Physiology and Pathology of the Supra-renal Capsules and Bronze Disease of Addison. By Professor TROUSSEAU. (Translated from the Archives Générales.)

In an important communication, made to the Academy of Medicine at its session on the 26th August, 1856, M. Trousseau adduced some new facts and added some reflections which form a valuable complement to the work already published in the Archives, upon the diseases of the supra-renal capsules. A literal copy of the note is here subjoined.

The supra-renal capsules have been nearly forgotten by anatomists, physiologists and pathologists. The researches of Addison. and of Brown Sequard prove that they merit consideration in respect both of their physiology and pathology. We subjoin the principal facts discovered by M. Brown-Sequard, relative to the physiology of these organs, which were submitted to another learned society:

1st. These capsules are endowed with great sensibility.

2nd. They increase in weight and in volume from birth until adult years; hence they can no longer be regarded as special organs of embryonic life.

3rd. The extirpation of the two organs as rapidly and as certainly destroys life, as the ablation of the kidneys. M. Brown-Sequard operated on sixty animals of different species and found death supervene after an average interval of eleven and a half hours.

4th. The duration of life, when but one of the organs was extirpated, did not exceed seventeen hours.

5th. In not a single instance could the death be attributed to either hemorrhage or peritonitis, nor to lesion of the kidneys,, the liver or other important organ in the vicinity of the capsules.

5th. When the semi-lunar ganglions were accidentally injured in these experiments, the heart's action was accelerated; but this could not be assumed as the cause of the rapid death of the animals.

7th. After the extirpation of these capsules, there follow with almost perfect constancy an excessive weakness, at first an accelerated respiration, then becoming slow, jerking and irregular; an acceleration of the heart's action, a depression of the temperature and various nervous phenomena, such as vertigo, convulsions and coma, supervened on the near approach of death.

8th. When but one of these organs was removed, the same symptoms were exhibited, but less rapidly and after an interval of apparent restoration; when convulsions occurred, they were manifested only on the side of the extirpation, and the animal performed spiral rotations, much as when the middle cerebellar peduncles have been divided, rotating from the injured toward the sound side.

9th. There occurred among the hares of Paris an entozooty or an epizooty, characterized by an inflammation of the supra-renal cap

sules, which give rise to the same symptoms as the extirpation of

these organs.

10th. The blood of the diseased animal, when injected into other hares, produced similar morbid phenomena to those resulting from the ablation or inflammation of these capsules.

11th. Wounds of the spinal cord determine an active hyperæmia of these organs, resulting in an hypertrophy or an acute inflammation, and speedily proving fatal. A fact established by BrownSequard in 1851,

The preceding facts, says Brown-Sequard, lead to the following conclusions, viz:-1st. That the supra-renal capsules are absolutely essential to life. 2nd. That their ablation or morbid change disturbs the economy, either by interrupting the functions of the organs as blood-vascular glands, or by irritating the nervous system and giving rise to convulsions limited to one side of the body.

If these experiments were exact, (of which there can be but little doubt,) or perhaps we should say, if the conclusions deduced by M. Brown Sequard are legitimate, then the functions of these organs in the animal economy is infinitely more important, than we have previously been led to believe.

Let us now consider their pathology. Some months since, my excellent friend Dr. Laségue published in the Arch. Gén. de Med. a very good abstract of the labors of Addison and other British physicians upon the diseases of the supra-renal capsules. They have established that certain individuals are affected with a peculiar cachexia, with an anæmia analogous in many respects, among other anæmias, to that resulting from hæmorrhage, and very unlike that special anæmia known as leucocythemia, (this name is not mine, and God forbid that I should forge a similar one,) a disease in which the blood contains globules analogous to the globules of pus.

In the cachexia described by Addison, the debility experienced was out of all proportion to the lesions that could be discovered; for those lesions, at least those known before the labors of Addison, were insignificant, and simultaneously with the debility a deep, bronze-like coloration of the skin was remarked, particularly on the face, the internal surface of the lips, in the axillæ, on the penice, and many other points; pigmentary matter was deposited under the epidermis and under the epithelium, giving the patient the appearance of a mulatto; the hands and the penice sometimes presented a hue as deep even as that of the negro. Addison moreover proves that the disease is always fatal, and the autopsies performed by himself, as well as several other physicians, furnished invariable evidence of the presence of grave lesions of the supra-renal capsules, viz.. cancer, tubercles, fatty degenerations, purulent collections, hypertrophy, &c.

Since these labors have become known in France, two cases of the bronze disease have been observed in the hospitals of Paris, one at St. Louis, by M. Second-Ferréol, the other in my ward at the

ERAL LIB

University

1857.]

Supra-renal Capsules and Bronze Disease.

HIGH

Hotel Dieu. The patient that fell under my observation, was a
coachman of the Minister of the Interior, aged thirty-seven years,
apparently in good condition and well nourished. During the past
five or six months his skin has acquired a peculiar and persistent
sallow hue. At the same time he grew weaker progressively; he
ate little, and had an especial aversion for animal food. He stated
that he had lost three-fourths of his weight, which, exaggeration
apart, was equivalent to stating that he had been fat and had be-
come lean. The symptoms presented by this man were very striking,
and the more so as we recollected the details furnished by the ab-
stract of Lasêgue, and I diagnosticated a disease of Addison. The
patient was soon attacked with a profuse diarrhoea, to the extent
of eight or ten dejections in twenty-four hours, yet without the spe-
cial character of cholera; the body became cold, and he speedily
succumbed to the disease. The autopsy revealed no lesion of either
the brain, lungs, heart or intestines, that could explain the symp-
toms or cause of death; the kidneys presented but a slight hyper-
trophy, and, according to Brown-Sequard, who examined the case,
a few tubercular granulations and fibrous filaments, but the supra-
renal capsules contained numerous tubercular masses.
The apex
of one of the lungs contained a very small tubercle, but none in
either the bronchial or mesenteric glands. The blood, examined by
M. Robin, presented no other alteration, but such as exists in hem-
orrhagic anæmia.

We here see a man, yet comparatively young, suddenly attacked with a cachectic and cachochymic disease, of which the data furnished by the previous condition of pathology yielded no explanation. We recognized in it the disease of Addison. He died, and the autopsy revealed abundant lesions of the supra-renal capsules, and no other.

The other case of the bronze disease was more carefully observed and reported by M. Second-Ferréol, interne of the hospital. The patient was a waiter and thirty-five years of age. He was addicted to all kinds of excesses, and had contracted a gonorrhoea a year before admission into the hospital. He had previously been admitted into the hospital Necker, and treated for some serious difficulty of the digestive organs; he then presented a deep coloration of the face, which varied in intensity with the condition of the digestive apparatus. He took at that period l'Eau d'Enghien, probably for an incipient pulmonary lesion. Towards the close of the year 1855 he presented himself at the hospital St. Louis with evident signs of tubercle in the apex of the lungs, yet the debility was greater than occurs in phthisis. He left the hospital and returned, and at last died there.

The autopsy, carefully observed by M. Second-Ferréol, revealed very important lesions of the supra-renal capsules; neither cortical nor central substance could be recognized; a fatty mass of an intense yellow color, as if from bile, was alone visible; filamentous tracts

resembling fibro-cartilage traversed the bodies of the capsules. M. Robin found pus globules, but no tubercles in the midst of the fatty mass. M. Ferréol adds that the hands presented the characters of that from the hands of the negro, and that pigment granules were abundant in it.

Let us remark that in the negro race the capsula supra-renales are of large size; on the other hand, the accidental development in excess of the pigmentary matter is connected with an augmented size or morbid change of structure of these organs. We might hence infer their connection with the production of pigment in the system.-[Peninsular Journal of Medicine.

Lectures on the Varieties of Continued Fevers and their Discrimination. Delivered at St. Thomas's Hospital, by THOMAS B. PEACOCK, M. D., Assistant Physician to St. Thomas's Hospital, etc.

LECTURE.-General Principles of Treatment.-It was not my intention in these lectures to have spoken of the treatment of the disease, but as the subject would be incomplete without some allusion to this point, I shall very briefly refer to the general principles which should guide us in our practice.

The first question which arises is, can we arrest or cut short an attack of fever? This question must be regarded as a purely practical one, to be decided by experimental investigation. We have sufficient proof that those forms of febrile affection which follow the most definite course-the eruptive fever-may be cut shortas variola;-by vaccination, and, in some cases, by vaccination practiced after the receipt of the variolous contagion; and, though the cases are not precisely analogous, there seems no reason why similar results should not ensue from the employment of remedial agents; and in typhus and typhoid, as well as in other forms of fever.

I. The means by which the arrest of fever has been attempted have been, 1st, Cold affusion; 2ndly, Remedies acting upon the secretions; and, 3rdly, Specific remedies.

1. At the time when Dr. Currie's work had attracted much attention, the plan of employing cold affusion was very much had recourse to in the treatment of all forms of fever-more especially in the early stage-in the hope of arresting the progress of the disease, and there is reason to believe that the remedy was occasionally, at least, successful. The prostration of strength which it occasioned, was, however, sometimes so serious, that the risk more than counterbalanced the advantage, and the practice was abandoned. Cold bathing is still, I believe, used by the hydropathic practitioners as a means of checking the course of fever, but I know not with what result.

2. Remedies which act upon the secretions have been employed for the arrest of fever, under the idea that as the subsidence of some forms of the disease is attended by so-called critical evacuations, such remedies may be the means of eliminating the poison from the system. Thus, as one of the most common symptoms which attends resolution in some forms of fever is profuse sweating, diaphoretics have been exhibited to promote perspiration, and so to bring about resolution. This is, however, an entirely erroneous view. In many cases the occurrence of sweats during fever, especially when only partial, so far from causing the subsidence of the disease, is followed by serious or even fatal prostration of strength. On the other hand, in cases in which the perspirations are most profuse, as in relapsing fever and sometimes in typhoid, the occurrence of the perspiration, so far from eliminating the poison, does not prevent the occurrence of the future paroxysms in the one case, or cut short the progress of the disease in the other. We can, therefore, only regard the occurrence of perspirations in these cases as indications of the resolution of the fever and not as its cause. Again, we sometimes see febrile attacks subside on the occurrence of spontaneous vomiting or purging; but it by no means follows, that the occurrence of these symptoms is the cause of the subsequent resolution; and even were sweating, vomiting or purging proved to be the means by which nature endeavors to eliminate the poison from the system, it would still not follow that it is sound practice for us to imitate.

Of the remedies of this description upon which the most reliance has been placeda s useful in arresting fever, emetics occupy the first place. It is quite possible, that, exhibited quite at the commencement of an attack of fever, before the chain of diseased action has been fully established, they may, by exciting powerful reaction, arrest the further progress of the disease. In the employment, however, of these remedies, great caution should be exercised; the more depressing emetics, such as the tartarized antimony and James' Powder, are of very doubtful usefulness, at least in the low forms of fever which we are called upon to treat in this me. tropolis. They may excite irritability of stomach, which is often a troublesome symptom, as in relapsing fever, and which it may be difficult afterwards to check; or they may cause great depression, if given in cases which are attended with much prostration, as in typhus; or they may excite diarrhoea, if given in typhoid. The objections do not, however, apply to the milder emetics, as ipecacuanha, or, at least, not to the same extent.

In the exhibition of purgatives yet greater caution is needed. In typhoid, diarrhoea is often present from the commencement of the disease, and at all times it is very prone to occur and active purgatives may excite very undue action; indeed, I have seen them give rise to uncontrolable diarrhoea and so occasion death. During the progress of typhoid it is always necessary to exercise