Case of Bronzed Skin, Associated with Disease of the Suprarenal Capsules
J. K. Spender
1857
BMJ (Clinical Research Edition)
RCadl lbfore the Bath auld Bristol Branch, February 10th, 1857.J ON the evening of the 3rd of October, 1856, I was called to visit a female, aged 21, uinmarried. I found her in bed, apparently very ill; and inquiry of her relatives elicited the following Iistory of her complaint. For nearly a year she had experienced an increasing sense of debility, i vlich begani without any obvious cause. There was notlhing in her occupation which accounted for it; and her habits of life were regular and
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... trious. Menstruation had always been normal, and there was no record of leucorrhma or of diarrhera. Progressive emaciation had accompanied the weakness, and a corresponding loss of animal heat; so that, although originally of good development, she had become exceedingly tllin, and lhad felt very cold even during the excessive heat of last summer. There had been great lassitude, and hardly any appetite for food. Within the last three months, both herself and her friends had noticed a muddiness of skin on the face and lbands; and, on the dorsal aspect of the latter, this nmuddiness lbad increased to such an extent that it might have been imagined that she had exchanged limbs withl a negress. The tint of the face was of a much less decided character. There was no history of any pulmonary or cardiac disease; and the surviving members of her family were in good health. The first interview I had with my patient was by candlelight, and her appearance indicated nothing beyond aggravated span,Tmia. It is lnot surprising that I should have overlooked, under such circumstances, the peculiar colour of the face; and the hands I did not particularly look at. The only thing which struck me was the extent and the deep hue of the areola round the eyes. I made a careful physical examination of the thoracic organs, but failed to discover anything abnormal beyond the usual anaemic murmurs. An examination of the abdomen led to only a negative result. No pain was complained of, blut much nausea whenever she raised herself in bed; and, in the same posture, she described herself as experiencing a weight in the right hypochondriac region. The bowels were costive; but this fact was explicable by the smal amount of nourishment taken. The urine was natural; the pulse was 80; the respirations 19. My patient had previously been under medical treatment, and, as far as I could learn, of a judicious kind. I was puzzled why she should have derived no permanent benefit from it, but I really coulcl not see anything to interfere with a diagnosis of simple aggravated antemia; and I offered rather an unguarded prognosis that she would probably be quite well in two or three weeks time. I prescribed a mixture of tincture of sesquiceloride of iron with tincture of hyoseyamus, a dose after each meal; and directed that food should be given in small quanti. ties at frequent intervals. October 4th. I visited my patient by daylight, and I could not help noticing the dark earthy tint of her face and hands. No other portion of the surfacJ was affected in the same way: the skin every where else was perfectly clear, and free from abnormal stain of any kind. However, the real nature of the case did not then occur to me. The medicine had caused a relaxation of the bowels, and therefore the citrate of iron was substituted for the sesquichloride; and an opiate pill ordered to be given at bedtime. A decided improvement became manifest during the next few days, so that she was able to leave her bed and come down stairs, still preserVing the recumbent posture on a sofa. On the 10th of October, the feeling of weight in the right hypochondriac region increased to absolute pain. I made another physical examination of the abdomen, and the result was, that deep percussion elicited a dull note over the seat of pain, and palpation imparted the sense of a soft solid, deep in the abdominal cavity. Although the strength had increased, the emaciation progressively continued; and, with view to remedy this, I recommended the administration of the cod-liver oil. To this, however, great objection was offered, the bare thought of taking an oily substance appearing to create nausea. October 13th. A retrograde step had already commenced. The citrate of iron mixture coald no longer be retained; the bowels had become confined; the indescribable sense of power-lessness had completely returned; and my patient went back to her bed, from which she never rose again. During the preceding week, I had been perusing Dr. Addison's celebrated monograph on Diseases of the Suprarenal Capsules, as well as a review of that work in the then current number of the British and Foreign illedico-Chirurgical Review. I now began to suspect the real nature of the malady; andl I at once communicated the possibilities and probabilities of the case to the patient's friends. They were astonished at the altered tone of my prognosis, and did not at all appreciate the reasons I gave for it. It was agreed, however, that further advice should be obtained. October 15th. Mr. Norman met me in consultation. It was clear that we had to deal with the results of a special dyscrasia, those results being manifested in a selious lesion of the nutritive processes. The data on which we had to form an opinion were principally subjective: tllese were the extreme lassitude and debility, the constant nausea and anorexia, the pain and the weight in the right hypocllondrium, the depression of spirits, and the loss of memory. The great objective plhenomena were two in number-the emaciation, and the bronzeed colour of the face and hands. Our diagnosis appeared to be limited to the alternative of scrofulous degeneration of the intestinal glands, or disease of the suprarenal capsules, attended by its well known cutaneous discolorment. If the case had come ulnder our notice some years ago, probably the former of these contingencies would have been the only one to present itself; but, for obvious reasons, our opinion now decidedly inclined to the latter. Mr. Norman strongly urged the administration of cod-liver oil, to which the patient reluctantly assented. Mr. Norman also suggested that a couple of grains of blue pill should be taken once or twice a week, not only with the view of maintaining a regular action of the bowels, but also to assist the functions of the liver; for the possibility of biliary toxuemia had occurred to our minds as tending to confuse the other elements of diaanosis; although suCh ani hypothesis would not account for the emaciation, and was almost certainly negatived by the clear pearly hue of the conjunctiva. Under the plan of treatment above laid down, and for some time faithfully carried out, the tendency to emaciation was certainly arrested, and the strength appeared to be somewhat improved. A blister was subsequently applied to the right hypochondrium, in order to relieve the local pain. Things remained very much in statu quto until the middle of November. Disgust of the cod-liver oil was now experienced, and consequently its use was abandoned; and so complete was, the repugnance to every kind of food, that beef-tea, in very limited quantities, was the only article of diet wlhich we could persuade her to accept. The sense of hunger was altogether suspended, and the withdrawal of the demand for nourishment was apparently the proximate cause of that wasting process which now continued uninterruptedly until death. And yet the secretions generally wvere properly carried on; there was nio cough, and no symptom referrible to the pulmonary organs; the sounds of the heart were sharp and clear; and, with the exception of the faculty of memory, the intellectual powers were unimpaired. For a short time, I gave her quinine, with a slight improvement of the appetite; but, at the beginning of December, she firmly refused to take medicine of any kind. A week afterwards, she would see nobody beyond her own family; and on Friday, December 19th, she quietly died away, as if she had only fallen asleep. POST MORTEM EXAMINATION, December 21st, fifty-fours after death. The body was greatly wasted; the breasts very much atrophied; there was very little adipose tissue anywhere; and the muscular structures were flabby and attenuated. The skin of the face was nearly as brown as a mulatto: the exact hue it would be difficult to describe, but it was duller and less intensa than bronze, and resembled more than anything else the tint of the lighter portions of a photographic impression. The colour was very marked when contrasted with the integument of the thorax and abdonmen, or with any linen article of clothing. The skin of the dorsal aspect of the hand was exceedingly dark,the knuckles being particularly so: here the word " bronze " most fitly conveys the real tint, because it really possessed the. shining properties of that alloy. The popular term " brown jaundice" is sometimes a very appropriate one in these cases.
doi:10.1136/bmj.s4-1.14.274
fatcat:hmidsrjkeff4zcs5ej4xgim55e