Tumors of the Adrenal and the Use of Air Insufflation in Their Diagnosis

Tumors of the adrenal are rare. The opportunity has fallen to few to study personally even a small number of these tumors. From among a large series of patients presenting symptoms suggestive of adrenal neoplasms, we have been able to show, at least to ourselves, that tumor could be proved to be the cause of the symptoms in relatively few cases. When tumor does occur, it is now accepted as to be without doubt the causative factor of the symptoms. Symptoms, when they occur, can be separated into different clinical pictures according to the sex of the patient and the type of tumor. This presentation will report the clinical classification of these tumors, with a discussion upon the diagnosis of their presence by perirenal insuffiation roentgenograms. The normal adrenal may be visualized in certain persons by ordinary roentgenograms. In most cases, because of the position of the glands and low density of the adrenal tissue, their shadows are not clearly seen. Pathological adrenals may produce a deeper shadow if their tissues have increased density. Some tumors of the adrenal because of an increase in density may form an interpretive shadow upon a film. If a tumor is large, it may displace some other shadow-producing organ, as the kidney, and thus suggest its presence. If very large, it may be palpated and the probable diagnosis arrived at by the use of contrast media to identify adjacent organs upon the films; from their apparently normal shadows which are displaced by the tumor, the diagnosis may be suspected by exclusion. As a diagnostic aid in suspected adrenal pathology we have introduced a gas (air) into the perirenal fascial planes to visualize them better and to outline the adrenal and kidneys. The procedure was first described by Carelli in 1921 (1). It has been used by us in several hundred cases since 1930. The normal adrenals are usually well visualized if sufficient air is introduced in the proper plane. They are better visualized in thin people. The right adrenal more frequently shows as a long thin wedge and the left as a wider, shorter wedge or crescent. When tumor is present it, also, is more clearly shown in thin people. It is rounder when small, ovoid when larger, and rounded or lobulated when very large. In our series when a tumor was diagnosed by shadow interpretation it was confirmed by operation and by removal. In a number of cases in which no tumor was shown, its absence was confirmed by operation and adrenal resection, both performed in a hope of symptomatic improvement. In several cases in which it was impossible from the films to determine whether or not tumor was present, operation showed no tumor, leading to the opinion that the method was of value in establishing the presence of a neoplasm. Its especial value is to determine if tumor is present in those cases in which a neoplasm is unrecognizable by any other method, is of early origin, and small enough to offer hope of a cure if removed.