History of adrenal surgery

Abstract

The adrenal glands were first depicted by Bartholomaeus Eustachius in 1552. They were drawn onto copper plates, Eustachius being the first anatomist to use this method, and reproduced in print in 1563 [1]. The early anatomists such as da Vinci,Galen and Vesalius had overlooked the glands, first named "glandulae renibus incumbents" (glands lying on the kidneys) by Eustachius. Successive names include "glandulae renales", coined by Thomas Wharton, physician to St. Thomas' Hospital, London, in 1656 [2], and "capsulae suprarenales", used by Jean Riolan of Paris in 1629 [3]. The terms cortex and medulla, to describe the two component parts of the adrenal,were first used by Emil Huschke,anatomist and embryologist at Jena, in 1845. The function of the adrenals was the subject of much speculation in the 19th century with the suggestion that they might release "a peculiar matter into the blood,"or conversely "absorb humid exudates from the large vessels nearby". The fundamental, but controversial, proposal that the adrenal glands produced 'internal secretions' ('secretion interne') was made by the Parisian physiologist Claude Bernard in 1855 [4]. Remarkably, in the same year,Thomas Addison described 11 patients showing clinical features attributable to adrenal insufficiency, namely anemia, debility, feebleness of the heart, irritability of the stomach,and a change in skin color. The autopsy findings were adrenal destruction by unilateral or bilateral tuberculosis, metastatic carcinoma, or simple atrophy. These observations were presented to the South London Medical Society in 1849, focusing on the anemia component of the syndrome, but the classical description of Addison's disease (the eponym being ascribed by Armand Trousseau [5]) was published 6 years later as a monograph,On the Constitutional and Local Effects of Disease of the Suprarenal Capsules [6]. Although the publication stimulated much interest, some controversy, and important experimental work, the syndrome of Addison's disease was not universally accepted for many years. Charles Édouard Brown-Séquard concluded that the adrenals were essential for life (essentials à la vie) after carrying out a series of experiments on dogs,cats, hares and guinea pigs in which bilateral adrenalectomy always resulted in death in a few hours and even unilateral adrenalectomy was often fatal [7]. William Osler was the first to attempt treatment of adrenal insufficiency in 1896, using an extract of pig's adrenal [8]. The isolation of epinephrine by Abel in 1897 [9], following Oliver and Schäefer's work with adrenal extract in 1894 [10], had attracted great interest, and the absence of this chemical was thought to be responsible for the weakness and low blood pressure of Addison's disease and the fatal consequences of adrenalectomy. Epinephrine was used at the Mayo Clinic in 1920 to treat a patient with symptoms of Addison's disease following nephrectomy [11]. Although administration of epinephrine resulted in temporary relief of the patient's weakness, he later succumbed. Others reported the lack of efficacy of this medullary hormone,and it soon became clear that Addison's disease affected the adrenal cortex only. In 1926, cortical extracts were used successfully in adrenalectomized animals, but it was not until the 1940s that cortisone was isolated and synthesized, work led by Edward Kendall of the Mayo Clinic[12], and Tadeus Reichstein of Basle [13], later to be award-ed the Nobel Prize for their remarkable achievements. It was realized that the adrenal cortex produced several steroids,with deoxycorticosterone being the first to be synthesized. Aldosterone, initially called electrocortin, was discovered later by James Tait and Sylvia Simpson in London [14], and was found to exert influence over electrolyte fluxes. Development of techniques to measure urinary and plasma steroids subsequently facilitated the assessment of adrenal gland function and paved the way for the precise identification and investigation of a whole range of pathological conditions of the adrenals, including Cushing's syndrome, Addison's disease and Conn's syndrome. In common with the investigation of most disorders of the endocrine glands, once the hormonal dysfunction has been confirmed it became necessary to localize the site of the pathological lesion.With regards to the adrenals there was an initial dependence upon the insensitive method of plain abdominal radiography. The first attempt of specific adrenal imaging was by retroperitoneal gas insufflation [15]. This technique was not reliable and many preferred pyelography. Caval venous sampling, first performed in 1955 to assay catecholamines, was a significant breakthrough [16]. The refinement of selective adrenal venous sampling subsequently aided localization of adrenal pathology, and indeed remains a most valuable diagnostic tool today [17]. Phlebography, whilst being a sensitive technique,was associated with complications such as adrenal rupture or gland infarction [18], and never really gained favor. Scintigraphy, developed by Beierwaltes and colleagues at AAnn Arbor, Michigan [19], employed radiolabeled cholesterol and was useful to diagnose hyperplasia and functioning tumors of the adrenal cortex. Cross-sectional imaging with computed tomography (CT) was first used in 1975 [20], and along with magnetic resonance imaging (MRI) [21] remains the mainstay of localization investigation today.