The inter-renal syndrome in childhood.

The adrenal cortex acts by the elaboration of a series of "hormones which include among their functions the regulation of the electrolyte balance; carbohydrate, fat and protein metabolism; the development of the secondary sexual characteristics; and possibly the development of the gonads themselves. Although the action of many of these hormones is regulated by the pituitary, the latter gland has apparently little influence on that function of the adrenal which is essential for life, namely the regulation of the salt and water balance. An adrenalectomized animal quickly diesof the symptoms of Addison's disease, whereas hypophysectomy has not the same fatal outcome. This is in keeping with the generality that processes essential for life are, to a degree, autonomous (Swann, 1940). The adrenal cortex is in a constant state of growth which takes place from without inwards. Throughout life new cells are being formed by multiplication of cells in the zona glomerulosa and from indifferent cells included in the capsule. The stage of growth takes place in the short zona glomerulosa. The cells then migrate inwards, forming the zona fasciculata, in the inner part of which and in the outer part of the ensuing zona reticularis the cells discharge their lipoid contents, possibly in part into a real glandular lumen continuous with the medulla (von Lucadou, 1938). The cells finally degenerate in the inner part ofthe reticulate zone (Zwemer et al., 1938). After hypophysectomy the adrenal cortex atrophies in the reverse direction to which it grows. The atrophy progresses from within outwards. No definite histological abnormality -occurs in the outermost zone (Crooke and Gilmour, l938). It is to be presumed that this glomerular layer secretes the ' salt and water ' hormone (Swann, 1940). Our own investigations on the appearance of doubly refractile lipoids in the adrenal cortex have shown that this takes place initially in a narrow zone in the region where the zona glomerulosa changes into the zona fasciculata. In states of hyperfunction of the cortex, the resulting clinical and metabolic picture depends on the nature and amount of the hormones produced. Haymaker and Anderson (1938) suggested there were two syndromes, the adrenogenital, associated with virilism and representing the excessive production of androgens; and the adrenocortical, associated with the clinical picture of Cushing's syndrome and the excessive production of cortin. These views have been supported and elaborated by Albright (1942), who concluded that the adrenogenital syndrome was due to an abnormal production of a ' N ' hormone which, having an action similar to testosterone propionate, was produced in normal individuals after puberty concomitant with an increased excretion of 17-ketosteroids and was concerned with sonlatic and secondary sexual development. The adrenocortical syndrome, according to this author, was due to an excess of 'S 'hormone which, acting by the inhibition of the synthesis of tissue, promoted the conversion of protein into sugar (glyconeogenesis) and inhibited the oxidation of glucose at the periphery. The relationship between virilism and cortical hyperfunction is obvious. The aetiology of Cushing's syndrome was rendered debatable by the occasional occurrence of a basophil adenoma of the pituitary in this disease. However, Anderson and Haymaker (1937) were able to prolong the life of adrenalectomized rats by the injection of sera from two patients with Cushing's syndrome. Occasionally there is a disturbance of the electrolyte pattern the opposite to that occurring in Addison's disease (McQuarrie et al., 1937, Willson et al., 1940). Albright et al. (1941) produced amelioration of symptoms by giving testosterone, which is known to inhibit cortical function. The consensus of opinion is that Cushing's syndrome is due to adrenal cortical hyperfunction, the primary cause for which may arise either in the gland itself or be caused by an excess of adrenotropic hormone engendered by pituitary dysfunction. The site ofproduction ofthese groups ofhormones is more speculative. Grollman (1936) considered