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VIRILISM: UNILATERAL ADRENALECTOMY.
By J. R. M. Whigham, M.C., M.S., F.R.C.S. (Eng.), Surgeon, St. Andrew's Hospital.
The patient, a woman L.P., aged 26, was sent to the hospital by Dr. G. 0.
Mitchell and was admitted to the wards under the care of Dr. R. M. Maher. There
had been symptoms suggestive of phthisis in the past for which she had been kept
under observation, but she now sought advice for a growth of hair on the face and
chin and irregularity of menstruation.
The patient was a brunette, 5 ft. 1 in. in height, rather thick set, and weighed 8 at. 9 lb. A
firm growth of hair was present on the cheeks and chin; the legs were hairy and over the lower
abdomen the suprapubic hair reached up to the umbilicus, simulating the distribution in the
male. The bodily contour presented no marked features, except that the breasts were ill developed.
The voice was low pitched. The psychological outlook was feminine. Menses had commenced
at 14½ years, lasting 3 days every 3 weeks. At 21 they had diminished and lasted only 2 or perhaps
1 day at a time. They had also become painful and associated with fainting attacks. The external
genitalia appeared normal. On further investigation it was noted that the B.P. was 120/90,
the W.R. negative, and the Kahn reaction negative. The blood count returned the following
figures:—hæmoglobin, 60 per cent.; red blood corpuscles, 5 millions; colour index, 0.6; leucocytes,
8,400; polymorphs, 60 per cent.; eosinophils, 6 per cent.; basophils, 1 per cent.; lymphocytes,
30 per cent.; large hyalines, 3 per cent. The blood urea was 40 mg., blood sugar 97 mg.,
and blood calcium 8.26 mg. per 100 c.c. The sugar tolerance test gave the following figures:—
fasting, 65 mg. per 100 c.c.; ½ hr., 101 mg. per 100 c.c.; 1 hr., 91 mg. per 100 c.c.; 2 hrs., 82 mg.
per 100 c.c. (Miss K. M. Collis.) There was slight hypochlorhydria as shown by the test meal.
An X-ray examination showed no abnormality in the skull, pituitary fossa, chest or abdomen.
An ophthalmological examination revealed myopia with astigmatism, but the media were clear,
the retinae healthy and the fields full (Mr. Jeremy).
The case was diagnosed as one of adrenal virilism (hirsutism), due probably to cortical tumour
or hyperplasia. As there was no indication as to which gland was involved, laparotomy was
decided upon, and this was performed on the 2.3.34. The gland on the left side was definitely
palpable and slightly enlarged, but no tumour was discovered; on the right side the gland could
not be identified by the examining finger. Small cysts were present in both ovaries; the uterus
was rather smaller than normal. The patient made a smooth and uninterrupted recovery from
the operation, and on 17.4.34, six weeks afterwards, a left adrenalectomy was performed through
a subcostal incision excising the last rib, following Bleicher's technique.
The operation was performed with the patient in the right lateral position, the knees being
slightly flexed, the right more than the left. A pillow was inserted below the costal margin to
open out the left loin. The patient was anæsthetised with rectal paraldehyde and gas and oxygen
inhalation. The skin incision followed the direction of the last rib extending from the erector
spinæ mass posteriorly along the costal margin to the mid axillary line in front. The skin, fasciæ
and muscles were divided down to the level of the 12th rib. In the anterior end of the wound the
muscles of the abdominal wall, the external oblique, the internal oblique and the transversalis
were seen, and the latissimus dorsi, the erector spina? mass, and the serratus posticus inferior
posteriorly. The periosteum over the last rib was incised and the rib resected subperiosteally.
This was done with due regard to its tendinous and aponeurotic attachments and respect for the
subjacent pleura. The rib was divided close back to the vertebral column, and when removed the
lower limit of the pleura, covered by oblique aponeurotic fibres, was revealed, with the 11th
dorsal nerve running obliquely forwards across it. The 12th nerve runs parallel and lower down.
A little blunt dissection with firm retraction of the wound edges exposed the extra-peritoneal fat
and the perirenal fascia. The latter was incised and the incision enlarged, thus allowing the
kidney to be brought into the floor of the wound so that its anterior surrace could be explored
and the reno-adrenal junction sought for. At this stage the operation was being conducted at
some depth from the surface, but with the bleeding well controlled and satisfactory retraction,
the exposure was adequate. The gland was identified by its shape and distinctive yellow colour,
though it is apt to be obscured by the surrounding fatty tissue. As the kidney is retracted the
adrenal gland tends to remain in the roof of the dissection, where the gland should be sought.
The capsular vein running down to the renal vein may also serve as a guide to the situation of
the gland. The preadrenal fascia was next incised and the hilum containing the capsular vein
clamped and divided. The gland was then removed by clamping the surrounding tissue which
was then ligated to control haemorrhage. The wound was closed by layers, and drainage instituted
for 24 hours. The convalescence was uneventful and the wound healed soundly without complications.
The histological report on the gland removed was as follows: "fuchsinophil granules
(Ponceau fuchsin stain) are present in a moderate number of the cells of the adrenal cortex"
(Dr. A. B. Bratton).
The patient, when seen recently, nearly a year after the operation, stated that
she occasionally had pain in the operation area, that the hair on her face had improved,
and that she had since got married.
References.
L. R. Broster and H. W. C. Vines. "The Adrenal Cortex." H. K. Lewis & Co., Ltd., London, 1933.
M. Bleicher. "Technique operatoire de la surrenalectomie basee sur l'anatomie. Archives
Franco-beiges de chirurgie, 33. 1931-2.
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