The Goulstonian Lectures on the Suprarenal Bodies: Delivered before the Royal College of Physicians of London
BMJ (Clinical Research Edition)
LECTURE I. THE ANATOMY, HISTOLOGY, AND MORBID ANATOMY OF THE SUPRARENAL CAPSULES. UIN his preliminary remarks the lecturer thanked the College for the honour conferred on him, and said that since the euprarenal capsules were attracting considerable attention at the present time, it seemed opportune to review the state of our knowledge concerning them.] Method qf Remwval.-The most satisfactory method of examining the suprarenal bodies and removing them in the course of a necropsy was described.
... psy was described. THE RIGHT SUPRARENAL CAPSULE. The right suprarenal capsule embraces the inner, upper, and anterior part of the corresponding kidney. Its outline, as seen from the front, is roughly triangular, with angles pointing respectively (1) outwards, (2) upwards, and (3) downwards. It is flattened and presents two surfaces, anterior and posterior, each of which is divisible into two secondary areas. The anterior surface is not uniformly flat; along its upper and inner borders there is a continuous depressed area. This bears a varying proportion, one-third to a-half, to the whole extent of the anterior surface, usually about a third. The two areas thus formed on the anterior surface are separated by a furrow. The furrow is overhung by the margin of the larger, outer, and comparatively elevated area. Section of the suprarenal capsule shows that the furrow corresponds to a projection on the posterior surface. This undulation on the anterior surface follows the curve of the upper and inner borders. At a point on this undulation, correspondiing to the upper and inner angle, the suprarenal vein issues from the medulla in the furrow, and runs upwards to enter the inferior vena cava. The depressed area is uncovered by peritoneum; the part which lies adjacent to the upper border is in immediate contact with the right lobe of the liver, while that part which corresponds to the inner border lies underneath the inferior vena cava. The remaining or elevated area on the anterior surface presents (1) a non-peritoneal portion (Anderson)' for the hepatic flexure of the duodenum near its lower angle; the extent of this portion varies very considerably (St. John Brooks) ;2 and (2) a portion covered by the peritoneum forming the hepato-renal fold. The posterior surface is divided by a projection into two secondary areas. This projection, which is the counterpart of the furrow on the anterior surface, fits into the groove between the kidney and the right crus of the diaphragm. This undulation in the suprarenal body is oblique, and the process on the posterior surface looks outwards. Of the two secondary areas the inner is flattened by the pressure of the right crus of the diaphragm, and is larger than the outer area, which is so tilted upwards by the underlying kidney hat it looks backwards and downwards. THE LEFT SUPRAIENAL CAPSULE. The left suprarenal capsule is applied to the inner margin of the upper half of the left kidney, which it overlaps; it passes into the upper margin of the kidney for a short distance only. The inner border is convex, and looks slightly upwards; the outer border is concave. There are two angles: the upper which is pointed, and the inferior rounded and covering the renal vessels. There are two surfacesanterior and posterior. The anterior has a crescentic outline. It is fiat, and traversed by a groove or furrow, from which the suprarenal vein runs downwards to join the left renal vein. This groove runs from above downwards and inwards, and thus divides the anterior surface into two secondary areas: (a) an outer and inferior, and (b) an inner and upper. Near the superior angle these areas are of equal size, but below the outer becomes the larger, and forms the lower rounded angle of the suprarenal body. Relations of the Anterior Surface.-The anterior surface is divided into (1) an upper portion covered by the peritoneum of the lower sac, and in relation with the cardiac end of the stomach near the entrance of the cesophagus, and below that with the superior extremity of the spleen; and (2) the lower part uncovered by peritoneum. and in direct contact with the pancreas and splenic artery. On the posterior surface there is a projection corresponding to the furrow on the anterior surface. This projection passes between the kidney and the crus of the diaphragm almost at right angles to the plane of the anterior surface. This undulation is vertical, thus contrasting with the oblique undulation in the right suprarenal body. External to the projection theie is the external area larger than the internal. This external area is thin, and is expanded by the pressure of the underlying kidney. The renal vessels as they pass into the hilum lie under cover of this area. Internal to the projection is the smaller internal area which rests on the crus of the diaphragm; it is thick and compact, and may cover the left semilunar ganglion, but this is not a constant relation. AANATOMICAL CONFORMATION. The different folding, as shown by the oblique and vertical directions of the undulations respectively in the right and left suprarenal bodies, depends on the differences in the packing of the two organs. The probable explanation of the more complicated form of the undulation on the right side is the close relation to the firm liver, and the pressure thereby exerted on the suprarenal body. Each of the organs weighs about a drachm or rather more, the left being rather the heavier. In cases where the kidney is displaced, the corresponding suprarenal capsule remains in its normal position. When a horseshoe kidney exists the position of the suprarenal bodies undergoes no change, even though the kidney is situated over the promontory of the sacrum. In an example of this kind the suprarenal bodies lay on the crura of the diaphragm, and were flat and not thrown into their normal undulations. This observation shows the influence which the pressure normally exerted by the kidneys has on the conformation of the adrenals. The suprarenal body has a firm capsule of fibrous tissue, and running in from it are septa containing small arteries which traverse the cortex and reach the medulla. The arteries derived from the aorta, renal and phrenic arteries, enter the cortex and pass inwards towards the medulla: at the hilum the cortex thins away and exposes the medulla, from which the suprarenal vein issues. The suprarenal vein in the medulla is surrounded by large bundles of smooth muscular tissue, which form a prominent feature on section. Guarnieri and Magini'3 suggest that the circulation through the organ may be slowed by the contraction of these muscular bundles. In fcetal life the large and very vascular suprarenal capsules are relatively, though not absolutely, larger than in adult life. Their large size and vascularity make it probable that their functions are more extensive and active in fcetal life. At the third month of intrauterine life the kidneys and suprarenal capsules are of the same size; at the sixth month the kidneys are twice the size of the suprarenal capsules and more than twice their weight. At birth the kidneys are about three times heavier than the suprarenal capsules, while in adult life, the kidneys weighing on an average 5i ounces and the suprarenal bodies 1 drachm each, the relation is 44 to 1. After birth the suprarenal capsules continue to increase in size, and, like other organs, attain a size varying roughly with that of the whole body.