewart 630 reported a decided hypercalcemia in most of their animals, other observers have noted no great change in the blood calcium to indicate any significant alteration in the calcium metabolism. However, it must be remembered that changes in other ions particularly phosphate, which is also increased, will act to modify the state and hence the physio- logical effectiveness of the calcium. Hence too great empha- sis should not be placed upon the total calcium concentration as determined by analysis. There is, however, no good evi- dence to show that the parathyroid glands are stimulated to over-activity by adrenal insufficiency and one cannot accept the suggestion that the changes in the alimentary tract ob- served in adrenalectomized animals are due to an excessive secretion of the parathyroid hormone. In the adreno-genital and Cushing's syndrome (cf. Chap- ter XXIII) due to tumors of the adrenals and pituitary, one observes a softening of the bones due to decalcification. This evidence of a possible parathyroid disturbance may be ascribed to changes in the ovaries or pituitary, which are known to exert an influence on the calcium metabolism. Both the pituitary and the ovaries are affected in these conditions and hence it would seem more logical to attribute the observed effects to the action of these glands on parathyroid activity rather than to assume any control by the adrenals over the parathyroid. As in the case of the thyroid, therefore, we must conclude that there exists no valid evidence to indicate any intimate adrenal- parathyroid interrelationship. 224 CORTEX THE GONADS The idea of an intimate relation between the gonads and the adrenals has recurred for several centuries (cf. Chapter I). The earlier bases for such a view have long been shown to be invalid and need not be reiterated here. The more recent theories which have been elaborated to explain an adreno- gonadal interrelationship have, however, also been unsatis- factory. On the one hand, there exists the indisputable evi- dence to be presented in Chapter XXIII of a clinical syndrome associated with certain tumors of the adrenal. This has led to the obvious conclusion that the adrenals are related to the reproductive organs and that their hyperactivity leads to hyperfunction of the gonads. On the other hand, attempts to demonstrate experimentally such a simple interrelationship have failed. This apparent paradox is due to the failure of previous investigators to distinguish properly between the androgenic tissue and the remainder of the cortex. In the author's opinion, the adrenal gland is comprised of three func- tionally distinct tissues, — the chromaphil, the interrenal (or true cortical), and the androgenic. The last named is limited (cf. Chapter IV) to man and certain animals, is only temporary in its existence, and differs anatomically and histochemically from the true cortical tissue. It is this androgenic tissue which, in the author's opinion, is responsible for the pathologi- cal adreno-genital syndrome and probably for certain physio- logical changes in the reproductive system of the lower animals. In the present section we shall consider the less important relation between the gonads and the medullary and cortical tissues. In Chapters IV and XXIII are discussed the ex- perimental and clinical relations of the androgenic tissue to the gonads. There is no good evidence for assuming any important rela- tion between the medulla and the gonads although insignificant differences in medullary activity of the male and female or- RELATION TO OTHER ENDOCRINES 225 ganism have been noted. Epinephrine injections do not affect the estrus cycle of mice. 639 Attempts have been made to find changes in the epinephrine content of the adrenals occur- ring during pregnancy in order to attribute certain pathological manifestations occurring in this condition to an hypothetical hypo- or hyperadrenalinemia. These attempts have yielded only conflictory and contestable results. Sex differences in the size of the adrenals have been repeat- edly demonstrated, the gland in the female being somewhat larger than in the male. In the rat, for example, Hatai and Jackson 286 found the adrenals to be about 20 per cent larger per unit of body weight in the newborn female as compared to the male. This difference gradually disappears so that in a 20 to 40 gram rat the adrenal weights are the same in the two sexes. Thereafter, however, the sex differentiation again appears and the adrenals of a 300 gram female rat are almost twice as large as those of an equal sized male. Cyclic changes in the size of the adrenal cortex coincident with the oestrus cycle were first pointed out by Stilling. 595 Similar changes have been described by Anderson and Ken- nedy 14 in the mouse. In doves, Riddle 521 described an adrenal hypertrophy coincident with ovulation. In the male also adrenal hypertrophy during rut has been described in rabbits, squirrels, and amphibia. 695 The reproductive cycle is accompanied by such profound changes in the general activity of the body as a whole that one need not attribute any specific importance to the changes occurring in the adrenal cortex. Such changes may be looked upon merely as a reflection of increased body activity requiring among other things an hyperfunction of the adrenal cortex. It is unnecessary to assume any more direct adreno-gonadal relationship and hypothecate the changes in the adrenal to be the prime instigators of the sexual activity. The same criti- cism is applicable to the changes in the adrenal during preg- nancy or after castration. It must be remembered that all 226 CORTEX organs and tissues of the body are to some extent interrelated and any change in one occurring concomitantly with that in another need not imply a fundamental interrelation between the two. This is particularly true where the interrelation is only minor, as in the cases to be described below. An increase in weight of the adrenals during pregnancy has been described by numerous observers in many animal species (Guieysse, 266 and Watrin 660 in the rabbit; Tamura 622 in the mouse; Verdozzi, 643 Kolde, and Kolmer 361 in the guinea pig; etc.). Donaldson 161 failed to find any enlargement in the rat during gestation, a result which has been confirmed by subse- quent workers. 15 Where such hypertrophy occurred it was due to a coexisting infection. As we have seen in Chapter IV, the degeneration of the androgenic tissue at the inception of preg- nancy is of more significance than the above described minor enlargement of the gland. Moreover, it is questionable if the increase in weight of the gland during gestation really repre- sents an hypertrophy. It may merely be the result of an increase in the lipid store of the gland coincident with the increased lipid content of the blood which occurs during preg- nancy. Experiments on the effects of castration on the size of the adrenals have given conflicting results. 16 In rabbits Livings- ton 397 found a tendency to slight enlargement after castration in the male, but none after spaying in the female. Tsubura, 16 on the other hand, found the average weight of the adrenals of 14 castrated rabbits to be 0.5424 grams as compared to 0.4176 grams in the controls. In the guinea pig, the respective weights were 0.2516 and 0.1759 grams. It is questionable how much of the adrenal hypertrophy observed after castration is to be attributed to infection, the effects of anesthesia, shock, etc. Failure to consider the effects of these variables (particularly infection) on the adrenal may account for the enlargements observed by some authors. 12 The failure of the reproductive system which follows adrenal- RELATION TO OTHER ENDOCRINES 227 ectomy has been repeatedly demonstrated by many observers since attention was first called to this phenomenon by Novak 476 in 1914. Adrenal cortical insufficiency induced by disease (as in Addison's disease) or experimentally leads to cessation of the reproductive activity. In the male there is atrophy of the testis with overgrowth of the interstitial tissue and impo- tence. In the female there is a cessation of oestrus and atrophy of the ovaries and other reproductive organs. This interfer- ence with the normal reproductive processes has been observed clinically in Addison's disease and may be produced experi- mentally with ease by maintaining animals in a degree of insufficiency compatible with life. Thus, rats in which acces- sory cortical tissue is left at the time of a bilateral adrenalec- tomy may survive with stunted growth but exhibit an oestrus cycle only rarely and remain sterile. At autopsy one finds in such animals marked atrophy of the genital tract. In male rats dying of adrenal insufficiency, one finds at autopsy pale soft and often edematous testes. Histologically the spermatic tubules are disorganized and degenerated. 476 The spermato- cytes are affected and spermatogenesis is abated. 205 There is an overgrowth of interstitial tissue. The secondary sex organs (prostate, seminal vesicals, etc.) are atrophic. In the female there is marked degeneration of the ova and an increase in the interstitial cells of the ovary. Corpora lutea formation does not occur. The uterus atrophies, both the musculature and mucosa assuming an immature appearance. Similar observa- tions have been made in mice by Masui. 443 The above described failure of the reproductive system is in part possibly secondary to changes in the pituitary, as already indicated in a preceding section. Implantation of normal rat pituitary bodies into adrenalectomized rats in diestrus results in a re-establishment of the oestrus cycle. This indicates that a pituitary insufficiency secondary to the adrenal insufficiency may be the direct cause of the failure of the reproductive sys- tem. At least the oestrus cycle is still elicitable by anterior 228 CORTEX pituitary implants even in the absence of adrenal activity. In males implantation of the anterior pituitary gland or injection of urine of pregnancy still stimulates the accessory sex organs. However, neither procedure prevents atrophy of the testis. 667 Attempts to affect the adrenals by injection of various sexual hormones have been negative. Thus menformon, theelin, and androtin produce no observable changes in the adrenals. Contrariwise, the injection of the adrenal cortical hormone which supports life is without demonstrable effect on the repro- ductive system. Experimenters who claimed to demonstrate precocious puberty in rats by injections of the hormone and other changes in the reproductive tract were misled by the crudity of the extracts which they had employed. Many workers in endocrinology are unaware of the ease with which one can produce changes in certain organs, particularly the thyroid, adrenals, and reproductive system, by injection of any one of a number of non-specific substances. Thus lecithin, as Jaffe" and Ranssweiler 321 showed, may produce hypertrophic or atrophic changes in the sex organs after long injection. Cholesterol produces marked hypertrophy of the uterus in rats. Thus the average weight of the uterus in six rats injected on alternate days for a month with a one per cent solution of cholesterol was 0.300 grams as compared to 0.170 grams in the control animals. The ovarian weights were not influenced by the injections. Precocious maturity in rats (as evidenced by opening of the vagina) and luteinization of immature ovaries may be obtained by injecting extracts of a variety of tissues. 321 Great caution is, therefore, necessary before drawing any con- clusions as to the existence of fundamental endocrinological relationships between organs. It is necessary to exclude the possibility that impurities such as lecithin, cholesterol, choline, histamine, etc., which contaminate extracts of glandular products, are producing the observed effects rather than some hormone which one is perhaps more desirous of crediting with the observed effects. As already stated many effects attrib- RELATION TO OTHER ENDOCRINES 229 uted to the adrenal cortical hormone were in reality due to impurities in the extracts utilized and this is true of the results of those who claimed to have elicited changes in the reproduc- tive system by the use of cortical extracts. These extracts potent as regards their ability to maintain normal growth and activity in adrenalectomized animals exert no demonstrable effect on the gonads when injected into normal animals. 575 Even after unilateral ovariectomy performed to reduce the potential ovarian activity, Howard and Grollman 321 were un- able to induce any observable change in the remaining ovary or in reproductive activity by the injection of concentrated adrenal cortical extracts. The above described considerations demonstrate the absence of any intimate relation between the adrenal cortex proper and the gonads. In Chapter XXIII, however, we shall consider an interesting group of clinical cases in which sexual and de- velopmental abnormalities occur coincident with or as a result of an abnormal growth of the androgenic zone of the adrenal. It was because of these abnormalities that earlier workers sus- pected and sought so assiduously an adreno-gonadal relationship, which gave rise to the numerous researches cited above. Their failure to appreciate the true significance of the androgenic zone prevented their teaching the true significance of the adreno-gonadal relationship. It is a specialized tissue of the adrenal only (which we have denoted as the androgenic tissue and described in Chapter IV) which is intimately related to the reproductive system. The cortex proper, although essen- tial for the well-being of the sex glands, neither controls them, nor does it by hyperactivity produce any demonstrable changes in the reproductive system. PANCREAS As we have seen in Chapter XII, dysfunction of the adrenal cortex is accompanied by an impoverishment of the carbohy- drate supplies of the body. Since insulin, the product of the 230 CORTEX islet tissue of the pancreas, is a hormone of such great impor- tance for normal carbohydrate metabolism, one would logically be inclined to seek an explanation of the abnormalities observed in adrenal insufficiency in a disturbed pancreatic function. Most of the work has been confined to the relation of the action of insulin to epinephrine, which we have already considered in previous chapters. The possible existence of a relation be- tween the cortex and the activity of the islet tissue has not been adequately studied. Since the hypophysis is also inti- mately related to carbohydrate metabolism, some of the changes observed in adrenal cortical insufficiency may be secondary to hypophyseal dysfunction. Further work in this field is necessary, however, before one can elucidate the rela- tion, if any, which exists between the internal secretion of the pancreas and that of the adrenals. 20 - 386 ' 402 - 424 Chapter XV THE PREPARATION OF EXTRACTS OF THE ADRENAL CORTICAL HORMONE Attempts to prepare extracts of the adrenal cortex containing its vitally important hormone have been made by many workers. 455 Abelous and Langlois 3 in 1891 prepared extracts which they claimed prolonged the survival period of adrenal- ectomized frogs. Brown-Sequard 98 in the following year also prepared extracts which, he claimed, gave temporary relief when administered to dying adrenalectomized animals. Num- erous other workers reported the preparation of extracts which they believed to contain the active principle of the adrenal cortex, but these claims like those of their predecessors have received little credence, for subsequent work showed the ex- tracts to be incapable of maintaining life in adrenalectomized animals for any appreciable length of time. It would seem quite obvious from our present knowledge that the extracts of earlier workers could have contained only an infinitesimal amount of the hormone, contaminated by a mass of extraneous impurities. It is not surprising, therefore, that with time all these preparations have been well-nigh for- gotten, and it is not necessary to describe or criticize them here. The preparation of extracts containing the cortical hormone is rendered difficult for several reasons. In the first place, the amount of hormone present in the glands is relatively small. It might be argued that our available methods remove only a small fraction of the hormone present in the glands, but this assumption is very unlikely, as shall subsequently be shown. The small amount of hormone present in the gland is demon- strated by the large amounts of the glandular material which must be fed to elicit any therapeutic effects. Rapid heating 231 232 CORTEX of fresh cortical tissue to 100°C. preserves the hormone content of the adrenals, but it requires several hundred grams of this tissue per day to maintain the life of an adrenalectomized dog. 246 Injection of fresh saline suspensions of the cortex into cats or dogs desensitized to beef protein also fails to elicit any thera- peutic effects because of the relatively large amount of material necessary to supply an appreciable amount of the hormone. The adrenal thus differs from the thyroid which may be effec- tively administered by feeding the dried gland, or the pituitary which when implanted elicits the effects of its growth hormone in hypophysectomized animals. Another important difficulty in the preparation of extracts of the adrenal cortical hormone results from the fact that unless the medulla is thoroughly removed immediately after slaughter of the animal considerable amounts of epinephrine and its disintegration products will be present in the extracts. Both epinephrine and its oxidation products are exceedingly toxic even when ingested orally in large quantities and their removal from the final extracts is therefore essential. Any beneficent effect of the hormone present in a given extract will be masked by the toxic effects of epinephrine or its derivatives unless these be thoroughly removed. The adrenal glands are noteworthy for the rapidity with which they undergo autolysis. The adrenal cortical hormone is very rapidly destroyed after death and hence proper preser- vation of the fresh glands is essential for the preparation of an active extract. 245 The failure to appreciate the importance of the factors just enumerated accounts undoubtedly for the results of the early workers who attempted to prepare extracts containing the hormone. They failed to effect a sufficient concentration of the hormone, did not thoroughly remove the noxious impurities present in their extracts, and improperly preserved the glands so that only traces of the hormone were present in their final extracts. It is not unexpected therefore that their products PREPARATION OF CORTICAL HORMONE 233 were ineffective at best, and were highly toxic when adminis- tered in large doses. The commercially available preparations consisting of dried preparations of the fresh glands or glycerine extracts are worth- less insofar as their content of the cortical hormone is concerned for the reasons already cited. Some of the effects that have been reported as following their use are undoubtedly attribut- able to the toxic action of the large amounts of epinephrine and its derivatives which they contain. 4142 None of these preparations can conceivably exert any therapeutic effect which depends upon the presence of the cortical hormone as is demon- strated by their inability to prolong the life of adrenalectomized animals. 249 The extracts which have attracted the greatest attention in recent years are those of Swingle and Pfiffner, 612 and Hartman and his collaborators. 275 The latter first described a prepara- tion (cortin) in which the hormone was supposedly precipitated by salting it out of aqueous solution. It is very unlikely that this preparation contained any appreciable amount of the hormone. Subsequently Hartman and Brownell 274 described a second method based upon the successive use of various lipoidal solvents. Swingle and Pfiffner's method consisted essentially in an application of the procedures which had been successful in isolating the estrogenic substances. Their claims of the great potency of their extract and its ability to maintain adrenalecto- mized cats and dogs alive for over one hundred days were most striking and numerous workers immediately began to apply the new extract to experimental problems as well as to Addi- son's disease. 613 Although the immediate acclaim which heralded the new extract seemed to substantiate the claims of its originators, subsequent work proved disappointing. Many of the patients reported in the literature as "saved" from imminent death by the "hormone" ultimately died within or in many cases before the average time of their survival when 234 CORTEX left untreated. The reports of immediate remedial effects in a disease characterized by spontaneous remissions must be accepted with caution and are of no value in determining the potency of a given preparation. It is only when patients have been maintained in health for a period surpassing that which they would have survived had they remained untreated (cf. Chapter XXI) that one can boast of any therapeutic effect from a given treatment. The results on experimental animals also failed to confirm the claims of Swingle and Pfiffner as to the high potency of their preparations, for relatively large doses of extract prepared by their method often fail to serve as a complete replacement therapy in adrenalectomized animals. 245 - 523 Aside, however, from the question as to the potency of extracts, as prepared by the methods of Swingle and Pfiffner or Hartman and Brownell, both methods are unnecessarily complex and expensive, and sometimes yield products of marked toxicity. They need not, therefore, be considered in further detail here. The effectiveness with which the adrenal cortical hormone is adsorbed from neutral aqueous solution by charcoal permits the preparation of extracts in a relatively simple manner. The charcoal-hormone combination thus prepared can be adminis- tered directly by mouth without necessitating the elution of the hormone. The hormone can, however, be eluted from its charcoal combination, freed of contaminating impurities, and thus prepared in a form suitable for parenteral administration. In the following sections shall be described the details of the methods utilized for obtaining these preparations. THE PREPARATION OF THE CHARCOAL-HORMONE COMBINATION Beef glands being most readily available are generally used as the source of the hormone. Pig glands are more difficult to obtain but yield approximately three times as much hor- mone per unit weight as do beef glands. Glands derived from sheep or calves are also probably rich in the hormone, but the PREPARATION OF CORTICAL HORMONE 235 difficulty of properly collecting and preserving them has here- tofore rendered their use impracticable. The adrenals rapidly undergo autolytic changes and the cortical hormone is rapidly destroyed after death. To illus- trate the course of this destruction various portions of a batch of glands obtained from one source were extracted and assayed. One portion of the glands was removed from the carcasses of freshly slaughtered animals and dropped into liquid air. These glands were then extracted and found to contain 500 rat units (as defined in Chapter XVI) per kilo of the original whole glands. A second portion of the glands was frozen with "dry ice" at the abattoir and packed in this refrigerant for two days before extraction. From each kilogram of these glands, an extract containing 100 rat units was obtained. A third portion of the glands was placed in the refrigerator of the abattoir and sent frozen to the laboratory on the following day. The ex- tract prepared from these glands contained only 10 rat units per kilo of glandular material. A fourth portion of the glands was sent unfrozen to the laboratory. The extract prepared from this material was found to contain only a trace of the hormone. The deleterious effects of poor preservation of adrenal glands on the yield of the hormone are obvious from the experiment just described. In order to ensure preservation of the hor- mone, the glands should be ground into two and a half to three times their volume of acetone immediately on removal from the animal. The adrenal cortical hormone is firmly attached to the lipids of the adrenal cells and is removed only when these lipids are simultaneously removed. Hence attempts to extract the hor- mone from the glands by the use of aqueous acid or alkaline solutions have been unsuccessful. Dehydrating the freshly ground glands in vacuo at a low temperature destroys the cellu- lar structure and permits extraction of the hormone by water. Unfortunately, this method of extraction is not practical. It 236 CORTEX is, therefore, necessary to use a lipid solvent (acetone, alcohol, or ether) which extracts the adrenal lipids and incidentally the cortical hormone. Acetone is by far the most practical sol- vent, for it not only extracts the hormone efficiently but re- moves less extraneous matter, and hence leads to the easier production of a relatively pure product. The fresh glands are thoroughly macerated and shaken at intervals for some hours with the acetone into which they were originally ground. This operation is carried out at room temperature for the acetone apparently inhibits the enzymic activity which acts so deleteriously in the intact unfrozen glands. The supernatant solvent is now poured off from the glandular material. This glandular residue is refluxed three times with approximately one-third of the acetone which was poured off, the mixture being pressed after each refluxing. In this way one carries out the three refluxings with the 2.5 to 3 volumes of acetone originally used. The refluxing of the glands is essential in order to extract the hormone which is tenaciously held by the lipids of the adrenal tissue. Three successive refluxings for about one-half hour, at the boiling point of ace- tone, extracts about 95 per cent of the hormone present in the glands. A fourth and fifth reextraction and refluxing give only small amounts of the hormone. Since the purified preparations of the hormone are soluble in acetone, it would be improbable that this solvent fails, in subsequent extrac- tions, to dissolve the hormone. Moreover, extraction of the glandular residue with ethyl alcohol, ether, ethylene dichloride, acid, or alkali fails to yield any appreciable amount of the hormone. Since the adrenal cortical hormone is not completely ad- sorbed from aqueous acetone solution by charcoal, the acetone must be removed before proceeding to adsorb the hormone on charcoal. After being chilled in the ice chest, the acetone extract, obtained as described in the preceding paragraph, is PREPARATION OF CORTICAL HORMONE 237 filtered to free it from the separated lipids. The clear filtrate is distilled in vacuo at 35 to 40° until all the acetone is removed. The completeness of this removal may be determined from the specific gravity of the residual aqueous fluid, which should be over 0.99 at room temperature. After being chilled in the ice chest, the solution is again filtered to remove the separated lipids. The filtrate is carefully neutralized with an aqueous solution of NaOH until neutral (pH 7.0) and shaken at inter- vals with activated charcoal (norit or decolorizing carbon). One gram of charcoal is used for every 200 grams of glandular material originally extracted. After some hours (6 or more, depending on the efficiency of the shaking) the carbon is col- lected on a Buchner funnel. The filtrate contains only a trace of hormone, but this can be recovered by treatment again with charcoal. Before utilizing the charcoal-hormone combination prepared, as described above, it is necessary to remove most of the epi- nephrine and other impurities which contaminate it. To re- move these impurities the charcoal-hormone combination is sus- pended in about 3 times its volume of 10 per cent hydrochloric acid (1 part of 33 per cent HC1 to 10 parts of water). After thorough agitation, the suspension is filtered on a Buchner funnel. The charcoal is then suspended in about 3 times its volume of a 0.1 n sodium hydroxide solution, agitated, and again filtered. It is then again washed with 3 volumes of 2 per cent hydrochloric acid and finally washed with a little distilled water and filtered. It is now ready for use. The charcoal-hormone combination may also be effectively freed of adsorbed impurities by washing on the Buchner funnel with dilute ammonia, water, and ethyl alcohol, respectively. These reagents elute an inappreciable amount of the hormone. The amounts of acid and alkali used for washing the char- coal are relatively small, and hence do not remove an appre- ciable quantity of the hormone. The trace removed can be reclaimed by neutralizing the washings and readsorbing on a 238 CORTEX 2/0 IT 30. NSZ6Z76 AP2829d ^M2897$ W2826J \ -a 3 4 *\ t f 5| : x- 1 • -A ^x :: ^\ X ^ y— 3 V >§> w \ 5 : — 1 I i i w N ft, susz?s0 ut w&f&stf /ipoff a ™ d 0) P o u .13 «T3^- £J 4 " a > O e " ' O o ■J* £ §1 o j X < HO0 -rats* 8 PS fe PS o o *° o > >£ «-S £-2 iJ S!S X SO « 5 " £ " W)£^ »» O 4) &■*> 2 ox 0) > « X *< 2 ?.S § §S"«§ c C £-2 C 4>-iS — J3 oS^ »to C C 03 « — OT O 4> 4> m C 2 "3 O t- ftH oS ^ a, " > 03 4,-rH 3^ QjJ 3 »5 « o a >^ o$Z |3 q; 3 S -a c o ^ a o-g - > ■* C3 V '-3 o-2." rt 00 Sa aH os 262 CORTEX same dose of the hormone. In Figure 16 are reproduced the average growth curves of groups of six adrenalectomized rats. One group of six rats was given an intraperitoneal injection of a purified extract. The food of a second group of six animals was mixed with an amount of the extract exactly equal to that injected into the first group. As is evident from Figure 16 the oral form of therapy gave a markedly superior therapeutic effect as compared to the injection of an equal amount of the same extract. ACCURACY OF THE RAT ASSAY METHOD One can assay preparations of the adrenal cortex by the rat method with a degree of accuracy which is unusually good for a biological method. Obviously, for the best results, certain rigid conditions must be maintained. The animals used should be uniform in quality and in good health. They should be maintained under constant conditions at a moderate and uniform room temperature (25°C). One would hardly expect different workers under varying laboratory conditions and using diverse operative techniques, to obtain perfectly identical results. To render the results of different workers comparable it would be necessary to have some standard as a unit of comparison. Unfortunately, such a standard is not available at present. However, the white rat is relatively uniform in its reactions and by using a standard- ized technique, comparable results should be obtainable by different workers. In the author's experience, the rat method of assay as outlined above is reproducible to within ± ten per cent. As shown in Figure 16, the administration of an excess of sodium chloride and bicarbonate in the diet does not permit normal growth in young adrenalectomized rats. The same is true of the administration of Ringer's solution in place of drinking water, or the injection of large amounts of physio- logical saline or Ringer's solutions. Only when the operation ASSAY OF CORTICAL HORMONE 263 has been incomplete and residual fragments of the adrenals or accessory glands have been left does the animal grow normally. In the case of adult animals the ability of adjuvant therapy with salt to maintain animals in relatively good condition for extended periods may lead to fictitious results in evaluating the effects of therapy with adrenal extracts. Young animals which grow normally under such adjuvant therapy may be shown to possess some functional interrenal tissue. Chapter XVII THE RELATION OF THE ADRENALS TO TOXINS, IN- FECTION, AND IMMUNITY Adrenalectomized animals are exceedingly sensitive to tox- ins. 52 - 138 - 155, 394, 479, 629 They are prone to infections and rap- idly succumb to disease processes which have only trivial ef- fects in normal animals. This same loss of tolerance to toxins and infections is manifested in Addison's disease, in which minor ailments may precipitate the patient into a crisis. Be- cause of these oft-observed hypersusceptibilities of the organ- ism in adrenal insufficiency it has been thought that the adrenals are in some way responsible for the production of those immunological bodies which protect the normal indi- vidual. 61 Further evidence implying a possible relation of adrenal function to infectious processes is found in the changes which the adrenals undergo as a result of various types of toxic agents and infections. Many of the anatomical changes described in the literature as associated with infectious processes are undoubtedly merely artifacts due to an imperfect technique or to post-mortem changes which are particularly marked after death from certain diseases. Nevertheless, there exists suf- ficient valid evidence to substantiate the idea that toxins and many infectious processes induce definitely recognizable changes in the histological appearance of the adrenal glands. It does not necessarily follow, however, that these histological changes indicate an intimate relation between the function of the adrenals and infectious or toxic processes. HISTOLOGICAL EVIDENCE OF ADRENAL INJURIES The adrenal after various forms of injury undergoes changes which differ according to the agent used in producing the in- TOXINS AND INFECTIONS 265 jury and the dosage employed. With chloroform narcosis, 237 an immediate damage is produced which is rapidly repaired. The earliest changes observed are congestion of the medulla and inner cortical zones followed by degeneration of the cells of the zona reticularis. A large proportion of the cortical cells may be ultimately destroyed. Recovery sets in within 48 hours during which the undamaged cells in the more peripheral layers of the cortex show active mitosis. This regenerative process is similar to that observed following necroses due to infectious processes. The regenerative capacity of the adrenal is entirely comparable in its extent with that of other organs as, for example, the liver. The zona glomerulosa and the outer portion of the fasciculata constitute the growth center where regeneration occurs, the newly formed cells being displaced in- wardly to supply the loss at the inner layers. In contrast to the effects of chloroform inhalations, the in- jection of diphtheria toxin produces a progressive injury of the adrenals the repair of which is slow. 301 Large doses of the toxin produce hemorrhages and focal necroses (chiefly in the reticularis) which during repair are replaced in part by con- nective tissue. Small doses decrease the lipid content (as ob- served microscopically) of the cortex and cause widening of the reticular zone at the expense of the fasiculata. Diphtheria toxin also causes a marked reduction in the epinephrine con- tent of the adrenals but this decrease, as Edmunds and John- son 172 showed, is not the cause of the circulatory collapse ob- served in the terminal stages of animals poisoned by this toxin. In scurvy and other diseases of inanition there is a marked increase in the lipid content of the cortical cells with granula- tion of the mitochondria. Administration of vitamin C to scorbutic animals causes active regeneration of the injured tissue. 301 From observations in a number of diverse diseases, Elliott 181 showed that the storage and disappearance of the cortical lipid occurred under conditions entirely different from those control- 266 CORTEX ing the body fat in general. The cachexia of cancer or dia- betes, though depleting the store of fat from the body, leave unchanged the lipid of the adrenal cortex. Pathological intoxi- cations, such as diphtheria, increase the apparent fat in the heart and kidney while they exhaust the cortical lipids. The cortical lipid may be unchanged in conditions in which the epinephrine store of the medulla is depleted. The greatest loss of epinephrine from the adrenals was observed by Elliott in cases of afebrile acute cardiac failure. The world-war afforded an opportunity of studying the his- tological appearance of the adrenals of individuals suddenly killed in the prime of health and comparing the results with those observed in their comrades dying of various toxic or in- fectious processes. In this way Dietrich 156 obtained consistent data on the changes in the adrenals as a result of wound infec- tions. In no case of death following these infections were changes in the adrenal cortex not present. These changes varied in intensity from a simple disappearance of the lipid to an actual disintegration of the normal cell structure, or con- sisted simply of circulatory changes such as hyperaemia, hemor- rhages, infiltration of leucocytes, or thrombosis. These changes in the adrenals were found in all cases of wound infec- tions whereas there was only an occasional appearance of simi- lar inflammatory changes in other organs. The morbid changes of the adrenal constituted the first and most pro- nounced findings observed at autopsy. The adrenals were most markedly affected in infections marked by a particularly toxic nature such as in the edema of gas poisoning or in peri- tonitis. Although the observed changes were not specific for any particular disease, they were related to the intensity and nature of the infectious process. 376 Injury of the adrenals fol- lowing the toxic and infectious agencies just described is limited chiefly to the cortical cells. The cells of the medulla undergo relatively slight changes as compared to the cortex. Prolonged injury results in the production of "colloid-droplets" TOXINS AND INFECTIONS 267 but mitoses are rarely observed in the medullary cells follow- ing such injuries. However, Graham 237 has reported active regeneration of the medullary cells in a case of fatal "shock." EFFECT OF TOXIC AGENTS AFTER ADRENALECTOMY Adrenalectomized animals are not only hypersensitive to such extraneous influences as excessive heat or cold, muscular exhaustion, excitement, etc., as pointed out in Chapter VIII, but they also show an abnormal sensitivity to various drugs and toxic agents. This hypersensitivity has been demon- strated for histamine, curare, strychnine, morphine, nicotine, acetonitrile, adrenaline, diphtheria or tetanus toxins, cobra venom, typhoid or staphylococcus vaccines, foreign proteins, and other toxic agencies. In many cases this hypersensitivity is very marked. 116 - U1 • 155 - 233 - 394 - 479 ' 629 The increased sensitivity of adrenalectomized animals to toxins will obviously depend upon the degree of adrenal insuf- ficiency from which the animals are suffering at the time of the injection of the toxin. Animals manifesting a marked degree of insufficiency will succumb to doses which are only a fraction of those tolerated by normal animals, while animals manifest- ing only mild or no symptoms of insufficiency after an incom- plete adrenalectomy will obviously not manifest an appreciable hypersensitivity. This variability in the response of adrenalec- tomized animals has led to the conflicting findings of different investigators. Thus the reported normal resistance of adrenal- ectomized rats to morphine or tetanus toxin is explained by the fact that the animals were incompletely adrenalectomized (as evidenced by their prolonged survival) and hence despite the absence of macroscopically visible accessory tissue, were not suffering from severe adrenal insufficiency. As first demonstrated by Dale and Laidlow, 148 adrenalectomy greatly enhances the sensitivity of animals to histamine. It is possible, however, that this hypersensitivity is in part (but not completely as claimed by Wyman 691 ) attributable to the 268 CORTEX extirpation of the medulla. Epinephrine and histamine are marked antagonists in their effects on the circulation. One would anticipate, therefore that the secretion of epinephrine called forth by an injection of histamine into a normal animal would raise its tolerance to this drug compared, for example, to a partially adrenalectomized animal in which no cortical in- sufficiency was manifest. In the case of most drugs hitherto investigated, however, the absence of medullary secretion is not responsible for an appreciable part of the hypersensitivity to toxic agents for such hypersensitivity can be counteracted by the maintenance of the animal on an adequate dose of the cortical hormone. 686 Adrenalectomized animals are also abnormally susceptible to anaphylactic shock as produced, for example, by the injec- tion of horse serum in rats or guinea pigs. 200 ■ 350 This effect is obtained if the animals are sensitized either before or after the removal of the adrenals, and is related chiefly to the degree of adrenal insufficiency. Rabbits with a high grade but sublethal adrenal insufficiency, after immunization with sheep blood-corpuscles, show hemoly- sin titers more than twice as high as in control animals. This increased antibody formation was attributed by Take and Marine 620 to a loss of some regulatory and inhibitory influence which the cortex of the adrenal normally exerts on the irrita- bility and susceptibility of the body cells. If the amount of antibody produced by an animal depends on the concentration of the dosage of antigen, increased formation of hemolysin in adrenalectomized animals would be explained by the failure of the body to detoxify the antigen in adrenal insufficiency thus maintaining it in a high concentration. There is also hyper- trophy of the lymphoid tissues in adrenal insufficiency and these may be concerned in antibody formation. 620 Rats immunized with typhoid vaccine within three weeks following adrenalectomy were found by Jaffe and Marine 336 to have agglutinin titers averaging two to three times that of TOXINS AND INFECTIONS 269 their controls. Although the resistance of rats to large doses of typhoid vaccine was still somewhat below that of normals six weeks after adrenalectomy, no difference in their agglutinin response could be determined. The increased antibody for- mation in recently adrenalectomized rats is a reflection of their decreased resistance to the antigen. The increased antigenic effect gradually disappears with resumption of normal cortical activity brought about by a regeneration of bits of tissue and accessory bodies left at operation. The above described effects are entirely the result of the re- moval of the cortex for epinephrine has no effect upon the opsonic properties of the blood or upon sheep-cell hemolysin or typhoid agglutinin production in rabbits. On the other hand, traumatization of the periadrenal tissues, as Perla and Gottes- man 496 have shown, produces the same effect as adrenalectomy on the formation of antibodies in rats. THE EFFECT OF THE ADKENAL CORTICAL HORMONE IN INFECTIONS One can attribute the marked sensitivity of the adrenals to toxins and infections to the unique chemical composition of these glands. Their high lipid content would obviously make them susceptible to attack by lipid solvents such as chloroform, ether, phenol, and the like. It is unnecessary to infer that the adrenals suffer because of their assumed anti-toxic function. On the other hand, one might be justified in assuming that the observed anatomical changes disturb the normal functional capacity of the glands and thereby play a part in producing some of the clinical manifestations of the toxic or infectious process. This has, however, not been proven and awaits fur- ther investigation particularly the study of the therapeutic effects of administering the cortical hormone in these condi- tions. 78 Scott and his collaborators 563 found their preparation of the cortical hormone to have no influence on the action of diphtheria toxin in guinea pigs, trypanosome infection in rats, and pneumonia in mice. Firor and the author in a few prelimi- 270 CORTEX nary experiments also found the injection of small doses of the cortical hormone to have no demonstrable influence on the mortality of mice infected with mouse typhoid. Nor did the infusion of 100 cc. of the cortical extract exert any demon- strable influence on a patient dying of peritonitis (probably pneumonic in origin). The above described experiments were too few in number and involved the use of insufficient doses of the hormone to make the results decisive. The reports of authors describing therapeutic effects in various infections of man are based on the use of extracts whose potency we know to be insignificant and hence must be viewed with scepticism. Further experi- ments using large doses of hormone are desirable to determine if exhaustion of the adrenals in certain infections is in part re- sponsible for the manifestations of these diseases. The evi- dence available at present does not suggest that this occurs except perhaps in rare cases. The fact that adrenalectomized animals succumb more readily than normal animals to the effects of toxic agents is no evidence, however, that the adrenal glands themselves play any direct role in conferring natural immunity on the normal animal. The facts only prove that in adrenal insufficiency the organism is incapable of its normal response to such toxic in- fluences due possibly to the incapacitation of the organs (e.g., the liver or kidney) which normally excrete, destroy, or de- toxify injected toxins or to a lowered resistance of the tissues generally induced by the adrenal insufficiency. It would not follow, therefore, that the adrenal cortical hormone will mani- fest antidotal actions against toxic agents or, as has already been indicated, that the hormone should manifest a therapeu- tically beneficent effect when administered in infectious dis- eases. The relation of the adrenals to the reaction of the organism to toxins and infections offers an interesting field for further study of the normal mechanism of these reactions. Chapter XVIII THE ADRENALS AND SURGICAL SHOCK Our ignorance of the function of the adrenals has made these glands the natural butt of theories purporting to explain the condition of shock. At first, dysfunction of the medulla was held responsible for the development of shock. With the shift of interest in the adrenals from the medulla to the cortex, these glands were again linked with shock, the absence of the cortical hormone being now held responsible for its develop- ment instead of epinephrine as in the older theories. Shock is a rather loosely defined term applied to a condition marked by a failure of the circulation manifested particularly by a fall in blood pressure. Shock occurs under a variety of conditions — after surgical operations, traumatic injuries, in toxic conditions, after excessive hemorrhage, in psychic dis- turbances, and the like. Many theories have been advanced to explain the underlying pathology which brings about a state of shock but none of these theories has proven satisfactory. Shock, like prostration, asthenia, or the like, is a term describing a condition rather than a disease entity and results undoubt- edly from a variety of causes quite unrelated to one another but having in common only the fact that they all cause a seri- ous collapse of the mechanism which normally maintains the circulation. One can explain the occurrence of shock under most conditions by a consideration of the underlying pathology accompanying the condition. Thus in a sudden widespread dilatation of the capillaries, the great increase in the capacity of the circulatory bed must necessarily result in a dangerous drop in blood pressure and a condition of shock. Similarly a sudden failure of the heart or the loss of a large volume of the circulat- ing fluid (as in hemorrhage) must result in shock. 271 272 COKTEX A large group of cases of shock occur under conditions in which simple hemodynamics does not explain the condition as easily as in the above described cases. Thus in the so-called cases of surgical shock, or in the shock following excessive trau- matic injuries, the local changes are not sufficient to account for the observed collapse of the circulation. In cases of this sort in which emboli (fat or air) have been released into the circulation it is obviously to embolism that we must attribute the observed shock. In certain cases, however, neither emboli nor the release into the circulation of toxic products can ac- count for the development of shock. Thus crushing of the testicles has been utilized experimentally to reproduce the condition in animals. In this form of shock, which also in- cludes many cases of surgical and traumatic shock, we must assume that the mechanical injury has released a stream of impulses which have resulted in the collapse of the circulation. The existence of such reflex impulses in response to trauma is easily conceivable when we consider the normal responses of the circulation to minor stimuli. 243 The present discussion of the supposed role of the adrenals in the causation of shock has been prefaced by the above con- siderations in order to indicate that shock is a symptom com- plex due to a variety of possible causes and is not to be con- sidered as a disease entity whose causation must be sought in some particular gland or condition. A failure to appreciate this has undoubtedly led to the many theories advanced for the condition, none of which has withstood the test of time. It would be wise perhaps if we were to cease using the term shock with the connotation of a disease entity of mysterious etiology and always modify the term by some expression indicative of its origin. The fact that epinephrine raises the blood pressure so spectac- ularly when injected and the fact that hypotension is one of the chief symptoms of shock led to the earlier theories relating SURGICAL SHOCK 273 the adrenals and shock. It was assumed that the abnormal stimulation which leads to shock, depletes the adrenal stores of epinephrine and thus leads to the observed drop in blood pressure. We have seen, however, that normally epinephrine plays no part in maintaining the vascular tone and that animals deprived of their entire medullarly substance maintain a normal blood pressure. We can thus dismiss the adrenal medulla and epinephrine as involved in the causation of shock. If shock really resulted from a depletion of the epinephrine of the adrenals, one would expect a marked rise in blood pressure to precede the fall. Such a rise is, however, not observed. Stimulation of the splanchnic nerves, 178 exposure of the vis- cera, 307 and sensory stimulation 105546 may cause an increase in output of epinephrine but it is doubtful if this secretion has anything to do with the ultimate development of shock in these conditions. The depletion of epinephrine from the adrenals in fatal cases of operative shock has been reported by Bainbridge and Parkinson 27 and Elliott, 181 but other workers have not confirmed these results. 639 Stewart and Rogoff 588 found that the output of epinephrine from the adrenals in their animals was the same during shock as under normal 'conditions but, as we have seen (Chapter VI), their values for the normal are probably too high. According to other in- vestigators epinephrine secretion is increased during shock. 547 In any case, these results would not prove the existence of any relation between the adrenal medulla and the development of shock. Rich 519 subjected normal and adrenalectomized animals to uniform intestinal manipulation and showed that the time required for the production of shock and the character of the blood pressure curves were the same in both cases. These experiments indicate that excessive epinephrine secretion is not responsible for the development of shock, but they do not exclude the possibility that the cortical hormone is involved. 274 CORTEX One can assume that in Rich's experiments sufficient amounts of the hormone remained in the organism after adrenalectomy to prevent the onset of shock for some time. Austmann, Halliday, and Vincent 25 kept dogs under ether for as long as 40 hours after removing both adrenals without any marked fall in blood pressure. Bazett, 47 on the other hand, found that although excision of the adrenal glands in cats causes no immediate fall in blood pressure, the extirpation hastens the onset of the fall which ultimately occurs in animals maintained for long periods under anesthesia (urethane) or after decerebration. This was particularly striking in the decerebrate preparations which normally maintain their blood pressure for several days if the body temperature be kept nor- mal. After excision of the adrenals, however, the blood pres- sure falls after about an hour and death occurs within ten hours after the operation. Injection of histamine causes a drop in blood pressure similar to that observed in shock. The adrenalectomized cat, as Dale 147 showed, is extremely sensitive to histamine. Although a normal, unanesthetized cat can tolerate an infusion of hista- mine in doses up to at least 10 mgms. per kilo., without severe effects, the same animal on the day following bilateral adrenal- ectomy is killed by doses as small as 0.16 mgms. per kilo. Anesthesia, likewise reduces the resistance of the cat to hista- mine. After an hour's administration of ether, 1 or 2 mgms. of histamine per kilo of body weight will induce the fatal shock characteristic of histamine poisoning. Dale pointed out that the "circulatory condition developing in the 24 hours following removal of the adrenals has features in common with that produced by histamine, including a pro- nounced increase in the proportion of corpuscles in the blood." As Dale recognized, it was impossible by his experiments to determine whether the absence of the medulla or the cortex was responsible for the decreased resistance towards histamine of the adrenalectomized animal. Histamine stimulates epineph- SURGICAL SHOCK 275 rine secretion (c/. Chapter VII) and this liberated epineph- rine may play a part in protecting the normal animal against histamine poisoning. Swingle and Parkins 611 have also studied the effect of various types of trauma on the arterial blood pressure of dogs with and without adrenal glands. Unlike the experiments of previous authors these were performed on animals adrenalectomized some days previously and kept alive by injections of cortical extracts. Swingle and Parkins found their adrenalectomized animals, supposedly maintained in good health on an adequate supply of the cortical hormone, to be extremely susceptible to traumatic shock. Administration of cortical hormone restored the adrenalectomized animals from a state of shock. The authors concluded from their experiments that depletion of the adrenal cortical hormone is the causative factor in surgical shock. Swingle and Parkins' conclusion is not proven, however, by their experiments. It is well known that animals after adrenal- ectomy go into profound shock under the effects of minor stimuli, an observation which has been noted by numerous workers. It is obviously necessary to conclude therefore that adrenalectomy (or more specifically the loss of adrenal cortical function) leads eventually to a state of shock which resembles in many ways that observed from a variety of other causes. To conclude, however, that shock in general is due to inade- quacy of the adrenal cortex, as Swingle and his collaborators claim, is not valid. The hypersusceptibility of their adrenalec- tomized animals to trauma is evidence only of inadequate therapy with the cortical hormone as the results of their own experiments, in which injection of hormone prevented shock, indicates. Restoration of adrenalectomized animals from shock by treatment with the hormone also proves only the long known fact that adrenalectomy reduces the tolerance of animals to influences which precipitate an animal into a state of shock. As has already been stated in Chapter IX, there is 276 CORTEX no evidence of any abnormal permeability of the capillaries in adrenal insufficiency, as claimed by Swingle and his collabora- tors, to account for the loss of blood volume which they assume is the cause of the development of shock in adrenal insufficiency. Heuer and Andrus 295 have recently reported that the adminis- tration of adrenal cortical extract controlled the shock which follows the injection of aqueous extracts of closed intestinal loops. Their results, however, do not appear convincing and the commercial extract which they utilized is of doubtful po- tency as regards its hormone content. Moreover, the fact that they were unable to obtain their results after heating the ex- tract to its boiling point indicates that they were deceived in attributing their observed results to the hormone, for as we have seen (Chapter XVI), the hormone is not so readily de- stroyed by heat. The cause of the state of shock which ultimately develops in adrenal insufficiency is still problematical. According to many authors the shock is due to the loss of fluid from the circulation, as described in Chapter XI. In some cases this may be true, for, occasionally, an intravenous injection of saline will induce a remarkable improvement in animals in severe adrenal insufficiency. In most cases, however, such injections are of no avail which is inconceivable if one accepts the view that adrenal cortical insufficiency expresses itself solely in the development of a state of circulatory shock. Other factors undoubtedly play a part and, except in those cases in which loss of fluid from the circulation results in a state of shock, we must look upon the development of this condition in adrenal in- sufficiency as an agonal manifestation comparable to that seen in many other fatal diseases. The question finally arises as to the implication of the ad- renals in the development of shock by influences other than adrenalectomy. It is quite conceivable that many conditions may deplete the supply of the cortical hormone from the body. In such cases the ultimate development of a state of shock may SURGICAL SHOCK 277 be comparable to that which follows adrenalectomy. A long period of etherization, protracted fevers, burns, etc. may pos- sibly lead to such a state. However, in most cases of shock it is difficult to see how the adrenals are implicated. Thus in such injuries as crushing of the testicles or manipulation of the intestines, it is unlikely that the adrenals should suddenly cease secreting the vital cortical hormone, or, if they do, that the supply of the hormone should be depleted so rapidly from the body. It is more logical and in accord with the known facts to attribute the shock which develops in such conditions to nervous impulses from the site of injury which reflexly cause a paralysis of the vasomotor system. Chapter XIX SURGERY OF THE ADRENAL Besides the complete excision of the adrenal glands, de- scribed in Chapter VIII, a number of other surgical procedures have been utilized for the experimental study of these glands. In order to simulate the condition obtaining in Addison's disease, efforts have been made to reduce the cortical tissue sufficiently to induce a chronic deficiency of the vital hormone without causing death from acute insufficiency. Partial ex- cision of the glands has been performed with this purpose in view. The results, however, have been unsatisfactory for the regenerative capacity of the cortical tissue soon leads to hyper- trophy of the remaining fragments and the resumption of normal adrenal function. 413, 571 - 582 - 594 Destructive lesions have also been produced experimentally by the injection of bacteria, bacterial toxins (diphtheria, tet- anus, pneumococcus, streptococcus, e£c.), 482 or chemical sub- stances (arsenic, mercury, chloroform, phenol, etc.). 52 The lesions of the cortex produced by these substances have al- ready been discussed in Chapters III and XVII. Martinotti 441 first observed the marked histological changes occurring in the adrenal after ligation of the lumbo-adrenal vein, and subsequent workers have utilized this procedure in an attempt to produce a chronic functional insufficiency. 184 - 248> 273 Ligature of all the vessels to the adrenal will usually result in a rapid onset of an acute adrenal insufficiency. In cats, how- ever, there exists a direct vascular connection between the adrenals and the kidneys and if this channel for venous drainage be left untied, one can produce a degree of chronic insufficiency. KoudintzefT 269 ligated the efferent vessels of dogs. His animals survived 16 to 24 days, had an elevated temperature, lost weight, and died in convulsions. 278 SUBGERY 279 Nothnagel 474 attempted to produce Addison's disease in animals by crushing the adrenals. He described the develop- ment of pigmented spots on the mucous membranes of rabbits in which this operation was performed. Abelous and Langlois 5 ligatured the adrenal pedicle and crushed or cauterized the glands in an attempt to induce a chronic insufficiency. Marine 434 and his coworkers froze the surface of the glands by a spray of ethyl chloride in order to induce partial cortical in- sufficiency. These methods have been only partially suc- cessful. It is difficult to adjust the degree of injury so that the animal will not die of an acute insufficiency or else survive without any demonstrable deficiency. 661 With a preparation of the cortical hormone available, the most satisfactory method of producing a partial insufficiency would seem to be the following : After complete adrenalectomy the animal is maintained on an adequate dose of the hormone until the operative wounds have thoroughly healed. The dose of hormone is now gradually reduced until a definite degree of insufficiency is clinically evidenced by a loss or failure to gain weight, a reduced body temperature, and general in- activity. By this method the author has succeeded in keeping animals (rats, cats, and dogs) in a state of chronic insufficiency for several months, during which time they developed the changes described in Chapter XIV. Many methods have been devised for destroying the med- ullary tissue without fatal injury to the cortex in order to study the effects of exclusion of epinephrine from the circula- tion. The adrenal may be scooped out, as in the experiments of Houssay and Lewis, 311 or destroyed by inserting glass capillaries containing radium or its emanations. 41 • 373 The possibility of destroying the medullary cells by a specific cytotoxic serum, as is reputed to have been done, 389 is very doubtful. Extirpation of one adrenal and denervation of the other has been the method most commonly used for excluding the medullary function, but it has not been proven and it is 280 CORTEX improbable that this procedure entirely prevents the secretion of any epinephrine from the denervated gland. SURGERY OF THE HUMAN ADRENAL Surgical operations on the human adrenal have involved chiefly the removal of the glands for tumors. Denervation of the glands or their resection for hypertension or hyperthy- roidism are based on such ill-defined grounds that they need not be considered here. 136 * Surgery of the adrenal has in the past been attended with an exceedingly high mortality. This is to be attributed probably to the acute cortical insufficiency which the patients suffer as a result of the combined effects of the trauma, anesthetic, reduction in the amount of active cortical tissue, and injury of the remaining gland by manipulation. The administration of large doses of the cortical hormone following the operation should offer a means of maintaining the patient in good condi- tion until the residual cortical tissue has hypertrophied. In the surgical approach to the adrenals in man either a lateral, posterior lumbar incision, or a transverse, abdominal incision half-way between the ensiform cartilage and umbilicus are most commonly employed. The former approach is similar to that used in operations on the kidney and avoids opening the peritoneal cavity. The second approach has the important advantage that it permits examination of the two glands. This is often of vital importance. An enlarged gland, assumed to be a tumor, has been removed with fatal outcome. Post-mortem examination proved the extirpated gland to be an hypertrophied gland while the other gland was atrophied. An abdominal approach also permits examination of the ovary for suspected tumors. 95 - 655 Crile 655 has emphasized the danger of handling the glands, the delicacy of which we have already discussed in Chapter III. Handling may cause a fatal apoplexy of the adrenals and Crile therefore recommends that the examination of each * Cf. Jour. Am. Med. Assoc, vol. 106, p. 279. SURGERY 281 gland be made at a separate operation. Judging from the results of adrenalectomy in animals this would appear to be a wise procedure. The discovery of a technique by which to differentiate the androgenic tissue which gives rise to the tumors described in Chapter XXIII from normal cortical tissue is very desirable. Broster and Vines 95 have described such a technique but it has not as yet found general acceptance. When such differen- tiation shall be possible, the removal of a slice of tissue for biopsy will permit an accurate diagnosis and determine the nature of the operation to be performed. At present the surgery of the adrenal is handicapped by the inability of the operator to judge the nature of the pathological process in- volved, unless there be an obvious f ungating tumor. An enlarged gland which appears to be a tumor may in reality prove to be a normal hypertrophied organ. The surgeon may remove the greater part of a gland and yet leave a large amount of the offending tissue. If the adreno-genital syndrome be due to hypertrophy of the juxta-medullary androgenic zone, as indicated in Chapters IV and XXIII, it would be futile to remove one adrenal and part of the other to cure the condition, for the remaining androgenic tissue will continue to grow. Where only one gland is involved, unilateral extirpation should prove adequate. When the affection is bilateral, as it appar- ently frequently is, it will be necessary to devise a technique whereby the internal layers of the cortex (consisting of the androgenic tissue together possibly with the medulla) are scooped out, leaving the normal and vital external layers of the interenal tissue. ADRENAL GRAFTS Transplantation of adrenal tissue has been performed by a number of investigators in both man and the lower animals. Most of the attempts in the human subject were performed many years ago when grafting of tissues was undertaken with 282 COKTEX an optimism that we now would deride. Thus Bra 119 trans- planted the adrenals of a dog into the cellular tissue of the abdomen in a child with Addison's disease. Death followed in three days. Jaboulay's two cases died within 24 hours following a similar transplantation as did also the patient of Courmont. 1 * 9 In view of the fact that the transplantation of human tissue is fraught with the greatest of difficulties, one is forced to disregard the claims of all early investigators who optimistically report favorable results from transplants of pig, sheep, and dog adrenals into patients suffering from Addison's disease. The introduction of foreign protein and the necessary operative procedures could only have aggravated the adrenal insufficiency of these patients. The small amounts of hor- mone present in the transplanted tissues were too minute to exert even any temporary amelioration which, when it oc- curred, must have been due to the natural remissions so com- mon in Addison's disease. Attempts have also been made to transplant the adrenals of premature fetuses into patients suffering from Addison's disease. In most cases the patients were in the late stages of the disease and the shock of the operative procedure hastened the onset of death. In only one case was success reported with recovery of the patient but when the latter, some years later, came to autopsy it was found that his adrenals were normal, that he had never had Addison's disease, and that the as- sumedly successful grafts into the testicle had undergone atrophy. 122 Other cures have been reported but must be viewed with scepticism. 145 In animal experiments, on the other hand, successful grafts and transplants of the adrenals have been made by several investigators, despite the failures of many of the earlier workers who failed to appreciate the difficulties attendant upon trans- planting any tissue to a new host. Boinet's intraperitoneal grafts in rats were unsuccessful as were also those of Strehl and Weiss, 600 and Hultgren and Anderson's 323 intramuscular SURGERY 283 grafts in cats and rabbits. In Poll's subcutaneous grafts some regeneration of the cortex occurred while the medullary tissue disappeared. Similar results were obtained by grafts in the omentum of the rat by H. and A. Cristiani. 137 Stilling 597 found cortical tissue grafted into the testicle of a rabbit to be active after three years. Busch, Leonard, and Wright 145 made successful grafts into the kidneys of rab- bits which maintained life after bilateral adrenalectomy. Death followed the removal of the grafts. In none of the above cases was medullary activity demonstrable, the medulla always disappearing in the transplanted tissue. Abelous and Langlois 4 successfully transplanted adrenal tissue into the lymph sacs of frogs. Abelous was also suc- cessful in producing homotransplants into the ileo-coccygeal muscles, the subsequent removal of which in previously adrenalectomized animals caused the frogs to manifest the typical symptoms of adrenal insufficiency. In recent years, grafting of adrenal tissue has been per- formed successfully in guinea pigs and rats. Elliott and Tuckett 183 found the subcutaneous tissues of the guinea pig to be peculiarly sensitive to adrenal grafts. The irritant sub- stance inducing this tissue reaction to grafts of guinea pig adrenals, occurred chiefly in the medulla but was almost absent from the adrenals of carnivores and was not, therefore, epinephrine. Jaffe, 334 however, found that autoplastic trans- plants into the abdominal wall of guinea pigs remained for months, growing to fairly large size. Homoplastic transplants, on the other hand, usually degenerated after a few months. Small autoplastic transplants maintained the life of completely adrenalectomized animals for weeks while large transplants maintained them indefinitely in good condition. In these experiments Jaffe avoided the transplantation of medullary tissue, transferring small bits of the cortical tissue, after wash- ing in saline, into pockets in the muscle of the abdominal wall. In the rat, Jaffe 333 and Wyman and Suden 692 have obtained 284 CORTEX successful autoplastic transplants in a large fraction of their animals. Homoplastic transplants are also successful in the rat but heteroplastic transplants have not been achieved. The growth of transplants is contingent upon a physiological need for their secretion and hence such transplants can not be used to induce hyperfunction of the cortical tissue. The total amount of tissue regenerating is fairly constant and limited by the needs of the organism and the amount of functional tissue already present in the animal. 692 The oft-quoted successful transplants of Haberer 261 are not really grafts but consist merely in transferring the whole adrenal after dislocating it from its peritoneal attachments to an incision into the kidney. The blood vessels to the gland are left intact. Such dislocated glands continue to grow in the kidney without suffering degeneration even of the medullary tissue. The medullary tissue shares the property of nervous tissue generally, to which it is embryologically related, in showing little or no regenerative capacity. Hence in transplants of whole glands the medulla soon degenerates. 141 Undoubtedly the liberation of epinephrine from the degenerating medulla will inhibit growth of the cortical cells and hence one should only use the outer zone of the cortex (which constitutes the active regenerative tissue) in transplants. The abdominal muscles, ovaries, testicles, kidneys, and subcutaneous tissue of the axilla have been favored as the most practical sites for successful transplants. In recent years, the effort to transplant cortical tissue into patients with Addison's disease has been revived, but thus far no convincing report of any success has beeen published. One of Beer and Oppenheim's 49 two patients showed micro- scopic areas of functional tissue at autopsy two weeks after the transplant. The other patient improved after the transplant, but such improvement must be attributed to a natural re- mission for it is inconceivable that the minute amount of SURGERY 285 hormone present in the transplanted fragments could have had any immediate remedial effects. A method for the successful transplantation of cortical tissue in clinical cases is highly desirable. Unfortunately the trans- plantation of all glands is still in the experimental stage. The difficulty of obtaining healthy material for the transplant and the desensitization of the recipient to the foreign tissue are the two outstanding problems which must be solved before one can hope for a successful general application of tissue grafting. The great need and value of a method for transplanting corti- cal tissue in man make it desirable that further studies in this field be inaugurated. Chapter XX OTHER CHEMICAL CONSTITUENTS OF THE ADRENALS Besides epinephrine and the cortical hormone, which we have considered in previous chapters, the adrenals contain a number of other compounds in relatively high concentrations. The presence of these constituents of the adrenals has excited the curiosity of many observers who have attributed to them an importance which the factual evidence at hand does not justify. In every tissue are found numerous compounds the significance of which to the animal economy is unknown. Many of these compounds (e.g., the lipids) are an essential part of the structure of the cell. The presence of others is perhaps incidental and dependent upon solubility relationships. Substances will distribute themselves throughout the organism in accordance with the physico-chemical laws of solution. Hence a lipid-soluble vitamin will be concentrated in glands having a high lipid content rather than in muscular or con- nective tissues. The mere presence of a compound in the adrenals does not therefore justify the assumption that it is necessary for the proper function of these glands or that it is produced by these glands. In the present chapter we shall consider a group of substances found in the adrenals and evaluate the available evidence as to the significance of their presence in the glands. The isolation of a chemical compound from the adrenals does not prove that it was present in the normal gland for its pres- ence may be the result of post-mortem changes or of the chemical manipulations utilized in its isolation. The adrenal is note- worthy for the rapidity with which it undergoes autolytic changes. If one extracts a fresh gland with a solvent such as alcohol or acetone the solution thus obtained is light yellow 286 CHEMICAL CONSTITUENTS 287 and free of many constituents present in the dark brown solu- tion obtained when glands are extracted which have stood for sometime at room temperature after the death of the animal. Obviously autolysis results in the production of a number of substances not present as such in the normal living organ. GENERAL COMPOSITION Even superficial examination of an adrenal gland will show its exceedingly high lipid content. In an analysis by Biedl, 56 the adrenals of the pig showed 74.61 per cent water and 25.39 per cent dry residue. Of the latter, 61.12 per cent was protein-like in nature while 38.88 per cent was of a lipoidal or fatty nature. The water content of the adrenal glands undergoes wide variations which are dependent on the lipid content of the gland. The greater the lipid content, the less is the water content of a given gland. Materna and Januschke 445 found the water content of the human adrenal to vary from 58 per cent to 85 per cent of the gross weight of the gland. This represents an unusual variation not frequently encountered in other organs. The adrenals are also characterized by an unusually high sulfur content, 3.77 per cent of their dry residue being com- posed of this element. Only the epidermis and its horny derivatives (hair and nails) have such high sulfur contents. This high sulfur content led Loeper and his coworkers and Aufrecht and Dresing 135 to assume that the adrenals are in- volved in the sulfur metabolism of the body, but other evidence for this view is lacking. The nature of the sulfur compounds present in the adrenals is not entirely clear. A great part of the sulfur is present as glutathione which is found in higher concentration in the adrenal glands than in other organs. Thus in the dog Blanchetiere et alii* 2 found the adrenals to contain 4.8 mgms. of glutathione per gram of adrenal tissue, while the liver and 288 CORTEX striated muscles contained only 3.1 and 0.7 mgms. per gram, respectively. In the rat, Houssay and Mazzoco 314 found the adrenals to contain 12 mgms. of glutathione per gram of gland. The venous blood draining the adrenals is particularly rich in glutathione. Perfusion of an adrenal with solutions contain- ing glutamic acid and cystine gives rise to the synthesis of glutathione, according to Blanchetiere and his coworkers. 62 On the other hand, Houssay and Mazzoco 3 ' 4 found the reducing action of muscle and liver to be increased after adrenalectomy which they attribute to an increased glutathione content of these tissues. Obviously one would not expect such a result if the adrenals were the site of synthesis of glutathione. Further work is necessary to elucidate the exact relation between the adrenals and glutathione metabolism. 449 A crystalline compound, having the empirical formula — C35H74O8N2S, has been obtained from the adrenals but the evidence adduced is so meager as to lead one to doubt that the compound is in reality a pure substance. Elementary sulfur is easily eliminated from the compounds in which it occurs in the adrenals. Deposits from crude adrenal extracts have often been found by the author to contain beautifully formed diamond-shaped crystals which Hendricks and Milner demon- strated to be elementary sulfur. LIPIDS As we have already noted, the adrenals are characterized by an unusually high lipid content and investigators since Virchow 650 have devoted much attention to the study of these lipids both from an anatomical as well as from a chemical viewpoint. These two methods of study often give results which superficially seem to be irreconcilable. For example microscopic observations will often reveal an apparent disap- pearance of the lipids from the adrenals in certain pathological conditions. Chemical analysis may show, however, only in- significant changes in the lipid content of the glands. The CHEMICAL CONSTITUENTS 289 lipids are thus able to assume forms which differ as regards their staining and morphological appearance and it is necessary to bear this fact in mind in interpreting anatomical observa- tions. There is a considerable species difference regarding the distribution as well as the composition of the lipids. In some animals (including man) the lipid shows double re- fraction but this optical evidence of anisotropy is absent in the adrenals of some of the lower animals. In man the lipids, as observed histologically, seem to be present chiefly in the fasciculata. The reticularis contains smaller droplets while the glomerulosa appears to be free of visible lipids. The fat droplets have a peculiar glistening appearance and show the double refraction referred to above, when observed under a polarizing microscope. After fixation in formalin or bichromate, the lipids are solidified but melt again when heated to 56°C. 157 In the dog, the glomerulosa is the chief depository of lipids while in the Cheiroptera (bats) the lipids are present chiefly in the reticularis. 362 Various stains are utilized to demonstrate the presence of the adrenal lipids histologically. Osmic acid stains the droplets black or greyish brown ; sudan and scarlet red, a brilliant orange or red; nile blue, violet or blue. Like myelin, the lipid is stained blue by Weigert's method. The adrenal lipids are also characterized by the relative ease with which they are removed from the cells by such sol- vents as xylol, ether, or chloroform. The chief constituent of the anisotropic lipid is cholesterol and its esters. Wacker and Hueck 653 found each human adrenal to contain 0.4 per cent of free cholesterol and 0.1 to 0.15 per cent of cholesterol esters. However, other substances are also present which contribute to the anisotropic property of the adrenal lipids. Thus Rosenheim and Tebb 135 have isolated stearic and palmitic acids, sphingomyelin (a phos- pholipid), and phrenosin (a phosphorous-free galactosid) from 290 CORTEX the adrenal cortex. They believe the anisotropic substance in the cortex to be free stearic and other fatty acids, as well as cholesterol esters. The existence of a cannaubic acid ester as claimed by Biedl 66 is questionable. With the exception of the central nervous system, no organ contains as much lecithin-like substances as the adrenals. 135 The lipid content of the adrenals undergoes marked changes in response to various physiological and pathological conditions, but the significance of these changes is not entirely clear. During muscular exercise, according to Elliott and Tuckett, 183 the lipids diminish in amount, reappearing during rest. By feeding with cholesterol, the anisotropic fat content may be markedly increased. The adrenals apparently reflect the lipid content of the blood. Thus small doses of saponin which increase the cholesterol content of the blood also increase the amount of lipids present in the adrenals, while large doses of this poison diminish the cholesterol content of both the blood and the adrenals. The cortical lipids also undergo changes in various path- ological conditions, but the significance of these changes is not clear. There is a disappearance of the lipids in infectious or toxic processes 78 as well as in anemia and severe hemorrhage. In chronic cardio-vascular-renal disease, in inanition, and cachexic conditions generally, the lipids are often increased. 156 There has been considerable speculation regarding the role which the lipids play in the adrenals. We have already con- sidered (Chapter XI) the changes in the cholesterol content of the blood in adrenal insufficiency and their probable relation to adrenal physiology. Lipids are widely distributed through- out the organism and constitute a fundamental part of the architecture of all cells. It is doubtful therefore if the lipids of the adrenal play the specific role which earlier writers attributed to them. The views that the cortex is the seat of manufacture of the lipids of the body, that the adrenal regulates the lipid me- CHEMICAL CONSTITUENTS 291 tabolism, or that the lipids of the adrenal perform an indis- pensable function in the organism are no longer tenable. The fact that adrenalectomized animals maintained on lipid-free extracts manifest no abnormalities attributable to the absence of the adrenals proves that although the adrenal lipids are probably essential parts of the cells, they are neither the product of these cells nor is the adrenal tissue per se necessary for the normal lipid metabolism of the organism. CHOLINE AND ACETYLCHOLINE Hunt 324 first demonstrated the presence of choline in ex- tracts of the adrenals and demonstrated that such extracts contained a substance which readily yields choline on chemical manipulation. Since choline is a product of the hydrolysis of the phosphatides, it is found wherever the ubiquitous lecithin occurs and it is often very difficult to decide whether the choline obtained from an organ was originally present as such or was derived from lecithin. Feldberg and Schild 193 found acetylcholine to be more abun- dant in the medulla than in the cortex, the proportion varying from 2.5:1 to 4.5:1. The reverse relation held for choline. These authors (Chapter VI) also demonstrated the secretion of choline from the adrenals during stimulation of the splanch- nic nerves. The presence of choline in the adrenals has led authors to assume that this substance is an important product of the gland and some have even hypothecated that it is the cortical hormone. There is nothing to support these views nor is there, except for the experiments just cited, any evidence to indicate that choline or its esters play any significant role in the ad- renals. These substances may, however, contaminate crude adrenal extracts. Some of the pharmacodynamic effects of such extracts described in the literature are undoubtedly to be attributed to the presence of choline rather than to the cortical hormone.' 68 The biological assay of the epinephrine content 292 CORTEX of adrenal extracts may also be vitiated by the presence of choline and its esters since the pressor effect of epinephrine is easily antagonized by small amounts of these substances. VITAMINS The adrenals contain appreciable quantities of vitamins A, B, C, G, and probably other vitamins in lesser concentra- tions. The idea of the existence of an intimate relationship between the adrenal cortex and vitamins A, B, (Bi), C, and G (B 2 ) has received much attention in recent years. This supposed relationship has been based upon: 1) the high con- centrations of the vitamins (particularly A and C) occurring in the adrenal; 2) the changes occurring in the adrenal during avitaminosis (atrophy in avitaminosis A; hypertrophy in avitaminosis B and C); 3) the increase in susceptibility to infectious disease in avitaminosis and in adrenal insufficiency; 4) the similarity between certain of the clinical manifestations of avitaminosis and of adrenal insufficiency; 5) the alleged ameliorating effects of cortical extracts in avitaminosis B and C ; 6) the similarity between certain of the chemical properties of the adrenal cortical hormone and vitamin G (B 2 ). 247 Vitamin A. The high concentration of carotene (pro- vitamin A) in the cortex may be attributed to the high lipid content of the gland. Other lipoidal tissues, such as the corpus luteum also contain equally high concentrations of pro-vitamin A, and we may therefore consider the existence of pro-vitamin A in the adrenal to be due to the laws of distribution based on simple solubility relationships. The adrenal atrophy occur- ring during avitaminosis A may be considered as part of a general reaction to the lack of a vital factor necessary for the well-being of many organs and tissues. There seems no reason, therefore, to assume the existence of an intimate rela- tionship between vitamin A and the adrenal cortex. 456 Vitamin B (J5i). Pico-Estrada 606 demonstrated the in- creased susceptibility of adrenalectomized rats to avitaminosis CHEMICAL CONSTITUENTS 293 B. It is well known, however, that adrenalectomized animals are hypersensitive to any abnormal condition — the adminis- tration of drugs, dietary deficiences, temperature extremes, excitement, et cetera. Hence his observations indicate no special relationship between the adrenals and vitamin B. 247 Schmitz and Kuhnau and Lockwood and Hartman claimed that they could ameliorate the symptoms of vitamin B de- ficiency by administration of cortical extracts. 247 However, since the adrenal cortex is rich in vitamin B content, it is im- perative to remove all traces of this vitamin before one can conclude that the effects observed after administering a given extract are due to the cortical hormone rather than to simple contamination by the vitamin. The cortical hormone as prepared by these authors was a relatively crude extract containing a number of constituents. When one considers the difficulty of removing the last traces of vitamin B from rela- tively pure casein or from refined lactose it is not unexpected that crude cortical extracts should contain this vitamin. That this contamination of the extracts was probably responsible for the observations of Schmitz and Kiihnan and Lockwood and Hartman was demonstrated by Grollman and Firor. 247 The last named authors demonstrated that the administration of adrenal cortical extracts did not ameliorate the symptoms of avitaminosis B and hence the assumption of an interrelation between the hormone and the vitamin was unfounded. The gross and histological changes occurring in the adrenals of animals suffering from avitaminosis B is no more striking than that which occurs in other endocrine glands and that might be anticipated to result from the inanition and retardation in growth which accompany vitamin B deficiency. Vitamin C (ascorbic acid). Vitamin C was first isolated in crystalline form from the adrenal glands. While seeking the active principle of the adrenal cortex, Szent-Gyorgi 6]5 isolated a crystalline compound having the formula, C 6 H 8 6 , which subsequent work showed to be identical with vitamin C. 294 CORTEX Szent-Gyorgi named the compound ascorbic acid but the name cevitamic acid has been adopted by the Council of the Ameri- can Medical Association to avoid any therapeutic implications. Ascorbic acid is present in both the cortex and the medulla. Reduction of silver nitrate to give a black precipitate has been used to indicate its presence but this test is interfered with by the epinephrine of the medulla. 326 Hence the conclusion of earlier workers that ascorbic acid was present in the cortex only is incorrect. The concentration of ascorbic acid differs in different parts of the gland. Glick and Biskind 225 found 1.2 to 1.3 mgms. of the vitamin per gram of medullary tissue in beef adrenals. In the fascicular layer of the cortex, it was present in a concentration \\ times as great as in the medulla. The structure of ascorbic acid has been determined and its synthesis accomplished. Its distribution in the organism and its chemical, physiological, and therapeutic properties have been widely investigated. The ascorbic acid content of the adrenals of various animals ranges from 0.76 mgms. per gram for the beef to 5.2 mgms. per gram for the rat. 607 The ascorbic acid content of the liver varies from 0.08 mgms. per gram for the rabbit to 0.46 mgm. for the sheep and the rat. Considering the relative sizes of the adrenal and the liver it is obvious that the latter organ is the chief store for ascorbic acid in the body. Other organs also contain an appreciable amount of ascorbic acid. Thus Svirbely 607 found the following average values for the ascorbic acid content of the guinea pig, expressed in mgms. per gram of different organs: adrenal, 0.25; liver, 0.02; kidney, 0.02; heart, 0.005; spleen, 0.08; leg muscle, 0.005. The presence of vitamin C in the adrenals led earlier workers to assume that these glands were intimately associated with the production of scurvy. Experiments were adduced which reputed to show that the administration of the cortical hor- mone ameliorated the symptoms and protected animals against scurvy. It was demonstrated by Grollman and Firor, 247 how- CHEMICAL CONSTITUENTS 295 ever, that ascorbic acid has no value as a replacement therapy in adrenal insufficiency. Nor conversely does the adrenal cortical hormone act in preventing the development or in mitigating the symptoms of scurvy. The results of previous authors who had claimed otherwise were due in part possibly to the contamination of their crude extracts with ascorbic acid, and in part to a misinterpretation of the significance of their observations. 330 Vitamin G (2? 2 ). Purified adrenal cortical extracts have no demonstrable effect on the development of avitaminosis in rats deprived of vitamin G. The failure of young animals main- tained on a vitamin-G-free diet to grow can not be attributed to adrenal insufficiency, for administration of the cortical hormone does not stimulate growth in such animals. The presence of this vitamin in the adrenals must be considered in the same light as has been indicated in our discussion of vita- mins A, B, and C. 247 As already indicated the vitamins are also found in as high a concentration as they occur in the adrenals in other organs. Moreover, adrenalectomized animals maintained on adequate doses of the cortical hormone manifest no symptoms of vitamin deficiencies. We are justified in concluding, therefore, that it is only incidental that these vitamins occur in the adrenals. The susceptibility of the adrenal gland to conditions of avi- taminosis is also not unique, for other endocrine organs (thy- roid, pituitary, sex glands, etc.) are equally affected by dietary deficiencies. The vitamins, apparently, are essential for the well-being of a great number, if not all, of the organs and tissues of the body. The similarity between certain clinical mani- festations of dietary deficiencies and of adrenal insufficiency are due to the fact that the cortical hormone is also necessary for the well-being of a number of tissues and organs. Hence, deficiency due to either vitamin or hormone leads to a mul- tiplicity of manifestations (in the gastro-intestinal, nervous, cardiovascular, endocrine and other systems) and to a super- 296 CORTEX ficially similar symptomatology. The increased susceptibility to infectious disease in avitaminosis and in adrenal insufficiency is only an indication of a general lowering of body-resistance — a condition occasioned by a number of causes. 247 OTHER CONSTITUENTS Small amounts of neurin are found in the adrenals and it has been suggested 68 that epinephrine may be derived from this neurin and pyrocatechol. Neurin is closely related to cholin which on decomposition yields hydroxy-ethyl-amine, the side group of the epinephrine molecule. Histamine is present in extracts of the adrenals but it is probable that it is formed during extraction, from labile mother-substances. It is to histamine, choline, and acetyl- choline that we must attribute the fall in blood pressure ob- served after injecting impure adrenal cortical extracts. Jecorin, originally thought to be a pure substance, was iso- lated from the adrenals by Menasse, but subsequent work has shown this substance to be an adsorption compound of kephalin, inorganic salts, sugars, and other organic sub- stances. 135 Adrenal extracts have been shown to manifest a number of enzymic actions. Thus the power of such extracts to oxidize salicylic aldehyde have been attributed to the presence of an aldehydase. 135 It has also been shown that the adrenals exert a marked diastatic activity. 56 The distribution of the lipo- lytic enzymes in the different zones of the adrenal has recently been determined. 226 The yellow color of the adrenal is due to the presence in the adrenals of carotin, xanthophyll, and lipochromic substances. Infiltration of lipochromes occurs in many conditions associated with anatomical changes in the adrenals. The lipochromes are derived from the ingested food while the melanin pigment observed in the adrenals is endogenous in origin. 196 PART IV. CLINICAL CONSIDERATIONS The involvement of the adrenals in Addison's disease, in adrenal tumors, and in certain anomalous developments of the reproductive system has been well established. Aside from these three conditions, which will be discussed in the following chapters, the adrenals have been implicated in a number of other clinical conditions on the basis of rather meager or ob- viously fallacious evidence. It is, nevertheless, very probable that the adrenals are involved in clinical conditions other than those generally recognized at present. Heretofore, pathologi- cal evidence and clinical observation have been the sole means whereby one might hope to detect the association of adrenal dysfunction with some clinical condition. Both of these methods are, however, notoriously unsatisfactory. The his- tological study of the adrenals is fraught (as we have seen in Chapter III) with great difficulty and unless the greatest pre- cautions are taken it is difficult to interpret the significance of any observed abnormalities. Clinical observation is also an unsatisfactory means of gauging adrenal function for the symptoms associated with adrenal insufficiency are shared by a number of diseases in which the adrenals are not involved. The development of potent extracts of the adrenal cortex has opened a new field of investigation in the clinical study of the adrenals. It is now possible by applying the therapeutic test to determine if insufficiency of the adrenals is responsible for a given clinical condition. Most of the earlier clinical literature on the adrenals was based on the belief that epinephrine was the sole or at least the important internal secretion of these glands. The litera- ture, even of recent years, contains voluminous reports based on this assumption. There is, however, no valid evidence to indicate that an insufficiency of the adrenal medulla manifests 297 298 CLINICAL CONSIDERATIONS itself clinically in any way. Despite its wide therapeutic ap- plications, there is no clinical condition which can be proven to be a result of an insufficient secretion of epinephrine from the adrenal medulla. Chapter XXI ADDISON'S DISEASE Thomas Addison's 7 treatise "On the Constitutional and Local Effects of Disease of the Suprarenal Capsules" published in 1855, is one of the classics of medical literature. His publi- cation initiated the modern study of the adrenal glands and remains today, from a clinical standpoint, almost complete in its accurate description of the disease. Addison's observations were soon confirmed by Wilks, 681 Greenhow, 242 Hutchinson, Isaac Taylor, and Trouseau. 640 The last named author first applied the term "Addison's Disease" in 1856. Addison's original conception of the disease was the one which is generally accepted today: viz., that any lesion of the adrenals sufficient to interfere with their function would give rise to the train of symptoms characteristic of the disease. This view, however, soon became the subject of criticism by Addison's contemporaries who considered the disease as origi- nating from a special lesion of the glands which resulted in secondary effects on the neighboring sympathetic nerves and ganglia. Addison also was led to alter his original views and to regard an involvement of the sympathetic system as a con- tributing factor in causing the disease. This "nervous" theory of the origin of the disease was in time abandoned when it was found that in many cases of genuine Addison's disease there was no involvement of the sympathetic system. Wilks, 681 who studied the pathological anatomy of Addison's first patients, reported in 1865 a total of 33 cases which he con- sidered as belonging to the disease entity which Addison had described. He excluded, however, certain of Addison's origi- nal cases as not belonging to this category. Wilks first noted the enlarged lymph nodes and lymphoid tissue, and the hypo- 299 300 CLINICAL CONSIDERATIONS plasia of the heart, which are found in patients dying of Addi- son's disease. He denied, however, the tuberculous nature of the adrenal involvement, for the variety of pathological forms in which tuberculous lesions manifest themselves was not clearly understood until a later date. INCIDENCE Addison's disease is relatively rare. In the United States 300 to 400 persons die annually from this cause, the death rate from Addison's disease being 0.4 per 100,000 population. In the British Isles the death rate is given as 0.6 while in Japan it is said to be only 0.04. 260 Only 5 of the 320 persons recorded in 1917 as dying from Addison's disease were negroes which is surprising in view of the high incidence of tuberculosis in this race. It may be that because of the impossibility of detecting the pigmentation, which is so important an aid in diagnosis, most cases of the disease in the dark-skinned races are not recognized. Addison's disease is one of middle life, the majority of cases occurring between the twentieth and fortieth years of life. Although cases have been reported in infants and in octoge- narians, the disease is rare in children under 10 years of age. Except in very rare instances there is no evidence of any hered- itary factor involved in the etiology of the disease. About two-thirds of all cases occur in males. 540 Many predisposing causes have been noted such as worry, emotional shock, alcoholism, heredity, infections— especially malaria, influenza, pneumonia, and tuberculosis, — but it is doubtful if any except the last named play an etiologic role. The incidence of Addison's disease was not materially increased following the influenza epidemic of 1918. Hence it is very doubtful if influenza can be considered as a predisposing fac- tor. 260 A patient will naturally date the onset of the disease to some illness which may have been incidental or have accen- tuated a previously latent condition. addison's disease 301 CLINICAL COURSE The onset of the disease and the development of the cardi- nal symptoms — asthenia, gastro-intestinal disturbances, and pigmentation — are extremely insiduous in their development. The patient begins to tire readily on slight exertion and be- comes incapable of physical or mental effort. His complexion gradually becomes darker. Gastric symptoms with loss of appetite, nausea, and constipation alternating with diarrhea occur with increasing frequency. The clinical course of the disease has been aptly described by Addison 7 as follows: "The patient, in most of the cases I have seen, has been observed gradually to fall off in general health; he be- comes languid and weak, indisposed to either bodily or mental exertion; the appetite is impaired or entirely lost; the whites of the eyes become pearly; the pulse small and feeble, or perhaps somewhat large, but excessively soft and compressible ; the body wastes without, however, pre- senting the dry and shrivelled skin and extreme emacia- tion usually attendant on protracted malignant disease; slight pain or uneasiness is from time to time referred to the region of the stomach, and there is occasional actual vomiting, which in one instance was both urgent and dis- tressing; and it is by no means uncommon for the patient to manifest indications of disturbed cerebral circulation." . . . "We discover a most remarkable and, so far as I know, characteristic discoloration taking place in the skin — suf- ficiently marked, indeed, as generally to have attracted the attention of the patient himself, or of the patient's friends." "The disease develops in the third or fourth decade of life, usually quite insidiously, with adynamia and apathy. To these are added disturbances of the digestive tract (constipation, often alternating with diarrhea), and pig- 302 CLINICAL CONSIDERATIONS meriting of the skin and mucous membranes : the patients succumb under a gradually increasing cachexia, not rarely with stormy terminal manifestations; autopsy almost al- ways shows disease of both suprarenals, mostly tubercu- lous caseation." Although the typical course of the disease leads to a fatal result in two to four years, chronic types have been reported 119 in which patients have lived for ten or twenty years after the onset of the initial symptoms. In the acute forms death may follow in less than a week. Thus in a case due to thrombosis of one adrenal and infarction of the other, death occurred in five days. 119 The average duration of the disease is about two years and varies according to the underlying pathological proc- ess as discussed later. SYMPTOMATOLOGY Asthenia, pigmentation, loss of weight, digestive disturb- ances (anorexia, nausea, vomiting, constipation, diarrhea), and abdominal or lumbar pain constitute the chief symptoms of complaint of patients suffering from Addison's disease. The symptoms of the disease will vary depending upon the stage of its development. In an acute crisis the gastrointes- tinal disturbances— nausea, vomiting, diarrhea, abdominal pains — may be the outstanding symptoms and lead to an er- roneous diagnosis of an acute "surgical" abdomen. Hiccup may precede the onset of a crisis. In the chronic stages of the disease, asthenia, weakness, pigmentation, hypotension, and decreased resistance to disease are the predominant symptoms. Asthenia. Asthenia (physical and psychic) is the most char- acteristic and constant symptom. There is extreme lassitude and constant fatigue, which steadily progresses in its severity except during periods of remission. The patient ultimately is unable to rise from bed or even to perform the slightest move- ments. 540 addison's disease 303 Pigmentation. A peculiar pigmentation of the skin is one of the most striking findings in Addison's disease. Addison 7 described the pigmentation as a "dingy or smoky appearance or various tints or shades of deep amber or chestnut brown." With progress of the disease, the skin becomes light brown, bronze, dark brown, and ultimately the dark hue of a negro. Although pigmentation has been considered by some authors as an indispensable symptom in diagnosis, Lewin 392 found pig- mentation in only 72 per cent of his cases. Lewin's estimate is probably too low, but there are a number of recorded cases 119, 54 ° in which the diagnosis has been confirmed by au- topsy and which during life were typical examples of Addison's disease except for the absence of pigmentation. In acute cases, particularly, pigmentation may be absent. In many cases the pigmentation may be the first symptom to attract the attention of the patient's friends. The pigmentation is most marked in regions normally pig- mented or exposed to light or pressure. It appears first on the face, neck, backs of the hands, and particularly on the knuckles. The skin of the scalp and areas covered by hair usually escape the pigmentation as do also the nail beds, palms, and soles. 119 Pigmentation of the mucous membranes of the mouth, con- junctiva, and vagina, and of the serous membranes also com- monly occurs. In the mouth this pigmentation usually is found as small spots and streaks of a bluish black color, on the lips, on the border of the tongue, the buccal mucosa, and gums. 540 Cases of remission in the pigmentation and even its disap- pearance have been recorded. However, an apparent reduc- tion of the pigmentation is produced by hydration of the skin. This may account for the claimed diminution in pigment ob- served after various forms of treatment. Biopsy of the skin in Addison's disease shows the deposition of an abnormal amount of melanin in an epidermis and cutis 304 CLINICAL CONSIDERATIONS of an otherwise normal skin. The pigment is intracellular and forms a cap above the nucleus of the basal cells. 458 Pigmentation is not confined to Addison's disease but may occur in abdominal growths, pregnancy, uterine disease, hemo- chromatosis, vagabonds, chronic arsenic poisoning, pernicious anemia, ochronosis, von Recklinghausen's disease, et cetera as well as in apparently normal individuals. The usual explanation of the pigmentation is that it results from disease of the medulla rather than of the cortex. The diseased medulla being unable to retain its normal store of epinephrine is supposed to release this substance into the cir- culation which deposits it (or possibly its oxidation product or a precursor) in the epidermal layers where it is retained as melanin. This hypothesis would account for the cases of Addison's disease which are unaccompanied by pigmentation by assuming little involvement of the medulla. It would ac- count also for the clinical fact that the more chronic form of the disease is more apt to be accompanied by deeper pigmen- tation than the acute, rapidly fatal form. In the former, it is the medulla which is most extensively involved, while in the latter, the cortex is chiefly affected. 260 There have been several reports of pigmentation in lower animals following adrenalectomy (Nothnagel, 474 Tizzoni, 628 and Marino-Zucco 437 ). Boinet went so far as to see the pigmenta- tion not only in the skin of rats but as hematoidin granules in the blood. The careful observations of recent years on thou- sands of rats, cats, and dogs have not confirmed the appearance of any pigmentation. This is not unexpected if one assumes that disease of the medulla is responsible for the appearance of pigmentation in man, since in animal experiments not only the cortex but the medulla as well is removed. Only in ani- mals in which the medulla is injured would one expect the pig- mentation to appear on shaved portions of the skin subjected to the sunlight. Indeed Kellaway and Cowell 348 observed pig- mentation under these conditions in two animals in which the addison's disease 305 medulla was partially destroyed by the insertion of needles containing radium emanations. In rats in which the medulla and most of the cortex was extirpated, the author failed to ob- serve pigmentation of the shaved skin after exposure for several months to the sunlight. These results as well as the absence of pigmentation in adrenalectomized animals maintained for long periods on cortical hormone would indicate that it is not the presence of a precursor of epinephrine which is responsible for the pigmentation. It is possible of course that in the diseased medulla epinephrine itself or its precursor is converted to a product which is deposited in the skin. It has recently been suggested that the absence of ascorbic acid in the diseased adrenal is responsible for the pigmentation and a case has been reported in which injection of this vitamin caused a disappearance of the pigmentation. This seems very improbable, however, if one considers the wide distribution of ascorbic acid in the body (cf. Chapter XX). From a chemical consideration (cf. Chapter V) and from the arguments cited above, one would incline to the view that disease of the medulla is responsible for the pigmentation. However, in cases of adrenal atrophy in which only the cortex is destroyed while the medulla remains apparently healthy, one still finds marked pigmentation. 668 Unless one assumes that the diseased cortex acts upon a precursor of epinephrine or interferes with the normal function of the medulla, it is difficult to accept the view that in these cases the medulla is responsible for the pigmentation. Geenhow 241 reported two cases and Bristow 119 one case of complete destruction of the glands by carcinoma in none of which was there any pigmentation. The only one of 28 cases described by Barker 39 in which pigmentation was absent was one in which some functional medullary tissue was demon- strable. From a clinical standpoint it is thus difficult to decide as to the anatomical basis for the appearance of the pigmenta- 306 CLINICAL CONSIDERATIONS tion. It has been suggested that the discoloration is due to sulfur derivatives normally removed from the circulation by the adrenals, or to some deficiency of the skin which causes the deposition of melanin, or to a protective mechanism on the part of the skin. The above cited clinical facts do not sup- port these assumptions. Further experimental work is neces- sary before we can arrive at a satisfactory conclusion as to the mechanism of the pigmentation. The difficulty (if not the impossibility) of producing pigmentation in experimental ani- mals has rendered a solution of this problem difficult. It ap- pears most likely that pigmentation results from a change in the human skin, due to the deficiency of the cortical hormone, and is merely an exaggeration of the normal pigmentary pro- cesses. It may not be caused by deposition of epinephrine, its related compounds, or other normal or abnormal products of the adrenal glands (cf. Chapter V). Loss of weight. Loss of weight which is so important a symptom of adrenal insufficiency in experimental animals is also a valuable index in gauging the progress of Addison's disease. The body weight is markedly reduced during exacer- bations of the disease and is increased during remissions. Despite the loss of weight, the skin maintains its elasticity and hence does not give the flabby appearance characteristic of other wasting diseases. 540 Digestive disturbances. In an analysis of 160 cases of Addi- son's disease, Marafion, Sala, and Arguelles 429 found the fol- lowing digestive disturbances: Cases Intense hunger 3 Inappetence (anorexia) 142 Dyspepsia 61 Nausea 39 Gastric ulcer 3 Diarrhea 45 Constipation 35 Pseudo-peritonitis 11 Hiccough 43 No digestive symptoms 19 addison's disease 307 Intense hunger which is an infrequent complaint was only ob- served during the beginning of the illness. Anorexia is the most common digestive complaint. The mere sight of food may arouse nausea. Vomiting is a troublesome symptom par- ticularly in the late stages of the disease. The severe diarrhea as seen in experimental adrenal insuf- ficiency also occurs in man and may simulate, in its appearance, cholera nostras. The pseudo-peritonitis referred to above, is marked by spasm of the abdominal muscles, by a small pulse, and in general may give the appearance of an acute affection of the abdomen. An aversion to fatty foods has been noted by Rogoff 522 as an important early symptom. One of the common findings in experimental adrenal insuf- ficiency, as we have seen (Chapter X), is inflammation and ulceration of the gastro-intestinal tract and digestive disturb- ances identical to those observed in Addison's disease. The disturbances observed in man may possibly be due to an in- flammation of the gastro-intestinal tract similar to that ob- served in experimental adrenal insufficiency. In the late stages of the disease there may be a diminution or even absence of the gastric hydrochloric acid and of the ferments. 119 Nervous manifestations. Certain nervous and mental mani- festations often occur in Addison's disease. The patient may be apathetic, listless, depressed, or irritable; mental activity is often impaired; neuralgic pains occur in the lumbar region, in the epigastrium, and in the extremities; headaches, tinnitus vertigo, rheumatoid pains, and insomnia are sometimes present. Pain in the back may be an early symptom and was present in every case in Snell and Rowntree's series. Pain on pressure in the costolumbar angle has been considered a noteworthy symptom. 522 In the late stages of the disease, nervous symptoms may be- come prominent. Delirium, acute mental confusion, convul- sions, numbness, and coma are common as terminal symptoms. 308 CLINICAL CONSIDERATIONS The agonal symptoms may be accompanied by clonic convul- sions, delirium, and stereotyped movements similar to those observed in insulin poisoning. These symptoms, which are also not infrequently observed in experimental animals, are sometimes probably due to hypoglycemia. 17 - 473 CIRCULATION Addison 7 noted the small, weak, easily compressible pulse of his patients. Wilks 681 observed the extreme hypoplasia of the heart with its tortuous coronary arteries. The heart sounds described by Addison as discernible over the apex are probably attributable to the anemia of his patients. The hypo- plasia of the heart and large vessels has been frequently noted, the transverse diameter of the heart being only 8 cms. in a case described by Zondek. 543 Rowntree 538 has reported the occurrence of precordial pains in some of his patients. In a series of 35 cases, this observer noted inversion of the T-wave in 2 cases, auricular fibrillation in 1 case, and heart block in another. The heart was normal in all the other cases. Sampayo and his collaborators 543 have recently examined the circulatory system of a large series of patients suffering from Addison's disease. They noted as constant findings a low potential of the electrocardiogram with evidence of conduc- tion defects in the P-Q, Q-R-S, and S-T complexes. The degree of these changes in the electrocardiogram was propor- tional to the intensity of the disease. There are, however, no clinical signs of cardiac decompensa- tion. In fact, the above described findings are those one might expect from an asthenic myocardium in fatigue re- sponding to a diminished demand on the part of the organism. Hypotension is usually considered as one of the most impor- tant findings in Addison's disease, but its significance has prob- ably been overestimated. The average blood pressure in Rowntree's 538 series was 96/67; with a maximum systolic pres- sure of 115, diastolic, 85; minimum systolic pressure, 60, diasto- addison's disease 309 lie, 40. Values as low as 30 or 40 mms. for the systolic pressure have been reported, but such values are inconceiv- able in the light of our generally accepted concepts of circula- tory hemodynamics. 243 Janneway first called attention to the fact that a low blood pressure is not as constant a finding in this disease as is gener- ally believed. In a quarter of Snell and Rowntree's 540 cases the systolic pressure was 105 mms. or more and in one case the blood pressure was 145/100 one week before death. The com- monly accepted view concerning the indispensability of hypo- tension in arriving at a clinical diagnosis of Addison's disease is thus erroneous. To attribute the observed hypotension to disease of the medulla and the absence of epinephrine secre- tion is also untenable, for cases of adrenal atrophy in which the medulla is spared are also accompanied by the usual degree of hypotension. It may be emphasized that the average blood pressure of normal, healthy individuals in the basal resting condition is only 105/67, which is much lower than the values obtained under usual clinical conditions. 243 The marked asthenia of the patient with Addison's disease will render truly basal values readily obtainable. The reduced metabolism observed in some patients and a vascular hypoactivity comparable to that observed in the rest of the tissues will also tend towards a low blood pressure. 243 All of these factors suffice to explain the observed hypotension without necessitating the assumption that some normal pressor agent is absent from the blood in Addison's disease. Patients with Addison's disease often suffer vertigo and faintness in changing from the recumbent to the upright posi- tion. There is, however, a rise in blood pressure during this change in posture which differentiates this condition from pos- tural hypotension. 540 The average pulse rate in Rowntree and Snell's series of pa- tients was 94. This elevation of the pulse rate in the presence 310 CLINICAL CONSIDERATIONS of a reduced metabolic activity is similar to that observed in the early stages of experimental adrenal insufficiency. Its significance is still unknown. Blood picture. Although considered by Addison as a form of "idiopathic anemia," the blood picture in Addison's disease is not usually strikingly abnormal. There is only a slight re- duction of hemoglobin to about 85 per cent of normal. Al- though the leucocyte count is within normal range, there is at times a lymphocytosis, first observed by Neusser. 468 This lymphocytosis is probably a reflection of the generalized hyper- trophy of the lymphoid tissue which is often noticeable clini- cally by the enlargement of the tonsils, papillae of the tongue, and a persistent thymus. There is often also an increase in the number of the large mononuclear cells while the neutro- philic cells are relatively and absolutely reduced in number. 260 Blood chemistry. The marked changes observed in the com- position of the blood of adrenalectomized animals in adrenal insufficiency have been described in Chapter XI. In Addison's disease one fails to note these striking abnormalities of the blood chemistry. During a crisis, however, changes very similar to those already described as occurring in experimental animals are encountered. Thus the sodium concentration may be reduced to about 120 milli-equivalents per liter in contrast to its normal value of 140. 399 The chloride and bicarbonate ion concentrations are correspondingly decreased while the potas- sium ion concentration is increased. The non-protein nitrogen and urea nitrogen may assume values twice as great as the normal. The total base of the blood is diminished. Due to the hemoconcentration attendant upon the loss of body fluid, the serum protein concentration becomes elevated. The blood sugar is often reduced to convulsive levels but, in many cases, practically normal values persist despite marked alterations in the concentration of other blood constituents. 640 Injection of epinephrine does not cause the rise in the blood sugar which it addison's disease 311 normally does. The sugar tolerance curve is also often mark- edly abnormal in Addison's disease. METABOLISM Although adrenal insufficiency in mammals, as we have seen (Chapter XIII), is attended regularly by a decrease in the basal metabolic rate, this decrease is not always observed in man. Of 13 cases studied by Rowntree, 638 8 showed a normal metabolic rate, one with active pulmonary tuberculosis showed a B. M. R. of +20, and the remaining 4 cases had a B. M. R. of -30, -20, -13, and -10, respectively. Of the 38 cases studied by Rowntree and Snell, 640 only 13 showed a low basal metabolic rate. Maranon, Pena, and Florit 427 observed a normal metabolic rate in two-thirds of their 52 cases. About a quarter of their cases showed a decreased metabolism while the remainder showed an actual elevation. These findings are in essential agreement with those of other investigators. 240 Addison's disease is often complicated by the co-existence of tuberculous infection elsewhere in the body which may ac- count in part for the normal and elevated rates, for the pyrexia of tuberculosis is occasioned by an increased metabolic rate. Maranon's observation of the depressing effect of cortical ex- tracts on the metabolism of his patients is undoubtedly due to the presence of noxious impurities in the extracts. Potent preparations cause a rise in the metabolism to its normal level in the experimental animal. Although the temperature is usually reduced, it may sud- denly rise to hyperpyrexic levels, particularly in the terminal stage of the disease. This hyperpyrexia may possibly be due to a flare-up of the tuberculous infection rather than to any cause related to the adrenal insufficiency. It may, on the other hand, possibly be a reaction analogous to that observed experimentally in an acute partial insufficiency (c/. Chapter XIII). The average temperature in Rowntree and Snell's 540 series of patients was 36.1° to 36.7°C. (97° to 98°F.) with pre- mortem rises to 39.4° to 40°C. (103° to 104°F.). 312 CLINICAL CONSIDERATIONS RESPIRATION The respiration in Addison's disease is usually normal except for dyspnoea on exertion, sighing, and yawning. In crises, the respiration may become irregular with the Biot type of respira- tion commonly seen in cerebral involvements. 540 REPRODUCTION In the late stages of Addison's disease there is loss of the reproductive activities and loss of libido. The failure of the reproductive system in women manifests itself first in irregular menstruation, oligomenorrhea, and amenorrhea. Conception is rare but cases have been reported in which normal pregnancy has proceeded to term. 119 During pregnancy the symptoms of the disease are ameliorated, probably for the same reasons suggested (Chapter VIII) for the prolonged survival of adre- nalectomized pregnant animals. In men there may be impo- tence. 540 LIFE EXPECTANCY Although there is no fixed order in the appearance of the symptoms, asthenia usually precedes the melanoderma. At times, however, the pigmentation may precede the appearance of the other symptoms. Though there is often a gradual in- crease in the severity of the symptoms, usually the disease is marked by paroxysmal remissions with intermissions during which the patient may be in fair health. The "paroxysmal mode of progress" of Addison's disease has been aptly described by Greenhow 242 as follows : "The asthenia, the constitutional symptoms generally, and the change of colour in the skin are all, it is true, progressive, but not steadily so. The course of the dis- ease, on the whole, is slow and chronic; but it is subject to alternate exacerbations and remissions, usually in some degree dependent upon favourable and unfavourable cir- cumstances but sometimes also apparently quite independ- ADDISON S DISEASE 313 ent of them. During the remissions, strength is in a great degree recovered, appetite improved, sickness abated; the discolouration becomes paler, and, above all, the patient's whole aspect bespeaks that a heavy weight has been lifted from his head. After each fresh exacerba- tion, however, the patient remains upon a somewhat lower level than during the previous remission. The recovery of strength and the abatement of other symptoms is less marked, and the skin, though paler than during the last exacerbation is yet visibly darker than before it. Similar alternations may occur several times before the onset of the fatal paroxysm, but on each occasion the patient takes at least one downward step that he never regains." The duration of Addison's disease is dependent to a large extent on the type of lesion present in the adrenals. The expectancy of life in cases of adrenal atrophy is about three times that of cases due to tuberculosis. 260 It has been often noted that patients in whom the pigmen- tation is an early symptom do better than those in whom the pigmentation is not marked, or absent. Thus in the series of 566 cases analyzed by Guttman, 260 the average duration of the disease was 43 months in patients in whom pigmentation was the first symptom and asthenia developed subsequently. In cases in which pigmentation and weakness developed simul- taneously, the average duration of life was only 12 months, while in the group of patients in whom weakness was the first and predominant symptom and pigmentation of subsequent onset, the average duration of the disease was only 8 months. PATHOLOGY In the earlier reports one finds cases described clinically as Addison's disease which at autopsy failed to reveal lesions of the adrenal glands. Thus in Lewin's 392 compilation of 639 cases, 12 per cent showed "normal" glands. It is most likely that the clinical diagnosis in these cases was erroneous for the 314 CLINICAL CONSIDERATIONS diagnosis of Addison's disease based solely on the occurrence of pigmentation and asthenia, as frequently made, is open to error. In the recent compilations only rare cases have been reported of normal glands and the clinical history and autopsy reports in these cases are not entirely convincing. 417 It is pos- sible, of course, that disease of neighboring organs {e.g., malig- nant involvement of the solar plexus 54 ) may lead to an acute suppression of the secretion of the vital hormone without gross anatomical evidence of disease of the adrenals. The adrenals of patients dying of the disease show almost complete destruction of both cortex and medulla or cortex alone, depending, as shall be described in subsequent sections, on the type of lesion encountered. 417 In Barker's 39 series of 73 cases of disease of the adrenals of diverse etiology, in which the cortex remaining comprised ap- proximately 10 to 50 per cent of the normal amount of tissue, no clinical symptoms of Addison's disease were evident during life. It was only when at least 90 per cent of the cortical tissue had been destroyed that clinical symptoms became prominent. Latent symptoms may possibly be present without such ex- tensive destruction but have not been noted clinically. In many cases of adrenal atrophy only the cortex is involved and the medulla remains almost intact. 668 Accessory interrenal tissue (cf. Chapter IV) is rarely en- countered except in the intimate neighborhood of the main glands. Hence pathological involvement of the adrenals usu- ally involves these accessories and it is extremely rare for such accessory tissue to prevent the appearance of symptoms of Addison's disease. In the early stages of disease, particularly in cases of so-called adrenal atrophy, the healthy tissue hyper- trophies forming adenomatous nodules but these are ultimately involved in the destructive process which caused the initial lesion. In an analyses of 566 cases of Addison's disease collected from the literature over the period 1900 to 1930, Guttman 260 addison's disease 315 found the causative agent to be: bilateral tuberculosis, in 68.3 per cent; primary atrophy, in 19.4 per cent; amyloid dis- sease, in 1.7 per cent; and neoplasms, in 1.2 per cent of all the cases. Fatty degeneration, pressure atrophy, venous thrombosis, arterial emboli, and syphilis comprised the re- maining 9.4 per cent. Hedinger 291 found tuberculosis in 14 out of 15 patients with Addison's disease. In Coneybeare and Millis' 122 29 autopsied cases, 22 had bilateral fibrocaseous tuberculosis of the adrenals and 6 had simple atrophy. In the remaining case, remnants of the adrenals could not be found. Philpott's 504 14 cases comprised 7 cases of tuberculosis, 4 of metastatic carcinoma, and 1 each of mycosis fungoides, simple atrophy, and amyloido- sis. Barker 39 in his detailed account of the autopsy findings in 28 cases, studied clinically by Rowntree, found tuberculosis in 25 and atrophy in the remaining three. Tuberculosis. The fibro-caseous lesions of tuberculosis are found in about 90 per cent of all cases of Addison's disease. The greater interest in cases due to other causes results in their being more frequently reported in the literature as isolated case reports. Hence, collections from the literature give an erroneous idea as to the relative frequency of the different lesions. 260 Atrophy of the adrenals is found in about 10 per cent of all cases. Vascular defects, malignant growths, syphi- lis, and other conditions are the cause of relatively few of the cases of Addison's disease. Tuberculosis affects the adrenals with more or less complete caseation, with softening, fibrosis, or calcification. The glands may be shriveled but most often are enlarged. Sections of the tuberculous glands show tubercles with en- dothelial cells, giant cells, fibroblasts, and lymphocytes. 296 Acid fast bacilli can be demonstrated. 39 The necrosis differs from the caseous necrosis of tuberculosis observed in other glands and tissues in its yellow color and firm consistency. Some normal cortical tissue was observed by Barker 39 in 316 CLINICAL CONSIDERATIONS 24 out of his 25 cases. The cells were hypertrophic and hyper- chromatic. The amount of this remaining tissue was esti- mated at less than 5 per cent of the whole normal gland. In only one case was any medulla seen, and this case was the only one in which no pigmentation occurred. In cases in which as much as 80 per cent of the adrenals had been de- stroyed by tuberculosis there were no symptoms of Addison's disease. The process apparently starts in the medulla or mid- cortical region and spreads centrifugally. Healed processes are not observed, indicating the progressive course of the disease. Although the adrenals are the chief site of tuberculous infec- tion in many cases, it is doubtful if the lesion in these organs is ever primary. The infection in the adrenals is probably hematogenous in origin. 255 As is the case in tuberculous infec- tion of the eye or kidney, the lesion is first unilateral and then extends to the second organ. The fact that 90 per cent of the cortical tissue must be destroyed before symptoms of Ad- dison's disease are evident, explains why (unlike in the kidney or eye) unilateral infection of the adrenals does not manifest itself during life. At autopsy, however, one frequently ob- serves tuberculous lesions of the adrenals from a slight unilat- eral to a partial bilateral stage of advancement without any clinical symptoms of the disease having manifested themselves during life. Miliary tuberculosis of the adrenals is not common, but careful examination of the adrenals in generalized miliary tu- berculosis will usually reveal some small foci of infection. 417 There is often extensive tuberculous destruction of both adre- nal glands with comparatively little disease of other organs. Elsasser 417 found isolated tuberculosis of the adrenals in 17 per cent of 549 cases. Atrophy. About 10 per cent of all cases of Addison's disease are caused by atrophy, which may involve the cortex only or may affect the entire gland so that no trace of the glands is visible on gross examination at autopsy. However, careful addison's disease 317 microscopic examination of the fatty connective tissue will reveal some remnant of islets of cells resembling those of the cortex. These were found by Crosby 140 near the superior poles of the kidneys embedded in retroperitoneal fat. In most cases the adrenals are shrunken to a quarter or less of their normal size. 84, 130 Considerable difference of opinion exists in the literature regarding the nature of the atrophy affecting the adrenals. Various descriptive terms have been applied depending upon the author's opinion regarding the nature of the process. The terms idiopathic, primary, or simple atrophy have been fre- quently used to indicate that the process is of the nature of an aplasia. Others have considered the process, in some cases at least, to be inflammatory in origin but in most cases the histological picture does not conform with that of an in- flammation. The assumption that the process is due to a toxic agency led Kovacs 364 to apply the term "cytotoxic contracted adrenal." Cirrhosis, chronic dystrophy, hypoplasia, etc. are other terms which have been frequently used. The process is not a simple atrophy in the sense that there is no shrinkage due to atrophy of the cellular elements. There is instead a necrosis of the parenchyma which leads to the dis- appearance of the cells. The expression "primary contracted adrenal gland" suggested by Guttman 260 is probably most ac- curate considering the unknown nature of the etiologic agent causing the lesion. We shall, however, retain the simpler ex- pression "atrophy" in the present volume. The older view advanced by Neusser 468 and Wiesel 678 that adrenal atrophy is part of a congenital hypoplasia of the chro- maphil tissue, in general, is no longer tenable. Pathological studies indicate that the process is acquired. Simmonds 573 con- sidered the etiology to be tuberculosis or syphilis but his views have not been substantiated by recent observers. The absence of an inflammatory hyperplasia of the interstitial tissue or of any inflammatory reactions around the glands speaks against 318 CLINICAL CONSIDERATIONS the view that adrenal atrophy is due to a chronic inflammation. The pathological picture closely resembles that encountered in yellow atrophy of the liver. 668 Brenner 84 considered the atrophy to result from a slow necrosis due to some toxin. The cells which remain unaffected tend to undergo compensatory hypertrophy and form adenomatous nodules which are in turn attacked or become exhausted. In Barker's 39 three cases of adrenal atrophy the medulla was normal while the cortex was reduced to a narrow strip. The remaining cortical cells were large, deeply stained, and pig- mented, with numerous lymphocytes interspersed between the cortical layers. In a few places were areas of recent hemor- rhage. The diffuse nature of the destruction and the fact that it is bilateral point to a toxic atrophy or a low grade in- flammatory process of unknown cause. 39 - 48: In general, as in the six cases described by Wells, 668 there is a selective necrosis of the cortical cells with much less visible injury to the elements of the medulla. The other changes observed in the adrenals appear to be secondary to this selec- tive necrosis and consist of attempts at regeneration by pro- liferation and hypertrophy. According to Wells it is impos- sible to say if the partial loss of medullary tissue is due to the same agency as is responsible for the cortical injury or if the medullary destruction is the result of the extensive lymphoid infiltration which follows the destruction of the cortex. A condition closely resembling adrenal atrophy as it occurs clinically is sometimes seen in rats subjected to an incomplete adrenalectomy. In such animals hypertrophy of the remain- ing fragments of the adrenals maintains them in normal health. In some animals, however, after a variable period of time, the hypertrophied adrenal tissue undergoes atrophy and the animal develops a fatal adrenal insufficiency. On microscopic examination the hypertrophied fragments of cortical tissue, which had maintained the animal in good condition following adrenalectomy, present a picture resembling that observed in adrenal atrophy as it occurs in man. addison's disease 319 Amyloid degeneration. Amyloidosis of the adrenals, which, as a rule, involves only the cortex, is an occasional factor in the etiology of Addison's disease. Bronfin and Guttman 94 in a series of 100 necropsies on patients dying of tuberculosis ob- served 14 cases of amyloid infiltration of the adrenals. In 5 of these cases a diagnosis of Addison's disease was made during life. In some cases, symptoms suggestive of Addison's disease were present while the remainder showed no symptoms indica- tive of this disease. Histological study of the adrenals showed that a definite relation existed between the extent of the amy- loid involvement of the adrenal cortex and the symptomatology (notably asthenia and gastro-intestinal symptoms). Amyloid degeneration of the adrenals, as of the spleen or liver, results from chronic suppurations, tuberculosis, or syphilis. The amyloid is deposited chiefly in the fasciculata but may extend throughout the cortex and the medulla, com- pressing the cells. 504 Parenchymatous degeneration, with the formation of hyaline or colloid droplets, have been described, but it is questionable if these are not post-mortem or agonal changes. These occur usually in the medulla. Fatty degeneration of the adrenal cortex has been noted in several cases of Addison's disease. 417 Malignant growths. Although the adrenals are occasionally the site of primary or metastatic malignant growths, Addison's disease is rarely caused by such invasions. 163 - 241 This is prob- ably to be accounted for by the fact that so large a part of the glands must be destroyed before clinical symptoms of insuffi- ciency are elicited. In most cases death from the malignancy intervenes before such extensive destruction of the adrenals has occurred. 417 Syphilis. There have been a number of clinical reports of cases of Addison's disease attributed to syphilis. These re- ports have been based on the favorable reaction of the patients to antisyphilitic treatment. 652 - 565 Syphilitic lesions in the form of gummata with caseation, fibrosis, and infiltration of the surrounding tissues, however, 320 CLINICAL CONSIDERATIONS have been rarely noted at autopsy. The occurrence of spiro- chaetes in such lesions in a case dying of Addison's disease has been reported. 417 Other findings. Rare changes in Addison's disease are echinococcus cyst, mycosis fungoides, abscess formation follow- ing pneumonia, trauma, and vascular lesions. Among the last named, venous thrombosis, 59 arterial embolism, and hemor- rhage into the substance of the adrenal have been reported as causative agents of Addison's disease. 260 ' 417 OTHER AUTOPSY FINDINGS IN ADDISON'S DISEASE Due to the concomitant presence of tuberculosis, the ravages of this disease will usually be present at autopsy in patients dying of Addison's disease. Among Barker's 39 75 cases of adrenal tuberculosis, there was active pulmonary tuberculosis in 10, genito-urinary tubercu- losis in 4, and both genito-urinary and pulmonary tuberculosis in 2 cases. Of the remaining 8 cases, there was active tuber- culosis of the spine, liver, spleen, or abdominal lymph nodes in 5. In only 3 cases could no active tuberculous lesions of other organs be demonstrated. Gsell and Uehlinger, 255 on the other hand, report the active tuberculous process to be limited to the adrenals in one-third of their cases. The body is usually wasted, although extreme emaciation is not present. The heart may show atrophic changes. Its walls are thin causing the coronary vessels to run a tortuous course. The cardiac muscle itself may be distinctly brown. The blood vessels show no distinctive changes except for the hypoplasia of the aorta and large vessels. 543 The stomach shows atrophy of the mucosa. The intestines may contain fluid faeces and the lymphoid follicles throughout the alimentary tract are hypertrophied. As might be anticipated from the renal impairment observed in adrenal insufficiency both experimentally and in Addison's disease, renal lesions are often demonstrable at autopsy. Bar- addison's disease 321 ker 39 found normal kidneys in only 7 of his 28 cases. Conges- tion, diffuse tubular atrophy, chronic pyelonephritis, and renal tuberculosis were observed in the other cases. The tubular atrophy had the appearance of a toxic nephrosis and was pres- ent in a third of the cases. The thymus is often persistent (cf. Chapter X) and the spleen is enlarged and soft. There is general hyperplasia of all the lymphoid tissues. Hedinger 291 found a status thymo- lymphaticus in 7 of his 15 cases. Guttman, 260 in his comprehensive analysis of the cases of Addison's disease reported in the literature, found no significant changes in the thyroid. On the other hand, in the six cases of Addison's disease due to adrenal atrophy, described by Wells, 668 there was a marked infiltration of the thyroid gland with lymphoid cells. This infiltration of the thyroid gland with lymphoid tissue has been described in Addison's disease of tuberculous origin but is less marked and less frequent than it is in cases of non-tuberculous origin. 668 In a small proportion of cases, extensive alterations occur in the sympathetic system (particularly the semilunar ganglion and the solar plexus) which may extend into the central nervous system. The hypophysis in some cases of Addison's disease shows a diminution in the number and size of the eosinophil cells and a scarcity of normal, well-granulated, basophilic cells. The significance of these changes has been discussed in Chapter XIV. The reproductive glands sometimes show atrophic changes. 417 Considerable controversy has always raged regarding the question as to whether the pathological changes in the adrenals were alone responsible for the clinical manifestations of Addi- son's disease or whether changes in other glands were in part also responsible for these manifestations. A number of workers described changes in the ganglia or the spinal cord to which they attributed the manifestations of the disease rather 322 CLINICAL CONSIDERATIONS than to the comparatively lesser changes demonstrable in the adrenal. Wiesel 678 attributed Addison's disease to destruction of the medulla rather than to the cortex. In view of recent developments in our knowledge of the relative functions of the cortex and medulla, we must accept the view that the cortex is responsible for most of the symptoms and for the fatal outcome of Addison's disease. As we have already seen, it is doubtful if the medulla is even responsible for the pigmentation. The symptoms of the disease are identi- cal to those observed in experimental cortical insufficiency. We may, therefore, consider damage to the cortex or to its secretion as the sole responsible agent for the disease. It is possible, however, that a diseased medulla may cause destruc- tion of the cortical hormone; for, as we have seen (Chapter II), the blood from the cortex which presumably carries the hor- mone is drained into the medulla. Wide involvement of the medulla might easily cause destruction of the hormone as it passes through the diseased tissue. This would explain the existence of cases of Addison's disease in which the adrenal defect was limited to the chromaphil tissue, but the evidence for the existence of such cases is very meager. It is more likely that the clinical diagnoses were in error in these cases. DIAGNOSIS It may appear from the preceding sections that diagnosis in Addison's disease is a comparatively simple matter. The pig- mentation, asthenia, hypotension, gastric disturbances, etc. define a clinical picture to which many cases closely conform. However, in a certain group of cases an error in diagnosis may easily result. Pigmentation closely resembling that of Addi- son's disease, as has already been noted, is frequent in other conditions. Asthenia is common in protracted debilitating illnesses as are also hypotension and digestive disturbances. Hence the occurrence of this group of symptoms may often, addison's disease 323 as in the cases quoted by Coneybeare and Millis, 122 lead to an erroneous diagnosis of Addison's disease. Cases of pernicious anemia, abdominal tuberculosis, and other conditions may simulate Addison's disease in many of their symptoms. On the other hand, failure to recognize Addison's disease may often occur, particularly in those cases in which there is no marked pigmentation. Cases of acute insufficiency of the adrenals, to which the name Addison's disease is strictly speak- ing not applicable, may also fail to be recognized. Thus, cases of acute convulsive seizures, accompanied by low blood pres- sure and respiratory irregularities, have been described in which autopsy revealed marked adrenal injury as the only find- ing to which the symptoms might be attributed. 473 Such symptoms are obviously to be attributed to adrenal insuffi- ciency. In other cases reported in the literature patients dying suddenly under an anesthetic, for example, or of some unknown cause are found at autopsy to have extensive adrenal disease without having manifested the symptoms of Addison's disease during life. In such cases we are dealing with latent forms of the disease, suddenly aggravated by an operation, or with an adrenal insufficiency which is marked by the co-existence of a second disease. In the absence of pigmentation, one might easily attribute the existence of asthenia, hypotension, etc. to an active tuberculous process elsewhere, when in reality they may result from disease of the adrenals. Calcification, demonstrable by the roentgenogram, is often present in cases due to tuberculosis. 30 One must avoid being misled by calcification of a lymph node or other adjacent structure. The reaction of patients suffering from Addison's disease to a sudden deprivation of salt has recently been suggested as a diagnostic aid in doubtful cases. 485 Patients suffering from Addison's disease may be thrown into a state of acute crisis by subjecting them to a salt-free diet. This test must, therefore, 324 CLINICAL CONSIDERATIONS be applied cautiously and any untoward reaction promptly counteracted by the administration of liberal amounts of the cortical hormone and salt. 351 The therapeutic test should prove of value in the future for arriving at a diagnosis in doubtful cases. The results of ther- apy with the adrenal cortical hormone should indicate whether adrenal insufficiency is the source of the observed clinical mani- festations. Such a therapeutic test may also prove to be a means of detecting the disease in its early stages. TREATMENT The history of the therapeutic management of Addison's disease has been one of repeated disappointments. False hopes of cure have been inspired by the natural remissions which characterize the disease. Many modes of therapy and reports of cures have been reported, from the case described by Addison as ostensibly cured by brandy to the cases of recent years ostensibly revived by adrenal extracts. Many apparent cures resulted from an original error in diagnosis as in the patient reported cured by an adrenal graft, but who at autopsy was found to have had no disease of the adrenals and no success- fully grafted adrenal tissue. Irradiation of the diseased adrenals has been tried with no success. Removal of a tuberculous gland in the early stage of the disease would be indicated (as in renal tuberculosis) but unfortunately the symptoms of Addison's disease do not mani- fest themselves until the disease has affected both glands. With a supply of the adrenal cortical hormone available to carry the patient through an operation, it may be that future developments in surgery will make it possible to remove the diseased portion of the glands and leave bits of the remaining healthy tissue to hypertrophy or transplant them to new sites. The absence of any method by which mild degrees of cortical insufficiency can be detected prevents early recognition and treatment of the disease in its early stages. The discovery addison's disease 325 of methods for detecting the disease in its initial stages is very desirable. The emphasis placed on epinephrine as the assumed hormone of the adrenals and its remarkable pharmacological effects led to its early application in Addison's disease. The administra- tion of epinephrine, hypodermically and rectally, and of ad- renal substance, by mouth, formed the basis for the so-called Muirhead 461 treatment. Recent studies have demonstrated that lack of epinephrine is certainly not responsible for the symptoms of Addison's disease. Injection of epinephrine into adrenalectomized animals is not only not beneficial but very harmful. It is logical to conclude, therefore, that epi- nephrine is not only of no value but is to be avoided in patients with Addison's disease. The use of dried glandular materials either in the form of a desiccated powder or as a glycerine extract, as advocated and used in the past, are also to be deprecated. The slight possible usefulness of these prepara- tions is overbalanced by the deleterious effects of the large amounts of epinephrine and its phenolic derivatives which these preparations contain. 42 ' 249 In the doses in which they are tolerated, no conceivable benefit could be derived, for it would require over a kilogram of most of these preparations to furnish enough of the hormone for the daily need of a pa- tient manifesting symptoms of adrenal insufficiency. Even the use of fresh glands would require an amount of material beyond the digestive capacities of even a normal individual. 246 Hence we must utilize concentrates derived from large quantities of glands. The potency of the preparation and its freedom from noxious impurities must be demonstrable by experiments on adrenalectomized animals. There can be no doubt that the symptoms of Addison's disease are due to an absence of the vital adrenal cortical hor- mone. Hence the first requirement of successful therapy must consist in supplying an amount of this hormone adequate for relieving the patient of asthenia, gastric disturbances, weak- 326 CLINICAL CONSIDERATIONS ness, etc. and permitting him to perform his normal activities without subjective discomfort. Except in rare cases due to syphilis, in which antisyphilitic treatment cautiously adminis- tered should prove curative, we must rely upon a replacement therapy to supply the patient with the vital hormone no longer furnished in adequate amounts by the diseased adrenals. Methods for preparing the hormone, its administration, and dosage have already been described in Chapters XV and XVI. The patient suffering from Addison's disease is particularly sensitive to extraneous influences — physical or mental — which tend to excite or exhaust and must be maintained in as calm and unperturbed an atmosphere as possible. Exhaustive examinations are to be avoided. Transportation over long distances has brought on a severe crisis. Extremes of heat or cold must be avoided. Drugs must be administered very cautiously. Purgation has proven fatal in several cases. 538 The operative risk of these patients is remarkable; even the extraction of a tooth has resulted fatally. Only when the patient has received an adequate course of treatment with the cortical hormone and has regained his strength should he be subjected to a surgical operation. The administration of large doses of hormone during and following the operation is desirable. Local anesthesia is preferable to the use of a general anesthetic. 540 The administration of an adequate supply of the cortical hormone should result in an alleviation of the symptoms due to disease of the adrenals. Certain of the bodily deficiences due to the disease may be remedied by other means. Thus the diminution in the blood volume which occurs in crises should be corrected by intravenous injections of glucose and saline solutions. Sodium chloride in Addison's disease has been in- tensively used in recent years since Loeb 399 demonstrated the remarkable clinical benefits derived from the use of this sub- stance. The rationale of sodium chloride therapy is well estab- lished. The loss of this substance from the body in adrenal addison's disease 327 insufficiency leads to a reduction in its concentration in the body. It is to be expected therefore that replacement of the lost sodium chloride will aid in preserving the well-being of the patient. The experiments of Harrop and his collaborators 266 would indicate that the use of sodium chloride together with bicarbonate of sodium is advantageous over the use of the former substance alone. The administration of sodium chlo- ride intravenously to patients in crisis has proven life-saving. Ten to twenty grams of sodium chloride administered daily has been of great aid during periods of remission from the more severe stages of the disease. This salt or a mixture of sodium chloride and sodium bicarbonate in the ratio of 2 : 1 by weight may be administered in enteric coated capsules, in milk, with lemon juice, etc. Z51 Since disease of the adrenals is often accompanied by tuber- culosis or other diseases it is of course essential to treat these conditions. Even with a replacement therapy available, the presence of the diseased adrenal remains a constant threat to scatter the germs of tuberculosis through the body. 579 In cases of syphilis, antisyphilitic treatment is indicated although this must be carried out with great caution and only after preliminary and continued treatment of the patient with the cortical hormone. The problem of adrenal grafts has already been discussed in Chapter XIX. A number of attempts have been made to graft fetal adrenal tissue into the testis, ovary, or abdominal connective tissue. The work in the past was of necessity unsuccessful for the patient could not endure the operative shock of the operation. More recently attempts have been made to transplant cells derived from tissue cultures into the axillary subcutaneous tissue. With a supply of the cortical hormone available to carry the patient through the necessary operative procedures, a new attempt at adrenal transplanta- tion of fetal cortical tissue or tissue cultures is warranted. Although the results of the therapeutic management of Addi- 328 CLINICAL CONSIDERATIONS son's disease have been exceedingly disappointing, in the past, there is every reason to anticipate better results in the future. The combined use of salt and ample doses of a potent prepara- tion of the adrenal cortex (administered orally in frequent doses) 249 should radically improve the poor results hitherto obtained. Chapter XXII TUMORS OF THE ADRENALS Primary tumors of the adrenals are relatively rare, but they are of great interest for the light a study of their clinical mani- festations throws on the function of the normal gland. Of 46,000 hospital admissions examined by Gibson 220 only four proved to be primary adrenal tumors. Metastatic growths, on the other hand, are relatively frequent. Thus in a survey of 371 malignant tumors which came to autopsy, Burke 100 found that 49 showed metastatic involvement of the adrenals. Such metastatic growths rarely, however, cause any clinical manifestations, for death results from carcinomatosis before sufficient destruction of cortical tissue has occurred to give symptoms of adrenal insufficiency. The majority of malignant tumors will metastasize to the adrenals but certain types do so more readily than others, namely, tumors of the breast, esophagus, stomach, testicle, penis, Hodgkins disease, and malignant melanomas. Either gland may be involved de- pending on the location of the primary growth. In many cases metastases are found in the adrenal where there is no general dissemination of the tumor. The medulla is more fre- quently the site of the metastases than the cortex. We may subdivide the primary tumors of the adrenal accord- ing to their site of origin as medullary, cortical, and androgenic. Previous authors have considered all adrenal tumors as being either medullary or cortical. The assumption made by the present author that a large group of the tumors arising in the cortex are derivatives of the androgenic tissue, although still unproven experimentally, is a useful hypothesis which avoids otherwise irreconcilable inconsistencies and is in accord with all the known facts available at present. We shall defer our 330 CLINICAL CONSIDERATIONS discussion of the tumors of the androgenic zone to the next chapter and consider here only those tumors which originate from the medulla and cortex proper. TUMORS OF THE MEDULLA As we have seen in Chapter II, the adrenal chromaphil tissue is derived from the sympathetic nervous system. The original cell which gives rise to both the sympathetic and chromaphil cells is a small, lymphocyte-like structure known as the sympathogone. From these sympathogonic cells arise the sympathoblasts which in turn give rise to the sympathetic ganglion cells, and the chromophiloblasts (also called phaeo- chromoblasts) which give rise to the chromaphil (or phaeo- crome) cells of the medulla. There are thus five types of embryonic and mature cells to be found in the medulla during its development, as indicated in the following schema: Sympathogone Sympathoblast Chromaphiloblast I I Sympathetic ganglion Chromaphil cell of the cell adrenal medulla and other paraganglia The sympathoblasts and chromophiloblasts, which are the intermediate cell forms between the sympathogone and the sympathetic ganglion cells and chromaphil cells, respectively, are morphologically similar. There are thus in reality only four types of cells in the medulla which can be anatomically differentiated. Each of these may give rise to a tumor con- forming to the cell-type from which it is derived. Two of these are immature cell forms: the sympathogone and sym- pathoblast (or chromophiloblast) . The other two are mature forms: the ganglion and paraganglion (or chromaphil) cells. Tumors derived from these cell types are denoted by the names of their cells of origin. The use of the terms glioma, round cell TUMORS 331 sarcoma, lymphosarcoma, et cetera to describe them is erroneous and fails to indicate their embryological origin. Sympathogonioma. These tumors (also called sympatho- blastoma) originate from the embryonic sympathogone cells and occur in intrauterine life or in earliest infancy, rarely after the first year of life. They are extremely malignant, invade the surrounding tissues, and metastasize to the liver, bones, and retroperitoneal lymph nodes. The tumor is usually bi- lateral. The fine fibrillar network of the stroma of this tumor resembles glial tissue and has led it to be erroneously designated as an adrenal glioma. Many of the retroperitoneal tumors of infants which have been described as "round cell sarcomas" are, according to Goldzieher, 230 actually sympathogonioma. The sympathogonioma are large, soft, mottled, yellow- brownish growths composed of small cells resembling lympho- cytes. These cells are irregularly scattered, or formed into clusters, or in perfect rosettes which are characteristic. 230 ' 335 Sympathoblastoma. These tumors are variously designated by different authors as neuroblastoma, sympathetic neuro- blastoma, neurocytoma, or sympathoblastoma. They arise from the sympathoblasts or chromaphiloblasts and are inter- mediate as regards the degree of their differentiation between the small celled sympathogonioma, described above, and the mature, large-celled ganglioma and paraganglioma to be described in the next section. The sympathoblastoma are usually divided clinically into: 1) the Pepper type with metastases to the liver, lungs, or abdominal lymph nodes; 2) the Hutchison type, with metas- tases to the orbit, skull, and long bones; and 3) the pernicious type characterized by severe anemia. This classification is misleading, however, for the various manifestations and metas- tatic predilections for certain organs are dependent chiefly on the age of the patient and the site of the initial lesion. Thus due to the different channels of the venous and lymphatic drainage, tumors of the left adrenal are more apt to give rise 332 CLINICAL CONSIDERATIONS to the Hutchison type while those of the right gland give rise to the Pepper type. 215 The tumors described by Hutchison 327 in 1907 are character- ized by the appearance of ecchymosis of one or both eye-lids, followed by unilateral exophthalmos, and an involvement of the auricular and submaxillary lymph nodes. The primary growth in the adrenal often remains small, but may invade the kidney and metastasize to the bones and viscera. Tumors of the orbit in infants are almost pathognomonic of a primary medullary tumor of the adrenal. In the tumors described by Pepper 494 in 1901, the first symp- tom to attract attention is usually a rapidly enlarging abdomen caused by diffuse nodular growths in the liver which may reach an enormous size. The primary growth in the adrenal may remain small. In the pernicious type of medullary tumor, the chief symp- tom is an extreme anemia resembling that observed in per- nicious anemia. 230 Most abdominal tumors in infants are usually renal or adrenal in origin. The appearance of the symptoms character- izing the above described three types of medullary tumors or of the abnormalities to be described in the next chapter, makes easy the differential diagnosis between renal and adrenal tumors in most cases. The usual clinical course of sympathoblastoma is progressive, with a rapidly fatal termination. The average duration of symptoms in 17 patients described by Askin and Geschickter 22 was 6 months and in half of the cases death followed surgical intervention within a month. In only one patient among the almost 200 cases cited in the literature has surgical removal of the tumor proven effective. Irradiation or other forms of treatment have not proven of value in altering the course of the disease. 22 Ganglioneuroma. The ganglioneuroma are derived from the sympathetic cells. They are exceedingly rare, usually give TUMORS 333 no symptoms, and are only discovered as incidental autopsy findings. As found in the adrenal they resemble similar tu- mors derived from other parts of the sympathetic nervous system. They are sometimes found within the adrenal but more commonly arise from the tissue around the capsule. Although generally benign, the less differentiated type of ganglioneuroma may be malignant and give rise to metastases, in which case they are often spoken of as ganglionic sarcoma. 215 Microscopically, the ganglioneuroma resemble the para- ganglioma to be described next but may be differentiated by the absence of the chromate reaction and by their fibrillar stroma which is interspersed with ganglionic cells. 230 Paraganglioma or chromaffinoma. These tumors are derived from the chromaphil cells of the adrenal medulla or extra- adrenal chromaphil tissue. They are also called phaeochromo- cytoma or chromaphil cell carcinoma. They form perhaps the rarest of the adrenal tumors. 515 Eisenberg and Wallerstein 176 have collected and analyzed 53 cases of this tumor from reports in the literature. Only 5 of these 53 cases were malignant and all of these 5 were bilateral. The chromaffinomas are most often found in the right gland. Half of all the cases occur during the fourth and fifth decades of life. In some cases they have been associated with tumors in other organs or with neurofibromatosis (von Recklinghausen's disease). The chromamnoma vary in size from 1 to 12 centimeters in diameter. The larger tumors are usually cystic and hemor- rhagic and are more apt to be benign than the small growths. The latter are greyish bodies of firm consistency, while the larger tumors are usually soft and reddish in appearance. They are characterized microscopically by cells of irregular size, shape, and staining properties. These epithelial-like cells assume an alveolar arrangement. When treated with chromates the typical chromaphil reaction is elicited. The cells are free of fat and glycogen. This differentiates them from similarly appearing tumors of the kidney. 230 334 CLINICAL CONSIDERATIONS The fact that the paraganglioma are derived from epineph- rine-producing cells and themselves give all the reactions of epinephrine has led to the belief that they may give rise to intermittent and essential hypertension. Patients with vaso- motor instability in whom sudden death follows minor injury {e.g., the extraction of a tooth or the injection of a drug) have been found in several instances to have had such a tumor. The sudden liberation of epinephrine from the tumor has been assumed to be the causative agent of death in these patients. Labbe, Tinel, and Doumel, 372 in 1922, first observed the phenomenon of intermittent paroxysmal hypertension asso- ciated with paraganglioma. Mayo, 446 Shipley, 566 Kalk, 347 and others 38 • 512 have reported similar cases cured by the removal of a palpable tumor. These tumors not only arise from the me- dulla but more commonly from other chromaphil tissues, par- ticularly from the organ of Zuckerkandl. The typical case of paroxysmal hypertension, associated with a chromaphil cell tumor, is characterized by periodic attacks which occur at intervals of some hours, or in response to some stimulus, for example, vigorous massage of the palpable tumor. The attacks last for some minutes during which the patient becomes apprehensive and deathly pale. Sweating, mydriasis, hypertension, and hyperglycemia are noted during the par- oxysm. Operative removal of the tumor is curative of the condition. In Kalk's 347 case, the ablated tumor was found to contain about 460 milligrams of epinephrine. The association of attacks of paroxysmal hypertension with tumors of the chromaphil tissue, as described above, may be rationally explained by assuming that the tumor when stimu- lated sets free into the circulation a large amount of epinephrine which gives rise to the observed symptoms. Sudden death in these patients may also be attributed to the toxic effects of the epinephrine secreted by the tumor and released under the stimulus of one of the numerous factors (Chapter VI) which cause an increased secretion of epinephrine. TUMORS 335 Although the blood pressure in many cases of chromaffinoma is normal, a group of patients have been described in whom this tumor was associated with hypertension, hypertrophy of the left ventricle, albuminuria, and spasm of the retinal arteries which have lead to the erroneous diagnosis of contracted kidney. At autopsy, however, the renal damage was found to be mini- mal. As typical of the clinical picture observed in these pa- tients, a case of a chromaphil tumor of ZuckerkandPs body described by Reichardt 517 may be cited. The patient, a 53 year old woman, complained of headache and fatigue with some loss of vision. There was marked pallor, a tendency to sweating, spastic retinitis, dilated pupils, and albuminuria. The blood pressure ranged from 200/115 to 230/140. There was no edema or signs of circulatory insufficiency, and the renal function tests gave normal results. The patient was bled and digitalized but died suddenly on the ninth day of her stay in the hospital. At autopsy a greyish red tumor, the size of an apple, occupied the site of ZuckerkandPs body. The kidneys and circulatory system were found to be entirely normal. Belt and Powell 51 have suggested the term "adrenal sym- pathetic syndrome" to denote the clinical condition associated with chromaphil cell tumors. The outstanding symptoms of this syndrome are evidences of instability of the sympathetic nervous system, hypertension or paroxysmal hypertension, glycosuria, periodic attacks of tachycardia, vasoconstriction and vasodilation of the peripheral vessels (as evidenced by pallor followed by flushing), headaches, nausea, vomiting, sensations of constriction in the epigastrium with dyspnoea, and a susceptibility to shock. Operative removal of the chromaffinomas has proven curative in a number of cases re- ported in the literature. 446, 566 TUMORS OF THE CORTEX The tumors of the adrenal cortex may be divided into those which originate from the interrenal tissue and those whose 336 CLINICAL CONSIDERATIONS origin, in the author's opinion, is to be sought in the androgenic tissue. The latter group of tumors produce abnormalities of the reproductive system and will be discussed in the next chapter. The tumors of the interrenal tissue are not char- acterized by any distinctive clinical symptomatology. Unlike the corresponding growths of certain other endocrine organs they do not manifest any symptoms attributable to an over- production of their specific hormone. It is only by their malignancy which expresses itself by their extension and ready metastasis, or by their destruction of the cortex to such an extent as to produce the symptoms of Addison's disease that their presence in the body is manifested. Because of certain very superficial similarities, earlier work- ers often confused tumors of the adrenal cortex with the more commonly occurring hypernephroma of renal origin. 642 The latter are not derived from the adrenals and should be more accurately denoted as renal or Grawitz tumors. The differ- entiation between tumors of renal and adrenal origin has been clearly pointed out by Glynn and Guthrie, 227 Goldzieher, 230 and most recent authors. The growths occurring in the adrenal cortex may be classi- fied as: 1) simple hyperplasia, 2) cortical adenomata, and 3) malignant carcinomata. Hyperplasia. Simple hyperplasia of the adrenals is a physiological response of the glands to an increased demand for the cortical hormone. Any condition requiring an excessive secretion of the hormone will therefore be expected to lead to hyperplasia. Infections, particularly, result in hypertrophic enlargement of the adrenals. Thus in an infant, 8 weeks old, dying of enteritis, Broster and Vines 95 found the adrenals to weigh 16.5 grams. Lucien and Parisot 407 have denoted as chronic hyperplastic adrenalitis, a condition in which the adrenal enlarges as a result of an inflammation of the cortical cells brought about by some toxic irritation. Cortical hyperplasia may occur either in the form of a diffuse TUMORS 337 hyperplasia or as circumscribed nodules ranging in size from microscopic islets of tissue to the size of a hen's egg and are incidental findings in about a third of all autopsies. They may be found in the medulla, in the cortex, or projecting from the surface of the gland, and are difficult to distinguish from acces- sory interrenal bodies which in a sense they really are. Microscopically these bodies consist of columns of cells similar to that of the fascicular zone, but at times an arrange- ment like that of the glomerulosa characterizes the peripheral layers of cells. 335 Adenomata. The cortical adenomata resemble superficially the nodular hyperplasia described in the preceding section. They differ from the latter by their atypical cell structure and their malignant tendencies. The cortical adenomata form yellowish or reddish masses well circumscribed from the rest of the cortex. They often deform or destroy the gland. 335 Although frequently manifesting all the signs of normal func- tional activity, the adenomata at times are found in varying stages of lipoidal degeneration. Clinically the cortical adenomata produce no demonstrable symptoms as might be anticipated from the innocuous effects of injections of large amounts of the cortical hormone. Never- theless, the larger growths appear to be definitely neoplastic. 254 Carcinomata. The adenocarcinoma of the adrenal resemble the adenomata from which they probably originate. Unlike the adenomata they contain atypical areas of malignant char- acter and metastasize readily to other organs. In the so-called undifferentiated carcinoma of the adrenals one finds large granular fatty cells arranged around the blood vessels, or rounded polyhedral cells free of fat and glycogen. These also metastasize early and infiltrate the surrounding tissues. 215230 - 335 Malignant tumors of the interrenal tissue are exceedingly rare. Many of the cases described in the literature as carci- noma of the cortex are neoplasms of the androgenic tissue which give rise to the adreno-genital syndrome to be described 338 CLINICAL CONSIDERATIONS in the next chapter. Malignancy of the cortex proper (i.e. of the interrenal tissue) does not give rise to virilism or to any abnormality of the reproductive system. These tumors rarely give rise to Addison's disease for the rapidity of their growth and ready metastasis lead to death from carcinomatosis before sufficient destruction of the cortex has taken place to manifest the symptoms of Addison's disease. OTHER TUMORS The tumors described in the present and following chapters are derived from tissues specific to the adrenal glands. Other tumors may arise, of course, from the connective tissue, smooth muscle, or blood vessel elements, but such tumors are exceed- ingly rare. Fibroma, myoma, lipoma, hemangioma, lymph- angioma, fibroxanthosarcoma, and sarcoma have been de- scribed. Many tumors erroneously described under these terms belong to the groups of tumors described in the pre- ceding sections. 230 Chapter XXIII THE ADRENO-GENITAL SYNDROME Certain pathological abnormalities involving the reproduc- tive system are regularly accompanied by anatomical changes in the adrenals. Although numerous reports are extant de- scribing obvious examples of the adreno-genital syndrome, the first extensive work, recognizing the relation of certain abnor- mal developments of the sex organs to an abnormal growth in the adrenal, was that of Bulloch and Sequeira" in 1905. Gal- lais, 210 in 1912, published a voluminous thesis on the subject and clearly indicated the clinical picture as it occurs in adult life. Glynn 227 in the same year also described at length the condition as it occurs in women and children. 18 In the absence of knowledge of the function of the adrenals, it is not surprising that early considerations of the adreno-geni- tal syndrome should have been rather confusing. This was particularly so since most adrenal anomalies are not accom- panied by sexual changes nor are the latter in the majority of cases accompanied by changes in the adrenal. Unless a clear differentiation is made between the androgenic zone and the remainder of the cortex one cannot describe logically the rela- tion of the adrenals to certain changes in the reproductive system and the secondary sex characteristics. Previous authors have attributed the development of the adreno-genital syndrome to hyperfunction of the adrenal cor- tex with the elaboration of an excess amount of the hormone specific to the interrenal tissue. This idea, however, is not in accord with the available facts concerning the interrenal tissue. As we have seen in Chapter XIV, the adrenal cortical hormone, although essential for maintaining the normal reproductive function does not control reproductive activity. Nor does the 339 340 CLINICAL CONSIDERATIONS administration of excessive amounts of this hormone induce changes in the reproductive system analogous to those ob- served in the adreno-genital syndrome. It is only a specific type of cortical hyperplasia which is associated with disorders of the reproductive system. The tumors of the interrenal system, described in the preceding chapter, are not associated with changes in the sex glands. It is thus erroneous to ascribe the development of the adreno-genital syndrome to overactiv- ity of the interrenal tissue of the adrenal cortex but we must seek some other functionally distinct unit in the adrenal as the source of the observed disorders. The earliest attempts to explain the relation of the adrenals to sex anomalies was based on a consideration of the common embryological origin of the adrenals and the gonads (Gallais, 210 Wiesel, 677 Glynn 227 ). As we have already noted in Chapter II, the adrenal cortex is developed from the mesenthelium of the abdominal hollow contiguous to the point of origin of the testicles and the ovary. There is thus an intimacy between the points of development of the adrenal and sex glands. Moreover, the origin of the ovary is hermaphroditic. 359 The ovary passes through a stage in which its cortical portion may be considered female ; its deeper medullary part, male. During subsequent development, this male part remains rudimentary. It is this male part which is so intimately related with the beginning stages of the adrenal cortex. 337 If these fetal testicu- lar cells by developmental anomaly are included in the adrenal they might develop into tumors which physiologically would manifest their testicular origin. Hence one might expect virilism to develop in patients in whom these adrenal growths occur. The above theory was propounded by Krabbe 365 and explains to a certain extent the clinical picture associated with the adreno-genital syndrome. However, it is unnecessary to resort to Krabbe 's hypothesis to explain the origin of the dis- orders of the reproductive system which are associated with ADRENOGENITAL SYNDROME 341 adrenal tumors. As we have seen in Chapter IV, the adrenal cortex of man (in whom alone the adreno-genital syndrome has been observed) contains a tissue which is anatomically and functionally distinct from the rest of the cortex. This tissue which we have designated as the androgenic zone is normally only temporary in its existence disappearing in the first years of life, but sometimes remains as a few scattered cells (the juxta-medullary zone) in the adult. It would seem most logi- cal, therefore, to ascribe to this androgenic tissue the occur- rence of the disorders of the reproductive system which are associated with tumors of the adrenals. The exact embryologi- cal origin of the androgenic zone has not been determined. It may well be that it has a common origin with the "testicular" cells of the ovary, asumed by Krabbe 365 to be the cause of the adreno-genital syndrome. The differentiation of the androgenic tissue as a unit distinct functionally from the remainder of the adrenal cortex would explain the fact that adenoma or carcinoma of the cortex proper do not give rise (Chapter XXII) to abnormalities of the reproductive system. It would also account for the failure of large doses of the cortical hormone to affect the reproductive system. Although Britton and his co-workers 127 have claimed that extracts of the adrenal cortex of cattle induce "precocious" maturity in rats, all subsequent observers (Castello et alii, i09 Cleghorn, 115 Howard and Grollman, 321 Simpson et alii, 575 and others who have investigated the problem) have disproven Britton's contentions. The author realizes that the views set forth in the present volume regarding the functional independence and the clinical significance of androgenic tissue require further experimental work to establish them upon a firm basis. However, although theoretical, the view advanced is in accord with all the known facts and permits one to account logically for the adreno-genital relationships. The use of this theory avoids the chaotic con- fusion otherwise encountered in trying to account for the rela- tion between the adrenals and the reproductive system. 342 CLINICAL CONSIDERATIONS The adreno-genital syndrome is characterized by a mascu- linization of the female. In children it occurs occasionally in males but in the adult it is limited to the female sex. Several cases have been reported 302 in adult males in whom adrenal tumors were associated with some evidences of feminization of the patient. However, the few cases in which this has been described are not convincing and one is inclined to explain the apparent feminization to other causes than to the existence of a tumor of the androgenic tissue. The masculinizing effects induced by a tumor will vary depending upon the age and state of development of the reproductive system in the patient. We can accordingly divide the adreno-genital syndrome into the juvenile type as it occurs in children before puberty and the adult type which gives rise to the condition of adrenal virilism. Besides these two conditions one also finds an hy- perplasia of the androgenic tissue in cases of hermaphroditism. These three conditions will now be described in greater detail. THE JUVENILE FORM OF THE ADRENO-GENITAL SYNDROME The literature records 24 cases of this condition, 19 of which occurred in girls while only 5 occurred in boys. The adreno- genital syndrome is thus predominantly an affection of the female in childhood. The onset of the disease is usually dur- ing the first two years of life. The condition is marked by an hyperplasia of the androgenic zone which although benign in its initial stages degenerates into a malignant process. This over-activity of a masculinizing tissue leads to the development of the secondary male characteristics — muscular development, deepening of the voice, hirsutism, et cetera. The characteristic points of the abnormal sexual develop- ments in female children is the luxurious growth of hair (pubic and sometimes facial), hypertrophy of the labia majora, pro- jection of the labia minorae, and enlargement of the clitoris which may assume a penis-like structure. There is also en- largement, at times, of the ovaries and uterus, but menstrua- ADRENO-GENITAL SYNDROME 343 tion is absent. In male children, there is also hypertrichiasis, a deep voice, enlargement of the penis, and external genitalia, but the testes remain immature and show no spermatogenesis. There is an unusual muscular development, more marked particularly in the male, so that the child appears as an "infant Hercules." The patients appear matured and have an adult appearance. A typical case in a male child as described by Gordon and Browder 232 follows: In their patient, at nine months of age, an abnormal development of the external genitalia was appar- ent. Pubic hair appeared at 12 months. On admission to the hospital, at the age of three, the patient appeared like an "adult dwarf with the musculature and general development of a young Hercules." The voice was deep and gruff. "The scalp was covered with thick hair extending well down over the forehead and posteriorly down on the neck. The eye- brows were heavy, shaggy and continuous across the bridge of the nose." There was a marked growth of hair on the face, upper Up, chin, back, pubic, and perineal regions. The skele- ton was markedly enlarged except for the humeri, which were the length expected in a three-year-old child. Dentition and osseous development were that of a child of seven to ten years of age. At no time had there been any priapism, nor evidence of nocturnal emissions or masturbation. Autopsy of the above described case revealed numerous metastatic tumors in the lung which had been the immediate cause of death. In the region of the left adrenal and extending from the dome of the left diaphragm downward to the upper pole of the right kidney and medially to the midline, was pres- ent an irregular nodular tumor lying entirely retroperitoneally. The right adrenal was absent. That part of the adrenal gland not affected by the tumor was normal on gross examination. An important feature of the juvenile form of the adreno- genital syndrome is the absence of true precocious puberty. Menstruation does not occur in the female at an early age nor 344 CLINICAL CONSIDERATIONS does priapism, spermatogenesis, or other signs of true puberty occur in the male. It is thus a misnomer to refer to the condi- tion as one of precocious puberty as is usually done. True precocious puberty occurs with tumors of the pineal gland (chiefly in males, rarely in the female) and with tumors of the testicles or ovaries. In these cases there is an actual functional precocity of the reproductive organs. In the female, menstrua- tion occurs as early as the first year, while in males, spermato- genesis, priapism, and masturbation regularly occur. This difference should serve as an important clinical sign to differen- tiate the adreno-genital syndrome from cases of true preco- cious puberty. 365 As regards the treatment for this condition, surgical removal of the affected gland before metastasis has occurred is obviously necessary. Improvement following such removal with retro- gression of the abnormal signs of masculinization have been reported. 120228 In many cases reported in the literature, as in the one cited above, there has been an anomaly or complete absence of the opposite adrenal. Hence the surgeon should ensure himself of the state of the unaffected gland before undertaking the removal of the affected adrenal. Should the adrenal on the unaffected side be absent, removal of the diseased gland would lead to death of the patient from adrenal cortical insufficiency. In such cases it is, therefore, necessary to preserve some of the normal cortical tissue either by allowing it to remain in situ or transplanting it to an ovary or testicle. Treatment of the patient postoperatively with the adrenal cortical hormone in minimal doses until regeneration of new cortical tissue has occurred is also necessary. The juvenile form of the adreno-genital syndrome is prob- ably caused by hyperplasia of the androgenic zone. Instead of disappearing as it does in normal children during the first year of life, this tissue for some unknown reason proliferates and ultimately assumes malignant characteristics. III I > u e. s S°aO 73 >>S^ "1 d)^ .. i, - - ~ i. :; so *g ' =t,-" c — it: ^ M (B ' 2 S 3 i IS O ra o3 S os^s 1 ADRENOGENITAL SYNDROME 347 Except for the arrhenoblastoma of the ovary, which occur very rarely in children, 475 the juvenile form of the adrenogeni- tal syndrome should offer no difficulty in diagnosis. Ar- rhenoblastoma of the ovary give rise to a condition which is identical, as far as one can judge from the few cases in the literature, to the adreno-genital syndrome. This identity in the manifestations of the two disorders supports the view that the ovarian cells which give rise to the arrhenoblastoma and the androgenic tissue are functionally equivalent. The diag- nostic errors so frequently encountered in determining the cause of precocious development in children is due to the failure to appreciate the fact that adrenal tumors do not give rise to true sexual precocity and that the occurrence of regular menstrua- tion or spermatogenesis precludes, therefore, the possibility of an adrenal tumor as the cause of the disorder. Failure to appreciate this fact, first pointed out by Krabbe, 365 has led to futile operations on the adrenal when the ovary, testicle, or pineal were the true sites of the disorder. In only two cases cited in the literature has menstruation been observed in chil- dren suffering from adrenal tumors. In one case" the patient was eleven years of age and in the other 655 (the patient of Figure 17) the bodily development was that of an adult. In both cases the menstruation occurred at rare intervals and was small in amount, thus differing from the cases of true precocious development in which a normal and regular menstrual flow may begin in infancy. ADRENAL VIRILISM By this term, we shall refer to the adreno-genital syndrome as it occurs in adult women. It occurs most often either during the early years of adolescence or at the time of meno- pause, that is, at those periods in life when the reproductive cycle is undergoing most rapid change. Cases have been re- ported, however, not infrequently in patients of intermediate ages. 95 ' 203 348 CLINICAL CONSIDERATIONS The adreno-genital syndrome as it occurs in women is marked by an appearance of secondary male characters and a retrogression of the female sex characters. Among the former are 1) hypertrichiasis of the male type, 2) changes in bodily contour, 3) changes in the larynx, 4) hypertrophy of the clitoris, and 5) the assumption of the psychological outlook of the male. The retrogression of female characteristics is marked by a cessation of menstruation and the loss of other female char- acteristics which are replaced by the masculine characters already noted. The above mentioned changes may now be discussed in further detail in the order in which they have been enumerated above. The development of hair of the masculine pattern is one of the most prominent signs of adrenal virilism and has given rise to the term adrenal hirsutism as descriptive of this syndrome. The degree of this hirsutism is variable. It is often distributed over the entire body. On the face it is commonly a moustache or beard. It may cover the thighs and chest and appear in patches over the dorsum of the feet and proximal phalanges. The axilla and pubis are well covered, the latter assuming the triangular distribution characteristic of the male. In older women baldness of the masculine type has also been described. 95 The bodily contour assumes a masculine form particularly when the syndrome develops early. The patients are broad- shouldered, narrow-hipped, and muscular. The breasts are usually undeveloped or may retrogress. In certain cases (cf. Figure 17) they appear large but these are probably composed of fatty tissue and part of the tendency to increase in weight which is observed in the early stages of virilism. Broster and Vines 95 found the involutionary changes of later life in one of their cases. A peculiar striation of the thighs was described by Gallais 210 and has been noted by subsequent authors as occurring in this condition. This may possibly be explained as analagous to that occurring during pregnancy and due to stretching of the ADRENOGENITAL SYNDROME 349 skin by the imposition of the skin of a small masculine contour over a large female pelvis. The larynx assumes a masculine form with development of an Adam's apple and a deep voice. 95 In the early stages of the disease, there is marked adiposity which is limited to the upper half of the body. Later cachexia and progressive asthenia occur, at which time there is a palp- able tumor of the adrenal. The female reproductive system undergoes a change in which there is suppression and atrophy of the female organs and hypertrophy of the male elements. The clitoris, the female analogue of the penis, becomes enlarged and may assume the form of a penile organ with well-developed glans and prepuce. In such cases the undersurface is grooved, as in hypospadias. The vagina, mons veneris, and labia become atrophied. In a large series of cases in which laparotomy was performed, Bros- ter and Vines 95 noted constant changes in the ovaries which were atrophic and often cystic and degenerated. The fundus uteri and cervix were small. Amenorrhoea is an important symptom. In the adreno- genital syndrome appearing after puberty, the menses become irregular, intermenstrual periods lengthen, the flow becomes diminished and finally ceases completely. Certain other clinical symptoms have been described as associated with adrenal virilism — hypertension, pain in the lumbar region, migrainous headaches, et cetera. Of greater importance are nausea, vomiting, weakness, and rarely pig- mentation on the forehead and border of the axilla. The last named symptoms are those of Addison's disease and are due to the encroachment of the malignant androgenic zone on the true cortical tissue. Psychologically, the development of male characteristics with suppression of the female may be marked by homosexual tendencies. The psychic disturbances so common and pro- found in subjects in whom the reproductive system has under- 350 CLINICAL CONSIDERATIONS gone a violent change are commonly observed in patients suffering from adrenal virilism. 95 • 303 - 655 In many of the cases of adrenal virilism described in the literature there has been a unilaterial tumor in one adrenal or rarely at the site of a so-called adrenal rest. 363 In the large series of Broster and Vines, 95 however, the affection was usually bilateral. The treatment of the adreno-genital syndrome in adults does not differ from that described in children in cases in which a definite tumor has given rise to the condition. Successful operations followed by retrogression of the abnormal signs of masculinization have been recorded. 95303,655 In patients with a bilateral affection of the androgenic tissue, the removal of one gland with partial removal of the other must lead to an un- satisfactory result, for the hypertrophy of the remaining andro- genic tissue will eventually cause a reappearance of the original symptoms. The logical treatment in such patients should consist in the enucleation of the internal portions of the ad- renals, thus removing the medulla and androgenic zones while preserving the outer layer of the cortex which is essential for life. Such an operation, performed in two stages to allow regeneration of the cortical tissue left after the first operation, would offer the best prospects for a permanent cure. A series of cases of adrenal virilism treated surgically with considerable success has been reported by Broster and Vines 95 in London, and Kepler, Kennedy, Davis, Walters, and Wilder 655 at the Mayo Clinic. The 10 cases of Broster and Vines showed no untoward signs following unilateral adrenalectomy. In general there was a gratifying return of menstruation following operation and some diminution in the degree of hypertrichiasis. However, as already stated, Broster and Vines found no differ- ence between the two adrenals, both showing the fuchsinophile reaction by which they detected the androgenic tissue. Bros- ter and Vines utilized the trans-thoracic route for their adrenal- ectomy which they considered superior to the sub-diaphrag- ADRENOGENITAL SYNDROME 351 matic approach. The average age of their patients was 20 years. The 7 cases of Kepler, et alii 655 differ considerably from those encountered by Broster and Vines. These authors encoun- tered a unilateral tumor in most of their cases. Removal of this growth by a lumbar, extra-peritoneal approach gave remark- ably good results in some of their patients. In figure 17 is reproduced a photograph of one of the patients of Walters and his co-workers 655 showing the curative effects of removal of the affected adrenal. THE ADRENALS AND HERMAPHRODITISM Gallais 210 in his monograph collected 11 cases of hermaphro- ditism in which marked anomalies of the adrenals were present. In these cases the secondary sexual characters were masculine, the anomalous development having occurred during embryonic development. The adrenals were hyperplastic and there were supplementary aberrant cortical tissues or tumors of cortical origin. Gallais considered the hermaphroditism to be of adrenal origin. However, there is considerable question as to the role of the adrenals in these cases. Further work is neces- sary to decide if the adrenal hyperplasia (probably of the andro- genic tissue) is the cause of the sexual anomalies or whether the changes in the two organs are part of the same underlying cause and due to a more fundamental anomaly of the germ plasm. In embryonic life, the internal genital organs are hermaphro- ditic containing both masculine and feminine generative potentialities. This embryonic bisexuality is manifested in the coexistence of the Miillerian and Wolffian ducts. Later in embryonic development, in the female, the Miillerian ducts persist while the Wolffian are partially resorbed. Their per- sistence results in a partial (tubular) hermaphroditism. The external genital organs are in reality only degrees of the same ascending evolution, each organ of one sex having its counter- 352 CLINICAL CONSIDERATIONS part in the other, e.g., the penis and clitoris, or the prostate and para-urethral glands of Skene. Hermaphroditism may involve a true co-existence of male and female generative organs in the same individual. A lesser degree of hermaphroditism exists in cases in which the sec- ondary characteristics of one sex are present in individuals with the anatomical generative organs of the opposite sex. These secondary characteristics in man are hypertrichiasis, muscular development, low pitch of the voice, and virility of character; in the female, they are menstruation, soft voice, adiposity, gynecomasty, and a feminine psychological outlook. The cases reviewed by Gallais 210 showed for the most part secondary male characteristics with female generative organs. One might consider the male characteristics as results of the accompanying hyperplasia of the androgenic zone of the adrenals. Whether this hyperplasia is primary or merely a compensatory mechanism due to deficiency in the female characters is still open to question. The most logical inter- pretation of the observed facts would be that the adrenals are not in themselves responsible for the development of herma- phroditism. If by some anomalous development hermaphro- ditism of the female type occurs, there is a tendency for the androgenic zone to become overactive and thus accentuate the secondary male characters present in these primary female hermaphrodites. In accord with this view we find that bi- lateral hyperplasia of the adrenal gland is found in about 15 per cent of female but in only 0.7 per cent of male pseudo- hermaphrodites. 227 The so-called adrenal cortical rests so commonly found in female pseudo-hermaphrodites 195 are com- posed of androgenic tissue and not true cortical tissue as has previously been believed. They have often been mistaken for a displaced testicle or ovary. According to the theory outlined in the preceding paragraph, the adrenal hyperplasia observed in hermaphroditism may be looked upon as a process analogous to the enlargement of the ADRENOGENITAL SYNDROME 353 androgenic zone in male mice following castration. In both cases there is a compensatory hypertrophy of a masculinizing tissue (the androgenic zone) as a consequence of a congenital or induced dysfunction of the normal reproductive system. OTHER CONDITIONS RESEMBLING THE ADRENO-GENITAL SYNDROME Two other clinical conditions occurring in women are charac- terized by a symptom-complex which is practically identical to the adrenal virilism described in the preceding section. These conditions are the "diabetes of bearded women" de- scribed by Achard and Thiers 6 and Cushing's syndrome. 142 According to most observers these two syndromes are identical. Achard and Thier's symptom-complex is marked by hyper- trichosis of the face, obesity, glycosuria with decreased carbo- hydrate tolerance, hypertension, and usually amenorrhea. At autopsy, a pronounced hyperplasia of the adrenals has been noted. It is probable that this adrenal hyperplasia represents an hypertrophy of the androgenic tissue which is in part at least responsible for the observed masculinization. Cushing's syndrome is characterized by a rapidly acquired and usually painful adiposity, confined to the face, neck, and trunk, the extremities being spared; a tendency to become round shouldered, associated with lumbo-spinal pains; sexual dystrophy, shown by early amenorrhea and sterility; hyper- trichosis of the face and trunk; a dusky or plethoric appear- ance of the skin with purplish striae distensae of the abdomen and legs; vascular hypertension; acrocyanosis; and osteo- porosis. In Cushing's earlier reports, 142 he attributed the above described disorders to basophilic adenomata of the pituitary which were present in his patients. However, more recently, cases have been reported which were clinically indistinguishable from Cushing's syndrome, but in which at autopsy no disorders of the pituitary were found. Instead, an adrenal tumor was 354 CLINICAL CONSIDERATIONS found as the only pathologically observable source of the dis- order. 102, 1388, 4U - 662 The question, therefore, arises as to what part the adrenals play in producing Cushing's syndrome. Broster and Vines 95 have suggested that all cases of the syndrome may be associated with a change in the adrenals manifested by a different staining reaction of the juxta-medullary tissue. If this suggestion of Broster and Vines is substantiated, one might consider Cush- ing's syndrome as a manifestation of adrenal virilism, primarily induced perhaps by the pituitary basophilism. Basophilic adenomata of the pituitary are frequently found at autopsy in patients who in life manifested no clinical symptoms. 351 Crookes 139 has suggested that it is only such basophilic cells as are characterized by a distinctive hyalinization of their cytoplasm that are associated with Cushing's syndrome. Further investigation is obviously necessary before one can decide the relative importance of the pituitary and the adrenal in causing Cushing's syndrome. It may be that the pituitary basophilism initiates the observed clinical picture by sup- pressing the ovarian function which in turn elicits a reaction of the androgenic zone. As we have seen in Chapter IV, castration in mice also causes an hypertrophy of the androgenic tissue. The observed disorder might according to this view be caused either by a primary hyperplasia of the androgenic tissue of the adrenal or by an hyperplasia of this tissue induced primarily by a disorder of the pituitary. Finally, attention may be called to those cases in which sex changes occur which are identical to those observed in adrenal virilism but in which, at operation or autopsy, no discoverable cortical abnormalities are evident on superficial examination. In Broster and Vines' 95 patients the adrenals in these cases showed a staining reaction of the juxta-medullary tissue which differentiated it from normal cortical tissue. This juxta- medullary tissue, in the author's opinion, is identical with what we have denoted as the androgenic zone and is probably the ADRENOGENITAL SYNDROME 355 cause of the observed disorder. What appears by the ordinary methods of staining as interrenal tissue is in reality androgenic tissue. Further investigation of the adrenals in these cases as well as those of Cushing's syndrome and other forms of virilism are desirable to elucidate the role of the adrenals in the genesis of these disorders. Chapter XXIV OTHER PATHOLOGICAL ABNORMALITIES OF THE ADRENALS Besides the destructive lesions of the adrenals which give rise to Addison's disease and the tumors of the adrenals dis- cussed in previous chapters, a number of pathological condi- tions are accompanied by abnormalities of the adrenals. The significance of some of these abnormalities is not clear at present and many of them are probably of no clinical im- portance. The adrenals rapidly undergo autolytic changes after death and many of the histological pictures described as characteristic of certain diseases are in reality post-mortem changes. It would appear, however, that these post-mortem changes are more prone to appear in individuals dying of infectious or toxic processes for the observed abnormalities are more striking in these subjects. 157 The gland subjected to toxic influences apparently becomes subject to easier attack by autolysis than the normal gland. Fissures are also often noted between the medulla and cortex but it is questionable if they are due to post-mortem changes or are the results of a necrosis which has occurred during life. 175 The pharmacodynamic effects of epinephrine have led authors to assume that certain diseases of the vascular system are resultants of abnormalities of the medulla, but there is little to substantiate this clinical hypothesis. Except for the rare cases of paroxysmal hypertension due to chromaphil cell tumors, there is no disease which has been definitely shown to be caused by hyper- or hypo- activity of the medulla or other chromaphil tissues. Many diseases have from time to time been suggested as associated with dysfunction of the adrenals. 230 Glaucoma, 356 OTHER PATHOLOGICAL ABNORMALITIES 357 paralytic ileus, thyrotoxicosis, diabetes, obesity, progeria, osteomalacia, rickets, peptic ulcer, bronchial asthma, cancer, etc. have been attributed to adrenal insufficiency or hyper- activity. The evidence for this association is so unconvincing and in many cases so obviously fallacious that we need not consider it here. In the following sections shall be discussed a number of clinical conditions in which the involvement of the adrenals is unquestionable, although the significance of the adrenals in the clinical condition is in many cases unknown. ANENCEPHALY The remarkable hypoplasia of the adrenals in anencephalic monsters was observed as early as 1723 by Morgagni. 55 Meckel 447 and Nagel 464 claimed that the adrenals were absent in these monsters and that their absence was responsible for the maldevelopment of the reproductive organs. Although one still finds these views quoted in recent texts it has been re- peatedly shown that they are erroneous. As shown by Meyer, 454 in the five-month anencephalic monster the adrenals may be completely normal. At birth they appear much smaller than the normal glands but this hypoplasia as Elliott and Armour 182 first showed is due to the absence of what they termed the "fetal" cortex or what we have designated as the androgenic zone. The other two components of the adrenal — the medulla and the cortex proper — are normally developed so that the glands really resemble a miniature adrenal of a one- year old child. Microscopically too the adrenals appear normal except for this absence of the androgenic zone of the new-born. The absence of the androgenic zone in anencephaly might be anticipated if we accept the view that the androgenic zone is associated with the development of the reproductive system. It is possible, however, that the maldevelopment of the hy- pophysis which occurs in anencephaly is the primary cause of the failure of the androgenic zone for this gland, as we have seen, and the androgenic zone may be closely related. 358 CLINICAL CONSIDERATIONS As noted by Zander, 696 the ganglia of the sympathetic system are fully developed in cases of hemicephaly. In spina-bifida and in hydrocephalus, no abnormality of the adrenals is noted. STATUS LYMPHATICUS The adrenal cortex is often hypoplastic in cases of so-called "status lymphaticus." 230 In adrenal insufficiency, conversely, there is often hyperplasia of the thymus and other lymphoid tissue. 335 Unfortunately, our ignorance of the exact function of the thymus and lymphatic system renders any discussion of the probable significance of this adrenal-lymphatic relation- ship futile. The lymphatic system responds by hypertrophy or atrophy to so many clinical conditions that it is unjustifiable to attribute any more fundamental relation between the ad- renals and the lymphoid tissue than exists between the latter and the thyroid, for example. As regards the relation of the adrenals to status lymphaticus, there is no longer a tendency to regard this condition as a disease entity. As Groll 157 showed, the hyperplasia of the thymus and other lymphoid tissues which characterize status lymphaticus were frequently observed in healthy normal individuals killed during the Great War. It would, therefore, be too far-fetched to attribute the sudden deaths, presumably due to a questionable pathological condition (status lymphaticus), to an acute adrenal insuf- ficiency. Instances of sudden death following a prolonged exposure to heat, narcosis, muscular exertion, or certain poisons have also been attributed to an acute adrenal insufficiency. Au- topsy in such cases has revealed a marked decrease in the epinephrine content of the medulla and vacuolar degenerative changes in the cortex with no changes in other organs to account for the sudden death. Since the influences cited above are accompanied by an increased utilization of the cortical hormone, it is not irrational to assume that they might by exhausting the supply of the hormone in the body OTHER PATHOLOGICAL ABNORMALITIES 359 cause collapse and death from cortical insufficiency. Further studies are needed, however, to substantiate these assumptions as to the role of the adrenal in these conditions. OTHER ANOMALIES Defects of the adrenal have been reported in other develop- mental anomalies but it is questionable if any very important significance can be attributed to these findings. Thus in Schridde's disease in which edema of the newborn is accom- panied by maldevelopment of the erythropoietic system, Yasukawa 694 noted fatty infiltration of the innermost layers of the cortex. This slight anomaly certainly appears to merit no great attention. There is also a reduction in the lipid content of the adrenals and hypoplasia of the adrenals and thymus in exfoliation of the skin of the newborn (Ritter's disease). These associations too are of doubtful significance. 230 Reports of absence of the adrenals reported by earlier workers 140 are now generally discounted. As we have seen (Chapter XXI), in Addison's disease due to atrophy, the remnant of adrenal tissue may be so small as to escape notice unless carefully sought. The reports of absence of one adrenal may be accepted as due to destruction by unilateral atrophy. The congenital absence of one gland has been reported in a patient in whom some of the other abdominal viscera on the same side were also absent and in whom a number of other congenital anomalies were found. 417 The adrenal has been described as malformed by an unnaturally projected fissure through the entire gland at the hilum. In some cases the gland on one side is doubled or the chromaphil tissue has failed to occupy its normal position within the cortex but occupies a position on the surface of the gland 157 as in the reptilian adrenal. HEMORRHAGE AND OTHER VASCULAR LESIONS The adrenals are sometimes the site of hemorrhages which if extensive may induce adrenal insufficiency. 572 Massive bi- 360 CLINICAL CONSIDERATIONS lateral hemorrhages following acute septic conditions have resulted in symptoms simulating peritonitis and rapid death from acute adrenal insufficiency. Such hemorrhages are apt to occur in leukemia or other conditions in which there is an hemorrhagic diathesis. 230 Death in the new born has been ascribed in some instances to hemorrhage into the adrenals. The hemorrhage observed in the androgenic zone of the new born has, however, been mistakenly attributed to injuries suffered during delivery, whereas in reality, as Landau 376 showed, such hemorrhages are part of a physiological process, and are observed in cases of infants delivered by Caeserian section. It is possible that the normal hemorrhage and diapedesis of the androgenic zone might result in an unnatural extravasation of blood particu- larly when aggravated by the trauma of a difficult delivery. Such hemorrhages may, if extensive, cause death by inter- ference with the normal cortical function. Large cystic hema- toma have been produced which in rare cases have ruptured through the capsule and filled the retroperitoneal space. Adrenal hemorrhages of sufficient magnitude to cause death are rare in adults but are found more frequently in infants dying of unknown cause about one day after birth. 390 Traumatic hemorrhages of the newborn are acquired during passage through the birth canal (particularly in breech presentation), or by slapping the lumbar region in attempts at resuscitation. 408 Small hemorrhages are frequently observed in general in- fections, intoxications, burns, and diseases in which there is an hemorrhagic diathesis. Such hemorrhages are replaced by pigmented scar tissue, calcified nodules, or the formation of bone. 230 - 432 The adrenals are also occasionally subject to other vascular lesions, passive congestion, thrombosis, infarction, or em- bolism. Passive congestion of the adrenals has been observed in obstruction of the portal circulation, in cirrhosis of the liver, and in conditions of general circulatory insufficiency. Throm- OTHER PATHOLOGICAL ABNOKMALITIES 361 bosis of the adrenal veins with death from acute adrenal in- sufficiency has been reported. Such thrombi have been con- sidered as due in most cases to an extension from smaller thrombi formed in the capillaries of the cortex in acute in- fections or other processes causing degeneration of the parenchymal tissues. Thrombosis may also arise in the adrenal veins as a result of conditions in the circulation. Infarction of the adrenals results in a rapid destruction of the medullary tissue. The cortical tissue is less apt to be ir- reversibly damaged. 230 The clinical symptoms attributed to extensive hemorrhage in the adrenals are convulsions, vomiting, diarrhea, abdominal pains, and hyperpyrexia. 230 As we have noted in previous chapters, these symptoms may occur in experimental acute adrenal insufficiency and it is thus not irrational to attribute their occurrence in man to the same cause. An elevated temperature is not uncommonly seen in animals for a day or two following bilateral adrenalectomy (Chapter XIII). HYPERFUNCTION OF THE ADRENALS In considering hyperactivity of the adrenals we must differ- entiate between the effects of hyperfunction of the three elements of the gland 1) the medullary tissue, 2) the androgenic tissue, and 3) the cortical or interrenal tissue. The only condition definitely associated with over-activity of the medulla is the occurrence of paroxysmal hypertension in cases of paraganglioma which we have described in Chapter XXII. There is no valid evidence for Unking other diseases of the circulatory, lymphatic, or endocrine systems with the adrenal medulla. The results of overactivity of the androgenic zone have been discussed in Chapter XXIII. No effects have been noted clinically which might be linked with overactivity of the cortex proper. The hormone elab- orated by this tissue is of a relatively small molecular weight 362 CLINICAL CONSIDERATIONS and is probably rapidly secreted or destroyed when introduced in great excess into the organism. Over-dosages of this hor- mone have also failed to demonstrate any changes in the organism. Hence we might anticipate that physiological hyperplasia of the adrenal cortical tissue with the production of an abnormally great amount of its hormone would lead to no pathological condition such as follows the elaboration of an over-abundance of certain other endocrine products such as insulin or the growth hormone of the pituitary. Hyperplasia of the adrenals, as noted in Chapter XXII, is not infrequently found at autopsy. Such hypertrophy is probably the result of an increased demand for the secretory product of the cortex and can be induced in animals by sub- jecting them for an extended period to any of the influences (cold, heat, drugs, toxins, inanition, etc.) which cause an in- crease in the rate of utilization of the cortical hormone. Al- though it can not be denied that an actual overproduction of the hormone beyond the needs of the organism occurs in certain cases (as evidenced by adenomatous growths) no clinical symptoms have been noted which might be attributed to this cortical overactivity. HYPERTENSION The fact that epinephrine produces so marked a pressor effect when injected has led authors from time to time to ascribe the condition of essential hypertension to over-activity of the adrenal medulla. Neusser 468 in 1898 first pointed out the association of tumors of the adrenal gland with hypertension and his theory as to the causal relation existing between these two conditions has been revived periodically. Even within recent years unilateral adrenalectomy has been performed for the relief of essential hypertension. As has been indicated in Chapter VI, there is no justification for assuming that hyper- tension is in any way related to overactivity of the adrenal medulla. Excision of a gland or cutting the splanchnic nerves OTHER PATHOLOGICAL ABNORMALITIES 363 is, therefore, to be deprecated in these conditions as a procedure involving great hazard for the patient with no reason for assum- ing that any therapeutic benefit will be derived. Aside from Neusser's findings, an association between hyper- tension and hyperactivity of the adrenals has been claimed on the basis of the frequency with which cortical adenomata and hyperplasia are found in cases of hypertension. Thus Aubertin and Ambard 24 in eight cases of hypertension found that four showed a diffuse cortical hyperplasia, three had adenomata of the cortex, and only one had normal adrenal glands. Hyper- trophy of the cortical tissue is, however, a common finding at autopsy and any observed hyperplasia is more apt to be sec- ondary to rather than the primary cause of the hypertension. It has repeatedly been shown that there is no increase in the epinephrine content of the blood in cases of hypertension. 639 The hyperglycemia observed in hypertension can not, there- fore, be attributed to an assumed increased secretion of epi- nephrine, but is probably due to a deficient pancreatic activity resulting from arterio-sclerosis. 483 It is extremely difficult to estimate the size of the medulla by simple examination at autopsy. Attempts to arrive at an accurate estimate have been made and would seem to indicate that there is some hypertrophy of the medulla in patients dying of hypertensive cardio-vascular-renal disease. These enlargements are, how- ever, inconstant, and best explained as the result rather than as the cause of the disease. 483 HYPOFUNCTION OF THE ADRENALS There is no clear-cut evidence to associate hypofunction of the adrenals with any clinical condition other than Addison's disease. This disease, however, is the result of marked de- struction of the adrenal cortex and it would seem most logical to suppose that lesser degrees of injury or temporary conditions which call for an excessive utilization of the hormone should also result in deficiency symptoms of a minor degree. Un- 364 CLINICAL CONSIDERATIONS fortunately we are at present ignorant of these conditions and can only surmise as to their nature and causative agents. Further clinical investigation and a study of the therapeutic effects of administration of the cortical hormone should elucidate these problems. One would anticipate that hypofunction of the adrenals should result in some of the symptoms which characterize insufficiency in experimental animals or patients with Addison's disease, viz., asthenia, gastro-intestinal disturbances, a tend- ency to infection, etc. Unfortunately these symptoms are also characteristic of other pathological conditions as well, and hence, to attribute indiscriminately any condition charac- terized by one or more of these symptoms to adrenal insuffi- ciency is unjustified. On the other hand, one is justified in our present state of ignorance to apply the therapeutic test in any given case in which there is a suspicion of adrenal hypo- function. For example, animals subjected to excessive heat require an excessive amount of the cortical hormone. It would seem logical to hypothecate, therefore, that the denervating effects of heat may in part at least be a result of a mild degree of adrenal cortical insufficiency. The experimental adminis- tration of the hormone to a statistically significant number of cases with proper controls and avoidance of vitiating factors would determine the validity of the above hypothesis. A number of acute and chronic diseases may cause degenera- tive changes in the adrenals and it is logical to conclude that such changes may induce a degree of adrenal insufficiency which contributes to the observed clinical picture. Thus in uncomplicated cases of superficial burns the most characteristic changes occur in the adrenals. 665 These organs are swollen and deep red. On section one may find extensive hemorrhage. The cells are pale and swollen and in a process of hydropic degeneration. The cause of death in extensive burns has not been definitely proven. It is generally assumed that absorp- tion of toxins from the injured skin and from bacterial infec- OTHER PATHOLOGICAL ABNORMALITIES 365 tions of the burned area is the prime cause of a fatal outcome. In view of the demonstrable lesions in the adrenals, it would seem worth while to investigate the therapeutic effects of the adrenal cortical hormone in these cases. INFECTIONS In acute bacterial toxemias, focal necroses are often ob- served in the zona fasciculata which resemble those occurring in the spleen and other viscera. Regeneration may occur in these areas as noted by mitotic activity. Cloudy swelling and edema of the adrenals also occur and are most prominent in the inner cortical zone. Such edema is common in patients dying of acute infections. Congestion and small focal hemor- rhages are also frequently found and there is a disappearance of the cholesterol bodies from the cortex. 157 Changes in the adrenals, of the nature described above, were observed by Klotz in 14 of 32 patients dying of influenza. 132 Paisseau and Lemaire described similar changes in pernicious malaria and others have found them in diphtheria, broncho- pneumonia and other toxemias of bacterial origin. 417 One might anticipate that bacterial toxins will affect the adrenals as they do other parenchymatous glands. The questions of prime importance are: Does this injury to the adrenal cortex as observed pathologically contribute to the clinical symptoms of these diseases? Are the epigastric pain, the vomiting, asthenia, hypothermia, and hypotension due to an acute cortical insufficiency induced by the disease? It is impossible to answer these questions at present. Clinical investigation of the effects of therapy with the adrenal cortical hormone is obviously necessary for elucidation of the problem. The symptoms of the nitroid crises following injections of arsphenamine and preventive vaccination have also been attributed to adrenal hypofunction. However, the nature of these symptoms and their acute onset speaks against an adrenal involvement. 366 CLINICAL CONSIDERATIONS Diseases other than those cited in the preceding sections have been associated with the adrenals. The evidence for this association has usually been so flimsy and in violation of so many well authenticated facts as to warrant little credence. Thus glaucoma has recently been considered as a disease due to adrenal cortical insufficiency. The basis for this view is the assumption that the intra-ocular tension which characterizes glaucoma is caused by an increased permeability of the capil- lary endothelium. Administration of a commercial prepara- tion of the cortical hormone is claimed to have relieved the glaucoma. As we have seen (Chapter IX), there is no basis for the view that the capillaries become more permeable in adrenal insufficiency. Hence the conception of glaucoma as a disease due to cortical insufficiency is not justified. Moreover, the preparation used in "curing" the glaucoma contains so little of the adrenal cortical hormone that one could scarce attribute any therapeutic effect to its use. The adrenal has been cited by several authors as in some way implicated in the causation of cancer. The claimed curative effects of concoctions derived from the adrenals have been shown to be unfounded. Joannovics 340 found that partial adrenalectomy did not affect the percentage of successful implants of virulent tumors into mice. The slight retardation of growth of the tumors in the adrenalectomized animals is attributable to their general poor condition and does not imply any specific relation of the adrenals to the development of carcinoma. 374 There is a natural tendency to apply any new therapeutic agent to all the sundry human ailments for which satisfactory methods of treatment are lacking, and to rationalize these attempts by a line of reasoning which is often fallacious, as exemplified by the cases cited above. Besides such ill-advised attempts to apply the newer knowledge, there may emerge, however, genuine cases in which the cortical hormone shall prove to be really efficacious and shall demonstrate relation- ships between the adrenals and pathological processes con- cerning which we are still in ignorance. EPILOGUE Despite the gradual advance in our knowledge of the adrenal glands, we are still unable to answer satisfactorily the question proposed by the Academy of Bordeaux in 1716 — "Quel est V usage de glandes surrenales?" Neither chance observation, which Montesquieu suggested might some day answer this question, nor the devoted zeal of the many workers who have applied themselves to its solution have answered satisfactorily this fundamental question. However, the labor of these in- vestigators has not been in vain. The past work has made possible the formulation of certain definite views concerning the adrenals and has divested our minds of some of the early confusing ideas concerning these glands. The fundamental problems relating to the adrenals which await future solution are clearly definable. The chemical study of the cortical hormone is of paramount importance. A knowledge of its structure will perhaps throw light on its action in the organism, and make possible an attempt to synthesize it. The synthesis of the hormone is extremely desirable because of the comparatively difficult and expensive task of obtaining it in pure form from natural sources. Any physiological effects of the cortical hormone when injected into normal animals has not been demonstrated. The claims that such effects have been obtained are to be attributed to the presence of sundry impurities. Future workers must ensure themselves that they are actually dealing with relatively pure preparations of the hormone and are not being misled by extraneous effects. The same criticism is to be applied to the past work on the effects of the hormone in disease. As we have seen, the extant work claiming therapeutic effects in surgical shock, infections, glaucoma, etc. is scarcely to be taken seriously. The worker in the future should be less naive in accepting the claims of potency as stated on the label of his 367 368 EPILOGUE purchased extract or the arrant claims of his predecessors. He must convince himself of the potency of his preparations, be certain that he is actually administering an adequate amount of the hormone, and refrain from drawing conclusions from results based on inadequately controlled work. The fields for the clinical application of the cortical hormone are too obvious to require specific enumeration. With a potent preparation available one should certainly be able to produce worthy therapeutic effects in Addison's disease. The pessimistic reports of recent workers in this field should not be taken too seriously. The use of impotent and impure extracts explains why such poor results have hitherto been obtained. With the administration of potent extracts in sufficiently large doses, there is every reason to believe that the cortical hormone should actually result in the beneficent effects which many writers, rather prematurely and on insufficient grounds, claimed to have obtained. The availability of the adrenal cortical hormone permits a more thorough and reliable study of the physiological and pathological results of adrenal insufficiency. The effects of the hormone on isolated tissues and on tissue cultures should also be studied providing one has available a highly purified solution. Adrenal cortical extracts are noteworthy for the ease with which they may be contaminated with highly active phar- macological agents, such as histamine, choline, epinephrine, etc. and the complete removal of these substances is imperative before one can rely on the results of many types of experiments. 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INDEX Abscess, 320 Accessory, androgenic tissue, 58 bodies, 32 role of, after adrenalectomy, 157 Acetonitrile, 267 Acetylcholine, 97, 291, 296 effect of, on blood pressure, 89 on epinephrine secretion, 103 Acid-base equilibrium, 187 Acromegaly, 210 Addison, 5, 299 Addison's disease, 299 clinical course, 301, 312 diagnosis, 322 etiology, 300 incidence, 300 latent, 323 life expectancy in, 312 pathology of, 313 symptomatology, 302 treatment of, 324, 368 Adenocarcinoma, 337 Adenoma, 337 Adrenal, anatomy of, 12 discovery of, 1 diseases of, 297 nomenclature, 2 synonyms for, 1 weights, 19, 23 see specific items Adrenalectomy, effects of, 161, 172, 179, 205, 227, 267 history of, 141 survival following, 143 technique for, 149 in rats, 252 Adrenalin, see epinephrine Adrenalitis, 336 Adrenalone, 83 Adreno-genital syndrome, 223, 339 juvenile form, 342 Adrenotropic hormone, 218 Agglutinins, 268 Aldehydase, 296 Amyloidosis, 319 Analeptic, epinephrine as, 134 Anaphylaxis, 268 Anatomy, comparative, 12 gross, 9 microscopic, 37 Androgenic tissue, 32, 56, 281, 341, 368 accessory, 59 in man, 58 in mice, 63 in other species, 64 involution of, 60 pathology of, 339 Androtin, 228 Anemia, 290 Anencephaly, 357 Anesthesia, effect of, on epinephrine, 99 epinephrine in, 134, 136 in Addison's disease, 326 for adrenalectomy, 144 Anomalies, of adrenals, 359 Anorexia, 163, 307 Ant-eater, 39, 69 Antibodies, 268 Antidote, for epinephrine, 134 Apes, anthropoid, 39, 69 Apnea, epinephrine, 122 Apocodeine, 118 Arecoline, 103 Armadillo, 39, 47, 69 Arrhenoblastoma, 347 Arsenic, 279 Arterenol, 86 401 402 INDEX Arteries, adrenal, 24 effect of epinephrine on, 119 Ascorbic acid, 81, 293, 305 Asphyxia, 99 Assay, of cortical hormone, 248 of epinephrine, 80, 88 Asthenia, 163, 302 Asthma, 135, 357 Atrophy, 310, 318 Atropin, 103, 134, 197 Auto-assay method, 90 Avitaminosis, 292, 295 Bacterial injections, 279 Base, of blood, 310 Basophilic adenoma, 217, 223, 353 Bat, 43, 53 Bdellostoma myxinidae, 13 Bear, 47 Beef, see cow Bensley-Helly fixative, 37 Bible, 1 Bicarbonate, 187, 310 Bichromate reaction, 71 Bile, 128 ducts, 126 Biot respiration, 312 Birds, 16, 38 adrenalectomy in, 150 Bladder, 126 Blood, in Addison's disease, 310 in insufficiency, 166, 172 chemistry, 179 pressure, in Addison's disease, 309 effect of epinephrine on, 117, 121 in insufficiency, 166 method for assay of epinephrine, 88 sugar, see glucose supply, see circulation vessels, 177 volume, 167 Body temperature, 164, 311 Bos taurus, 21 Boundary-zone, 57 Bronchioles, 123 Bufo agua, 74 Burns, 54, 105, 364 Caffeine, 102, 116 Calcification, 323 Calcium, 185, 223 Camelopardalis, 43 Camphor, 101, 102 Cancer, 56, 357, 366 Canis familiaris, see dog Cannaubic acid, 290 Capillaries, action of epinephrine on, 120 Capsule, of adrenal, 23 Carbohydrate metabolism, 131, 197 effect of, cortical hormone on, 203 epinephrine, 198 in insufficiency, 203 utilization, 130 Carcinoma, 328, 337 Cardiac output, effect of epinephrine on, 120, 121 in insufficiency, 166 Cardio-vascular disease, 290 Carotene, 292, 296 Carotid gland, 27 epinephrine content of, 74 exclusion of, 101 Castration, effect of, on adrenals, 226 on survival after adrenalectomy, 148 Cat, adrenals of, 21, 28, 32, 47 circulation in, 25 adrenalectomy in, 156 Cauterization, 279 Cavia cobaya, see guinea-pig Cebus, 43 Center, for epinephrine, 97 Cevitamic acid, see ascorbic acid Charcoal, as adsorbant for cortical hormone, 234 hormone preparation, 234 activity of, 239 dosage of, 243 elution of hormone from, 240 INDEX 403 Chelonia, 16 Chicken, embryology of, 30 see bird Chimpanzee, 39 Chiroplera, 43 Chloral, 116 Chloretone, 113 Chlorides, blood, in Addison's dis- ease, 193, 310 in cortical insufficiency, 187 Chloroform, 55, 101, 265, 279 Cholesterol, 54, 228 blood, 289 in insufficiency, 179 Choline, see acetylcholine Chromaffinoma, 333 Chromaphil bodies, 11, 26, 48, 54 abdominal, 28 accessory, 28 diseases of, 297 staining of, 27 tumors of, 330 Chromophiloblast, 330 Chronic insufficiency, 279 Circulation, of adrenals, 24, 94, 111 in Addison's disease, 308 after adrenalectomy, 166 effect of epinephrine on, 116 Coagulation, of blood, 133 Coccygeal body, 27 Cold, effect of, on epinephrine secre- tion, 100 in cortical insufficiency, 168 Conductivity, of blood, 188 Coniine, 103 Connective tissue, 40, 55 Coronary arteries, 120 Cortex, extracts of, 231 function of, 139 injection of, 232 oral administration of, 232 Cortin, 233 Cow, 21, 33, 38 Creatinine, 182 Cricetus, 53 Curare, 48, 103, 267 Cushing's syndrome, 217, 223, 353 Cuttle fish, 86 Cyclostomata, 12 Cysteine, 80 Cystisine, 103 Cytology, 47 Dasypus, see armadillo Decerebration, 198, 274 Degeneration, of adrenal cells, 55 Dementia praecox, 54 Diabetes, 54, 357 adrenalectomy in, 199 Diagnosis, of Addison's disease, 322 by use of epinephrine, 136 Diarrhea, 163, 307 Diastase, 296 Diet, for assay, 256 Digestive disturbances, 306 Dioxyindole, 85 Diphtheria, 54, 55, 279, 365 toxin, 105, 265, 267 for assay of cortical hormone, 249 Dipnoi fishes, 15 Diuresis, 128, 182 Dog, adrenals of, 21, 28, 35 circulation in, 25 adrenalectomy in, 154 assay method, 249 Dogfish, 29 Dopa, methyl ether of, 83 reaction, 85 Dopase, 85 Duckbill, 39 Echidna aculeata, 39 Echinococcus cyst, 320 Elasmobranchs, interrenals of, 13, 28,29 extracts of, 14 interrenalectomy in, 14, 149 Electrocardiogram, in Addison's dis- ease, 308 in cortical insufficiency, 166 Electrolytes, of blood, 191, 192 Elephant, 39, 47, 69 404 INDEX Embolism, 320, 360 Embryology, of adrenals, 28 in amphibia, 30 in birds, 30 in mammals, 31 Emergency function, of adrenals, 109 Emu, 47 Endocrines, 209 Enzymes, 296 Ephedrine, 86 Epilepsy, 54 Epinephrine, in Addison's disease, 325 administration of, 134 adsorption of, 82 analysis of, 80 antidote for, 134 assay of, 87 benzoyl derivative of, 80 borate, 80 center, 97 clinical significance of, 298 content, of adrenals, 73, 105, 106 of blood, 95, 105 of extra-medullary tissues, 74 of extracts, 232 diagnostic use of, 136 fate of, in body, 138 function of, 106 in histamine poisoning, 268 optical activity of, 76 origin of, 82 oxidation-reduction system, 80 parasympathetic action of, 114 pharmacology of, 113 physical properties of, 79 physiology of, 87 piqure, 97 preparation of, 77 related compounds, 86 secretion, rate of, 94 control of, 96 factors affecting, 98, 101, 104 stability of, 79 structural formula of, 76 sympathomimetic action of, 113 synthesis of, 76 Equus caballus, 43, 53 Erinaceus, 43, 53 Erythrocytes, 183 Estrus, effect of epinephrine on, 225 effect of, on survival after adrenal- ectomy, 147 Ether, 101, 144 Exercise, muscular, 130 Extracts, cortical adrenal, 231 charcoal, 234 dosage of, 243 effects of, on carbohydrate metabo- lism, 203 in normal animals, 367 on reproductive system, 228 efficacy of, 242 glandular sources of, 235 glycerine, 233 mode of administration of, 245 for parenteral use, 240 preparation of, 234 see Hormone Eye, excised, 90 effect of epinephrine on, 124 Fasciculata, 40 Fatty degeneration, 319 Felis catus, see cat Femmes a barbe, 353 Fetal cortex, 57 Fever, 100, 105 Fibroma, 338 Fibroxanthosarcoma, 338 Fishes, elasmobranch, 14, 29 interrenalectomy in, 149 selachian, 15 teleost, 15 Fixative, 37 Flying-fox, 39 Folin-Denis reagent, 81 Freezing-point, of blood, 188 Frog, adrenal of, 15, 17, 48 adrenalectomy in, 149 grafts in, 283 Function, of adrenals, 3 of epinephrine, 106 of interrenal tissue, 138 INDEX 405 Gall bladder, 126 Ganglioneuroma, 332 Gastro-intestinal disturbances, 163, 173 Gelsemin, 103 Giraffe, 43 Glands, feeding of fresh, 231 source of, 235 Glaucoma, 356, 366, 367 Glioma, 331 Glomerulosa, 40 Glucose, blood, in Addison's disease, 192, 310 in experimental insufficiency, 203 injections, intraperitoneally, 189 tolerance, 311 Glutathione, 80, 287 Glycogen, effect of epinephrine on, 131 in insufficiency, 203 liver, 197 mobilization of, 200 muscle, 199 Glycogenolysis, 197 Goat, 157 Golgi apparatus, 48 Goose-flesh, 127 Grafts, 281, 327 in Addison's disease, 282, 284 Graves' disease, 207, 220 Growth, in cortical insufficiency, 213 effect of extracts on, 215 Guanidine, 102 Guinea-pig, 19, 28, 39, 44, 47, 55, 226 adrenalectomy in, 154 grafts in, 283 Hagfish, 13 Hamster, 53 Heart, in Addison's disease, 308, 320 block, 117 denervated, 92 effect of epinephrine on, 116 electrocardiogram of, 166, 308 injection of, 138 in experimental insufficiency, 177 output of, 166, 120 Heat, 100, 168, 364 Hedgehog, 43, 53, 129 Hemangioma, 338 Hemicephaly, 62, 358 Hemolysins, 268 Hemorrhage, 55, 173, 290, 320, 359 effect of, on epinephrine secretion, 100 Hen, see bird Hermaphroditism, 59, 351 Herpesles mungo, 127 Hibernation, 129 Hirsutism, 348 Hirudo, 12 Histamine, 104, 115, 267, 274, 296 as antagonist to epinephrine, 268 for assay of cortical hormone, 249 Histology, 37 History, 1 Homoarterenol, 86 Hormone, cortical, assay of, 248 chemistry of, 245 crystallization of, 245 effect of, on blood sugar, 203 on glycogen, 200 on metabolism, 208 on normal animals, 245, 367 on reproductive system, 339 excretion of, 245 inactivation of, 247 in infections, 269 oral administration of, 260 solubility of, 246 see extracts Horse, 43, 53 Hutchison's tumor, 332 Hydrastinin, 103 Hydrocephalus, 62, 358 Hyperfunction, of adrenals, 361 Hyperglycemia, 136, 198 emotional, 202 Hypernephroma, 336 Hyperplasia, of adrenals, 336, 362 Hypertension, 109, 362 intermittent, 334 Hyperthyroidism, 207, 220 Hypoglycemia, 136, 198 406 INDEX Hypophysectomy, cortical hormone after, 211 effects of, 202, 210 Hypophysis, in Addison's disease, 210, 321 extracts of, 210 implants of, 227 in insufficiency, 173, 209 relation of, to adrenals, 209 Hypoplasia, of adrenals, 363 Hypotension, 308 postural, 309 Hystrix cristata, 39, 69 Ileus, 357 Immunity, 265 Inanition, 265, 290 Infantilism, 218 Infarction, 360 Infections, 264, 265, 364, 367 cortical hormone in, 269 epinephrine in, 105 wound, 266 Influenza, 300, 365 Insufficiency, cortical, chronic, 212 experimental, 161 Insulin, 101, 173, 201, 202, 229 Interrenal, 11, 31 accessory, 32, 35 Intestines, in Addison's disease, 320 for assay of epinephrine, 88 in cortical insufficiency, 173 effects of epinephrine on, 123 Involution, of androgenic zone, 60 Iris, denervated, 92 Irradiation, 105, 324 Jecorin, 296 Juxta-medullary zone, 47 Kephalin, 296 Kidneys, in Addison's disease, 320 effect of epinephrine on, 128 in insufficiency, 170, 173 Lamprey, 13 Lecithin, 228, 290 Leech, 12, 74 Lemur, 43 Leucocytes, 55, 167 Ligation, of adrenal vein, 278 Lipase, 296 Lipids, 54, 287, 288 of androgenic tissue, 62 anisotropic, 54, 289 in disease, 265, 290 Lipochromes, 296 Liver, 197 glycogen of, 174, 199 in cortical insufficiency, 170, 173 Lobelin, 103 Lymphangioma, 338 Lymphatics, 25 Lymphocytosis, 310 Lymphoid tissue, 175, 321, 358 Magnesium, 185 Malignancy, see tumors Malnutrition, 55 Mammals, 16, 38 embryology of, 30 see individual species Man, 20, 30, 39, 47, 58 Marchand's bodies, 59 Marmot, 47, 157, 192 Marsupials, 39 see opossum Medulla, destruction of, 279 relation of size of, to cortex, 39 see epinephrine, chromaphil, etc. Melanin, 83, 86, 296 Melanophores, 127 Mercury salts, 48, 279 Metabolism, 205, 206, 216 in Addison's disease, 311 effect of epinephrine on, 129 Metachirus opossum, 39 Metallic salts, 55, 104 Metamorphosis, of amphibia, 220 Milk, secretion of, 128, 215 Mitochondria, 48 Mole, 47 Molluscs, 12, 74 Mongoose, 127 INDEX 407 Monkey, 21, 28, 39 adrenalectomy in, 156 Monotremes, 39 Morphine, 103, 267 for assay of cortical hormone, 249 effect of, on epinephrine discharge, 101 Mouse, 39, 47, 226 adrenalectomy in, 151 androgenic tissue in, 63 Muirhead treatment, 325 Mus musculus, see mouse Mus norvegicus, see rat Muscle, effect of epinephrine on, 129 glycogen of, 200 see asthenia Mustela foina, 39 Mycosis fungoides, 320 Myoma, 338 Nephlhys scolopendroides, 12 Nerves, of adrenal, 25, 26 Nervous system, 177 Neurin, 103, 296 Neurofibromatosis, 333 Nicotine, 101, 102, 267 Nitroid crisis, 365 Non-protein-nitrogen, of blood, 180, 192, 310 Obesity, 348, 357 Opossum, 28, 43, 69, 157, 192 Opsonins, 269 Oral therapy, 260 Ornithorhynchus, 39 Osmotic pressure, 187 Osteitis fibrosa, 222 Osteomalacia, 357 Ovaries, 227 Ovis aries, 21, 54 Oxidation, 80 Palmitic acid, 289 Paludina vivipara, 12 Pancreas, 173, 176, 229 Pancreatectomy, 204 Paraganglion, 26 aorticum, 26 epinephrine content of, 74 suprarenale, 26 Paraganglioma, 333 Parathyroids, 222 Parenteral therapy, 260 Pathology, of Addison's disease, 313 of the adrenals, 54 of cortical insufficiency, 161 Pepper type, 332 Peptone shock, 104 Perfusion, for epinephrine assay, 89 Peritonitis, 54, 266, 270 Pernicious anemia, 54, 323 Petromyzon, 12 pH, of blood, 187 Phaeochrome tissue, 11 Phaeochromocytoma, 333 Phenol, 55, 279 Phenolsulphonephthalein, 180 Phocaena communis, 39, 40 Phosphates, in blood, 187 Phrenosin, 289 Physeter macrocephalus, 21 Physostigmin, 103, 115 Picrotoxin, 102 Pig, 21, 69 Pigeons, adrenalectomy in, 150 Pigmentation, in Addison's disease, 303, 313 in cortical insufficiency, 172 origin of, 86 Pilocarpin, 101, 103, 115 Pilomotor muscles, 126 Piqure, 97, 197 Pisemsky's method, 90 Pithing, 48 Pituitary, basophilism, 217, 223, 353 see hypophysis Pituitrin, 219 Plasma volume, 183 Pneumonia, 269, 279 Porcupine, 39, 69 Porpoise, 39, 40 Potassium, blood, 185, 192 408 INDEX Precocity, 343 Precursors, of epinephrine, 82 Pregnancy, in Addison's disease, 312 adrenalectomy in, 147 effect of, on adrenals, 43, 226 epinephrine in, 225 Progeria, 218, 357 Propterus annectens, 15 Prostate, 126 Protein, blood, 183, 310 Protocatechuic acid, 75 Pteropus medius, 39 Pulmonary artery, 120 ventilation, see respiration Pulse, in Addison's disease, 308 effect of epinephrine on, 116, 121 in experimental insufficiency, 166 Pupil, of eye, 124 Purpura lapillus, 12 Quinine, 103 Rabbit, 28, 35, 47, 69, 226 adrenalectomy in, 152 grafts in, 283 innervation of adrenals in, 25 Radium, 279 Raja, see elasmobranchs Rat, 20, 21, 41, 49, 226 adrenalectomy in, 21, 28, 151, 252 assay method, 251 grafts in, 283 Regeneration, after injury, 265 of medulla, 284 Reproduction, in Addison's disease, 312 after adrenalectomy, 227 in experimental insufficiency, 170, 215, 224 Reptilia, 16 Respiration, in Addison's disease, 312 effect of epinephrine on, 122 in cortical insufficiency, 164 Reticular zone, 40, 44 Reversal effect, of ergotoxin, 115 Rhinoceros, 39, 47 Rickets, 357 Ritter's disease, 359 Saliva, 127 Salt, therapy, 193, 261 see metallic, sodium, etc. Santonin, 102 Saponin, 290 Sarcoma, 331, 333, 338 Scarlet fever, 54 Schridde's disease, 359 Scurvy, 265, 294 Scyllium, 29 Secretions, see specific items Semilunar ganglion, 321 Sensory stimulation, 98 Sepia officinalis, 86 Sex, effect of, on survival after ad- renalectomy, 148 on weight of adrenals, 225 Sheep, 21, 54 Shock, anaphylactic, 104 epinephrine in, 135, 273 extracts in, 276 histamine, 274 peptone, 104 relation of adrenals to, 271 surgical, 270 Siderophile zone, 44 Simmond's disease, 210, 217 Size, variations in, 23 Skate, 13, 14, 29, 149 Sodium chloride, in Addison's dis- ease, 193 in cortical insufficiency, 184, 310 in diagnosis, 323 therapy, 326 Solar plexus, 321 Spartein, 103 Sphingomyelin, 289 Spina bifida, 62, 358 Splanchnic nerves, 96 Spleen, 126, 173 Spongy zone, 44 Squirrel, 28, 157 Stannius corpuscles, 15 INDEX 409 Starvation, 54, 105 Status lymphaticus, 175, 321, 358 Stearic acid, 289 Stomach, in Addison's disease, 320 effect of epinephrine on, 123 in experimental insufficiency, 173 Stone-marten, 39 Streptococcus, 279 Strophanthus, 101 Strychnine, 101, 267 Sugar, see glucose Sulphate, blood, 187 Sulphur, 287, 288 Suprarenal, 2 Suprarenin, 75 Surgery, epinephrine in, 134 in hypertension, 109 on human adrenal, 280 procedures used, 279 Sus scrofa, see pig Sweating, 127 Sympathoblast, 330 Sympathoblastoma, 331 Sympathogone, 330 Sympathogonioma, 331 Sympathomimetic action, 71 Syphilis, in Addison's disease, 319, 326 effect of, on androgenic tissue, 61 Tamandua, see ant-eater Teleosts, 14 Temperature, 130, 217 Testudina, 16 Tetanus toxin, 105, 267, 279 Tetrahydronapthylamine, 103 Theelin, 228 Theobromine, 102 Therapeutic use, of cortical hormone, 326, 367 of epinephrine, 134 Thrombosis, 320, 360 Thymus, 173, 175, 321, 358 Thyroid, extracts of, 219 relation of, to cortex, 219 to epinephrine, 221 to metabolism, 205 Thyroidectomy, 206, 219 action of epinephrine after, 130 Thyrotropic hormone, 217, 218 Thyroxin, 221 Toad, skin glands of, 74 Toxemias, 365 Toxicology, of epinephrine, 133 Toxins, 264 Tragulus javanicus, 47 Trauma, 320 Trichosurus, see opossum Trypanosomiasis, 269 Tuberculosis, 315, 320 miliary, 316 Tumors, of androgenic tissue, 339 as cause of Addison's disease, 319 classification of, 329 of cortex, 335 Grawitz, 336 of medulla, 330 metastatic, 329 renal, 336 Tunica dartos, 126 Typhoid, mouse, 270 vaccine, 267, 269 Tyrosinase, 83 Urea, 180, 192 Ureter, 126 Uric acid, 182 Urine, effect of epinephrine on, 128 in cortical insufficiency, 184 Urodela, 16 Uterus, for assay of epinephrine, 90 effect of, epinephrine on, 125 lecithin, 228 in cortical insufficiency, 227 Vaccination, 365 Vagina, 126, 228 Vas deferens, 126 Vasomotor nerves, 169, 277 Veins, of adrenal, 25 effect of epinephrine on, 121 Venom, cobra, 267 Veratic acid, 75 Vesperugo, 53 410 INDEX Virilism, 58, 347 Vitamin, A, 292 B,, 292 B 2 , 295 C, see ascorbic acid G, 295 Vomiting, 163, 307 Vulpian's reaction, 71 Weber-Fechner law, 118 Weight, of adrenals, 19 Whale, 21 Wound infections, 266 X-rays, 105 X-zone, 63 Xanthophyll, 296 Water, balance, 182 content, of adrenals, 287 of blood, in Addison's disease, 192 in insufficiency, 182 of muscles, 192 Zona arcuata, 43 Zones, of adrenal, 40 Zuckerkandl's bodies, 26 pressor effects of, 28 tumors of, 334