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SURGEON GENERAL'S OFFICE



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THE
SUNBURNT APPEARANCE OF THE SKIN
AS AN EARLY DIAGNOSTIC SYMPTOM OF
■npra  $enal  (Capnle  disease.
      ISAAC E. TAYLOR, M.D.,
             M *
PHYSICIAN TO BELLEVUE HOSPITAL, NEW YOKE.
(ZJ®Hf> (Eoloreti Sllustratfons.)
Reprinted from the New York Journal of Medicine
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            NEW YORK-

MILLER & HOLMAN, PRINTERS, CORNER OP CENTRE AND WHITE-STS.

               1856. 
WO"
T^4as
« 
%\t  Swnlrornt  gptanmct of %  Skin
AS AN EARLY DIAGNOSTIC SYMPTOM Ot
SUPRA RENAL CAPSULE DISEASE.
  The attention of the medical profession has been directed
by Dr. Thomas  Addison, of London, in a monograph, pub-
lished May, 1S55, to a new form of disease in which the supra
renal capsules are involved, and of so serious a nature, as to
prove fatal in every instance that has been reported where an
autopsy has been made, and having, as one of its most marked
and prominent symptoms, the discoloration of the skin. This
discoloration, according  to Dr. Addison, at  page 5  of his
Monograph, " pervades the whole surface of the body, but is
commonly most strongly manifested, on the face, neck, supe-
rior extremities, penis, scrotum, and in  the  flexures of the
axilla, and around the navel.   It may be said to present a
dingy or smoky appearance, or various tints or shades of
deep amber or chesnut brown ; and in one instance, the skin
was so universally and so deeply darkened, that it  might
have been mistaken for a mulatto."  At page 7, line  17, Dr.
Addison further remarks, " that the great distinctive mark
of this form of anaemia is the singular dingy or dark discolora-
tion of the skin ;  nevertheless,  at a very early period of the
disorder, and when the capsules are less extensively diseased,
the discoloration may doubtless be so slight and e'quivocal as 
4
to render the source of the anaemic condition uncertain;  and
when, on a searching inquiry into the history of the case, no
miasmatic poison can be detected, or malignant visceral dis-
ease found, and when to all this is superadded a dark, dingy,
or smoky looking discoloration of the integument, he shall be
justified  at least in entertaining a strong suspicion in some
instances—a  suspicion amounting almost  to certainty in
others.   It must, however, be observed, that  every tinge of
yellow, or mere sallowness, throws a still greater doubt over
the true  nature of the case, and that the more decided the  dis-
coloration partakes of the character described, the stronger
ought to  be our impression as to the capsular  origin of the  dis-
order."  I have copied these quotations from the monograph
of Dr. Addison, as it is probable but few have met with it,
and  they are given in his own language, for I have  not been
able to discover, in his essay on the subject, the term " bronze"
applied as it appears to have been given to the discoloration,
by Dr. Jonathan  Hutchinson, in the report of his  collected
cases, published in the Medical Times and Gazette, of London,
1855 and 1856.  Though the application of the word "bronze,"
to the character of the discoloration, might appear proper,
yet it could only be  in the more advanced  cases, for in  the
early stages of the disease, I have not been able to recognize
its adaptation,  and even  in the advanced  cases, the analogy
to the color of the mulatto, or rather of a West Indian, seems
more correct and just. In the quotation from page 7, line 19,
reference is made to the color, " doubtless being so slight and
equivocal, as to render the  source of the anaemic condition
uncertain;" and on  page 8, line 1, " Every tinge of yellow-
ness, or mere sallowness, throws a still greater doubt  on  the
true nature of the case."   On examining the cases of  Dr.
Addison, it appears  that the /discoloration  had existed  for
some length of time, and in some it was not recognized  till
after death; and  that they were not therefore seen in  the
early stage of the discoloration  and disease,  and  I believe
it will be  shown that the dingy, or smoky, or deep amber,
or chestnut-brown, or mulatto appearance of  the discolora-
tion, becomes quite characteristic when  the  disease is of a
chronic nature.
  In the publication of the cases which have come under  my
observation, I would  particularly wish to call the  attention
of the profession to the discoloration of the skin, and the pig-
ment on  the lips, as I believe in  the early, and in two cases
in the incipient, stage of the disease. 
5
   During my term of service in Bellevue Hospital, for the
months of June and July, six cases were observed, and the
seventh is at present in the New York Hospital ;  to the lat-
ter case, Dr. John Watson was so kind as to ask my atten-
tion. From the history this patient gives of the discoloration,
we learn that it has existed for a year, though, during the last
three or four months, it has shown itself more generally over
the whole body, the scalp being free, and has the dark line
on the lips—resembles in appearance the color of a mulatto.
This was the case also in a patient  of Drs. J. M. Smith and
Bulkley, which was reported by Dr. H. D. Bulkley, in the
New York Medical Times for September, 1855,  and entitled
" A Case of Change of  Color of the Skin, in a  Yovng  Man,
from  White to that of the Mulatto,"  and the disease, in this
instance,  had existed for more than a year, but had not been
recognized as having any relation to the supra renal capsules.
Since my attention was given to this subject, I  have learnt
the early history of this patient, which will be referred to in
another part of this paper.   During the second or third day
of my attendance at  the hospital,  a case similar to the first
case  reported  (that  of White)  was  noticed,  and  though
believed to be this form  of disease, was not distinctly diag-
nosed, but from the exact resemblance to Thomas White, who
came into the hospital, June 13,1 have now not the slightest
doubt of  the correctness of the opinion formed at that time.
   Case  1.—Reported by Dr. Saunders,  House-Physician.—
Thomas White, yet. 22 ;  laborer ; native of Ireland;  single ;
admitted into  Bellevue Hospital,  Ward No. 10, June  13,
1S56 ; had been a moderate drinker; his  mother died  of
phthisis ; the other members of his family were healthy.  He
had a cough some three years ago, and spat up some blood at
that time.  His cough left him, and he was not troubled with
it much  afterwards.   The  lymphatic  glands of  the  neck
became enlarged  and suppurated at this time.   He lived in
part of the city where intermittent fever was prevalent, and
says he had it for a very short time before entering the hos-
pital.  He never  had any chills after admission.  When he
entered the  hospital, his face and neck were of a light sun-
burnt hue ; w;is very feeble and emaciated, and complained
of pain in tin' right side;  no  cough or expectoration ; pulse,
small and weak; the eyes  presented  a sickly and pearly
appearance ; the palpebrae conjunctiva were quite arurmic ;
his bowels were constipated, with a little nausea and vomiting,
retching, as  he termed it, occurred sometimes.   He  would 
6
vomit frequently without any evident cause, and was some-
times flighty.  There was no epigastric tenderness.  A physi-
cal examination of the  chest was made, when  there was  a
slight pleurisy found on the right side, where he complained
of pain ; but no evident signs  of phthisis.  The treatment,
after he was relieved of the  pleurisy in a  few days, was of the
tonic order, as quinine, iron, bitter tonics, and good nourish-
ing diet.   Dr. Taylor, on seeing him, advanced  the opinion,
judging from the color of the skin, and other symptoms, that
it might be disease of the supra renal capsules, as described
by Dr. T. Addison.  He seemed  to mend  under the treatment
for a while; and was able to  walk  about the yard.   The
color of the skin grew darker, if  anything, and he always
complained of being weak and languid.   Two  days  be-
fore his death, his friends came to visit  him, and  brought,
without permission, two small  bottles of brandy, of which
he partook quite freely, with marked  exhilaration of feelings.
After getting sober, he said he  felt very weak; I noticed he
was heavy and drowsy, and continued in this condition for
twenty-four hours ;  his bowels  had not'been moved or his
bladder emptied, and on introducing  the catheter there was
no urine found.  There was some tenderness over the region
of the kidneys.   Dry cups were applied, and  a purgative
enema ; he, however, became comatose, and died at 6 p.m.,
July, 26.
  Autopsy, fifteen hours after Death.—Rigor mortis moderate,
emaciated.  The discoloration of the  skin was most marked
on  the  face and neck ;  there were  slightly darker tinges
about the  axillae than other parts of the  body;  on the  right
side of the abdomen there  was a  patch of the size of the
hand, of a light shade.  On opening the thorax and abdomen,
the viscera were found occupying their relative positions.
There were several old bands of adhesion  on each side, uniting
the pleura to their respective parietes ; at the apex of each
lung were  old cicatrices, and through each were scattered  a
few tubercles.  The heart was normal in size and thickness;
liver, natural in size and color;  spleen, the same ; large and
small intestines, with stomach, healthy to all appearance.
  While extracting  the left kidney, we noticed some pus
emerging  near its upper part,  and on  closer  examination,
after removing the  left  kidney, capsule, and the  pancreas
together, we found it came  from the left  supra renal capsule.
The capsule had in it a deposit, which proved to be, under
the microscope, tuberculous matter.  The kidney was pale ; 
7
cortical substance deficient, and had undergone some fatty
degeneration ; the right kidney was fatty, the supra renal
capsule had undergone a tuberculous degeneration, but was
not so much broken down as the left.  Weight of left kidney
and capsule, 8\ oz.;  of the right, 7i oz.
   Remarks.—The appearance  of White, as to his physical
constitution, presented  a  tuberculous diathesis ; there was
some emaciation.  The  expression of face was dull, listless,
and rather stupid;  he  answered  questions slowly, hesita-
tingly, and would drawl out his words ; his mind was feeble.
The expression  of  eye was sickly,  earthly; wanting  the
natural hue and expression.  The conjunctiva oculi et pal-
pebrae was pearly, anaemic, and contrasted markedly with the
color of his face.  The discoloration, when first noticed, was
of a light sun-burnt appearance, of a dirty shade of yellow,
and extended across the centre of the forehead and no higher,
being a perfect line of demarkation, to the natural  color of
the skin.  The whole of the scalp  was free.   The sun-burnt
discoloration extended down the temples, along the side of
the cheeks on both sides, around the  lower  portion of  the
ear, and then  to the  back of  the  neck, and engaged  the
whole neck as low as the half of  it.   The  ears were free,
and all the lower part of the scalp.  In truth, he was a per-
fect representation of a man who had been exposed to  the
sun with his hat on, divested of the cravat, and with  collar
turned over, and only that part that could  be exposed was
discolored.  The shade and appearance  of this color  could
not be better marked; the  posterior part of the neck,  and
the lateral sides of the cheeks and forehead were the darkest,
as though it had been of a longer duration.  The spots where
the glands of the neck had suppurated, remained free. Every
week the appearance  of the discoloration became of a more
deep and sunburnt character.   The upper and lower lips had,
when first noticed, several  small,  darkish red spots;  three
or four on each lip.  These spots were on the outer edge of
the lips, and  gradually became darker by degrees.  They
were distinctly evident to a number  of the students whose
attention was  directed to this feature of the  case,  as aiding
in the  diagnosis.  They appeared very different from the lips
m ordinary  anaemia or cachetic state, and  induced me to
feel a stronger conviction in the opinion I entertained of  the
nature of the disease.  The back of the hands also presented
the same appearance,  which extended to the wrist, the in-
side was free.  There was no albumen in the  urine, though 
8
he died in  a state of coma,  indicating the nervous  system
was strongly affected.  The result  of the autopsy verified
the  diagnosis,  and I regret I was prevented from  being
present at the time.   The kidney and the supra renal capsules
were given to me for inspection, and they were both  found
in a state of tuberculous degeneration.   The  left more so
than the right.   The left capsule  was much larger than nat-
ural, being of the size of half a large hen's egg.  On cutting
through the capsule, there was but  a few lines of thickness
of the cortical structure, it contained a solid and a semi-fluid
mass of a yellow color.   The whole medullary  structure was
gone.  The right capsule was not  so large, and two-thirds of
the capsule consisted of concrete tuberculous matter, the rest
being semi-fluid.  Under the  microscope, nothing was devel-
oped but what would appertain to tuberculous degeneration
as broken up cells, fatty matter, and granular particles. There
was no original trace of the natural organ.  The left capsule
weighed 4  drachms.  The result of  the post mortem  as to
the character of the disease showed  the supra  renal capsule
to be involved in disease, as was anticipated from the  tuber-
culous diathesis which the patient presented.
  Case  2.—Reported by Drs. Saunders  and Janes, House
Physicians.  George  Comb, aet. 42, laborer, married,  native
of England, was admitted into Bellevue Hospital, June 24th,
1S5G.   Has  had no hereditary disease ;  never has  drank
much ; has always been tolerably healthy until six months
ago, when he had what he termed  " sun-stroke,"  and  after
working for some time in the sun, became  very  weak and
dizzy in the head, which caused him to sit down,  and then
cease from work.   When he came into the  Hospital,  he
looked quite anaemic, eyes pearly,  tongue  pale and broad, in
other words, he had the appearance of a patient  suffering
from  albuminuria, considerably advanced.    His  bowels
were constipated;  his urine was tested, and a small deposit
of albumen was  found, the specific gravity 1.010.   Skin dry,
without perceptible anasarca or ascites.  Mild diuretics, fer-
ruginous preparations, and bitter tonics, was the  treatment
adopted.  After being in the  wards over two weeks, Dr.
Taylor noticed that the lower part of the forehead began to
have a  sunburnt appearance,  and this gradually  extended
over the whole of his face.   There was on the body  small
spots which resembled very much the appearance of a faded
syphilitic eruption, though he protested that he  had  never
had the disease.   He gradually grew worse, and afterhaving 
Drama on. Stone, by Htnry A. Daniels
Prints by C W Lewis, /22 Fulton St
GEORGE  COMB. 
 
9
two convulsions, died in a  state of coma, Aug.  4th.   Two
ounces of urine were removed from his bladder a short time pre-
vious to his death ; specific gravity 1.010, and albuminous.
   Autopsy ten hours after death.—Weather cool, rigor mortis
well marked, much emaciation, color of the  face not quite
as dark as before death.  The upper lobe of the left  lung
was consolidated by miliary tubercles in the first stage; in
the apex of the right lung were cicatrices of old tubercular
excavations; heart healthy; liver fatty to some extent; spleen
much  enlarged, weighing l£ lb.;  kidneys pale  and in the
last stage of fatty degeneration.  The left supra renal  cap-
sule was almost completely atrophied, being less than a fourth
its natural size, and broken down into a grumous mass ; the
right was somewhat smaller than natural, had lost its natural
color and become a dark chestnut, on cutting it open it was
found that the greater part of the organ had become broken
down into a grumous semi-fluid mass, leaving only a thin part
of healthy tissue.
  Remarks.—The case of George Comb is one of the most
interesting of this form  of  disease* having chronic disease of
the kidney, when he came into the Hospital,  which in the
course of a few weeks terminated  his existence.  The  post
mortem revealed a fatty degeneration of that organ to the
eye and by the microscope.  The discoloration of the skin,
in Comb's case, commenced between two and three weeks
previous to his death, taking its rise on the centre of the fore-
head, as if he had been exposed to the sun, and was in marked
contrast at this early period,1 to his clear, white, and anaemic
skin, particularly so,  as  he was quite bald.  The pigment
gradually extended itself from the forehead, on both sides of
the face, down the cheeks to the side of the neck,  avoiding
the ears, to the posterior part of the neck.   The lips at the
juncture of the mucous  membrane and the skin,  began also
to exhibit the light reddish line.  Nothing could be more
plain than  the  commencement, and  the progress of the
discoloration, pursuing  to all  appearance,  as symmetrical
a course almost  as that of  erysipelas,  differing from  that
disease in  its externally manifesting its  appearance,  as
though the pigment was there, and only required to be elimi-
nated by the action of the atmosphere, to become more dis-
tinct and positive in its characteristic  features of tint.   In
three weeks-it had become like a perfect recent sunburnt color,
showing the  rapidity with which it may manifest itself, its
extent  and locality.  After death it faded in its color so much 
10
that in twenty-four hours, when I saw the body  a second
time before its interment, there was left but a light dirty yel-
lowish, though quite characteristic, discoloration. The spots
that were noticed on various parts of  the  body, but more
especially on the back, were of a darkish yellow, and looked
like one of the forms of psoriasis, though it had no furfur-
ous character.  From the investigation of the urine, with its
light specific gravity, and the slight proportion of albumen,
it was not expected that  he would survive long, and the kid-
ney affection was the chief, if not sole, cause of his death.  But
it was exceedingly gratifying to perceive the pigment mani-
fest itself, thus rendering  strong the probability that the supra
renal capsules were beginning to be involved in disease which
would hasten on his dissolution.  This opinion was corrobo-
rated by the autopsy.
  Under the  microscope  nothing definite was  discovered to
throw further light on  the subject,  although corpuscles,
irregular cells, small portions of anaphous matter, and some
oil  granules were also found, and there was but a trace of
healthy tissue left, while the whole of the medullary struc-
ture was gone.
  These  are the only two cases I have as yet  been enabled
to verify the  diagnosis of the nature  of the disease by post
mortem examinations, and I think they bear additional testi-
mony in corroborating  the opinion of  Dr. Addison,  and
showing the  relation of the discoloration of the skin to  the
disease of the capsules.   By  a further  illustration  of  the
subject,  especially in reference to the pigment deposited, I
would wish to add a short history of two of the other cases
which are still in the Hospital.  Colored lithographic plates
of  these two patients have been drawn  from ambrotype
likenesses, for the purpose of showing  the sunburnt  appear-
 ance of  the skin, and the line  of demarkation, in the early
stage particularly in the case of Bishop, which did not exist
when his likeness was taken more than five weeks since, and
in Comb after death.   The remaining patient in the hospital
is too enfeebled to have his likeness taken, and from  his ap-
pearance, his life will not be of long duration.   Being of a
chronic nature, the pigment in this  case,  corresponds with
the man in the New York  Hospital, in which  patient the
discoloration pervades the whole body, with  the exception
of the scalp, and also shows the line of demarkation. In these
two patients the color of the skin corresponds with the first
 case of Dr. Addison, resembling the skin of a mulatto.   Had 
 
*1
Dra/vn, on Stone, by Henry A Daniels
Printed by G W Lewis. r2Z/~ulion,St
PETER  BISHOP. 
11
I supposed that so many cases, numbering seven, would have
been  met with,  (and including the patient of Drs. Bulkley
and Smith, which I think we might  correctly do, from the
very early history I have of it,  from his uncle, after  his
nephew returned from the country, and his description cor-
responding so perfectly with the cases of my own,  in all
respects, that when related before  several of the medical
staff of the Hospital, it was  apparent, that it  was the same
disease fully advanced, the number would amount to eight.)—
I would have had the first case lithographed, and the appear-
ance of the post mortem changes in the capsules, also repre-
sented, though I think it would have availed little,  as  the
capsules  in both'cases, were so destroyed.
   Case 3.—Reported by Dr. Janes, House Physician.   Peter
Bishop ;  barkeeper ; Irishman ;  aet. 2S.  Admitted to Ward
No 3 of Bellevue Hospital,  July  1,  with  lead paralysis of
the wrists and hands ;  says he has always been healthy, with
the exception of the paralysis, from  which he has suffered
before, and been cured.  In both instances it  was caused by
drinking beer drawn through lead pipes.   About the middle
of June, he first noticed that his face began to change  color,
as if it had been tanned by the sun ; it has gradually been
growing  darker  and darker, up to the present time.   The
discoloration began about the middle of the  forehead,  and
extended over the whole face, except a circle  of half an inch
around the eyes, which remains  of  a natural color.   The
patient eats, drinks, and sleeps well; he says he feels perfectly
well except his paralysis;  he is not emaciated.
   Remarks.—The colored lithographic plate which represents
Bishop, gives a beautiful description of the sunburnt hue of
skin, and shows the line of demarkation on the forehead,  and
the lips and which  is so peculiarly manifest also in the case
of Comb, and was marked in all  the others.   The pigment,
in the patient Bishop has  not yet  extended to  the  neck,
but  it is beginning to be  perceptible, and  doubtless will
become so  before many weeks have  elapsed.   The color on
the lips is very marked, at times more so than in some of the
others, it is about two lines in breadth, and  when the  lips
are expanded, appears  distinct; there is no discoloration on
the body;  and there would be nothing to call attention to
his condition of  health, but  this sunburnt appearance of the
face, as he feels well,  except his paralysis.   It is a  case, I
think, of much  interest in tracing the development  of  the
disease, and as showing how serious  and fatal a disease may 
12
exist, judging from the result of eighteen post mortem exam-
inations, and not be recognized  till it is far advanced.  But
I fear that when we realize the result  of these other cases,
that the stamp of fatality is impressed upon them even at this
early stage of the disease.  How important, therefore, is it
that in the  investigation of disease, the early features of it
should be recognized ?  If not important to the patient him-
self, that an intimation of his disease be imparted, it may be
especially so that his family be apprized of the fatality, in all
probability, of his disease.
   Case 4.—Reported by Dr. Saunders, House-Physician.—
Ezra Bonnel, aged 55 ; native of New Jersey; boilermaker ;
married for fifteen  years; has been a temperate man for fif-
teen years, previous to that was a hard drinker.  His mother
committed suicide; father died in his seventy-third year.  At
twenty-one, he had yellow fever,  and soon after bilious remit-
tent.  After recoverving from that disease, he remained well
until nine years ago, when he had a cold on the lungs, prob-
ably pleurisy, which confined him to the house three months.
Three  years ago he  had rheumatism in the left arm and leg,
but was not confined to the bed with it.  About two years
since, had a return of the rheumatism and was kept from
work by it for a year.  On the 7th January last, he  slipped
and fell on the ice and broke his left arm, and was treated in
this Hospital.  He  has  been feeble since that time, and has
done no work since he left the hospital.  He re-entered the
hospital,  July 25,  complaining of pain  in  the side  and
debility.
   Remarks.—Ezra Bonnel, from  whom a colored lithograph
was made, from an ambrotype, appeared, when first seen,
much  enfeebled and emaciated; he converses slowly, hesi-
tatingly ;  utters his words in a drawling manner; appears of
feeble  intellect, and action of mind.  He appeared very dif-
ferently when in the hospital before.  The aspect of counte-
nance, and expression of eye, are sickly; there is great want
of natural liveliness ; conjuntiva pearly,  or deadly white,
which  appear in singular contrast to the discoloration of the
skin, and which he did not know existed till his attention was
called to it.   He  makes no  complaint of any disturbance of
the stomach; bowels regular. He looks as though he would
die with exhaustion, without any evidence of serious disease
existing ;  has the same general  appearance of physical con-
stitution as White;  retains his seat by his bed nearly all the
time, for his inability to walk much, though he goes out occa- 
Pram on Stone >/- ,-inu-y A Ihilitls.
Print-eA by 0 WLe/l/U, 122 FulXon St
EZRA  BONNELL. 
 
13
sionally;  is listless and feeble.   We have here  the same
dark sunburnt appearance of the skin, occupying the same
locality on the face, though the line of demarkation, instead
of being distinct and even,  rather shades  off; the whole of
the scalp and ears are perfectly free, and of the natural color.
The spots on the lips also have the dark brownish color on
them, and have become dark since he has been in the hospi-
tal.  The hands, on the back part, are  of the same color.   In
fact, he is a " counterfeit presentment" of Thomas White.
   The  6th  patient, in Ward  12, is  a German,  very much
enfeebled, of whom mention  has  been made, has been an
invalid for a number of months, and is in a debilitated state.

   From the number of cases here given of the discoloration
of the skin, and with two post mortem examinations, which
proved them to be connected  with the supra renal capsules,
and the rest having all the  general features of the two cases
of that disease, I think it will be perceived,  that they differ
from the lithographic representations as given by Dr. Addison.
This difference is still more apparent, when we consider that
we had the opportunity of observing the pigment deposit itself
in the patient Comb, whilst under treatment for renal disease.
 and of noticing the election of its seat to commence on the fore-
 head, with  a clear and distinctly marked line, and on the
lips; and in the case of Bishop, which has only  existed five
 weeks, and noticed by him one week before he came into the
 hospital; and that of White, for two or three months previous
 to his admission ; and next, in that of Bonnel, and all these
 patients presenting the same sunburnt appearance, commenc-
 ing from a light shade of tanning and progressing to a darker
 hue, and which are beautifully illustrated in the portraits of
 Bishop, Bonnel,  and Comb.   The discoloration  of the skin
 could not have occurred from  the effects of the sun in the case
 of White,  as he had not been exposed to the sun for the
 last three or four months, and had not noticed the change of
 his skin till his attention was called to it; and from the length
 of time he was in the hospital, if that had been the cause, it
 should have become paler.  And again, in the case of Comb,
 we were enabled to justify the opinion entertained  that the
 discoloration pointed to both capsules as the seat of the disease
 __for in all the kidney affections I have seen, I never noticed
 this coloration of the skin before, showing they  had become
 involved before death.   In the representations of Dr. Addi-
 son, there is no line of separation  visible on the forehead, 
14
but in his cases, the pigment embraces the whole of the scalp
and ears.   This was not the case in the patient at the New
York Hospital, for we had the line of demarkation very evi-
dent, and  also the pigment on  the lips, although the whole
body is tinged of a mulatto color.  The general history of
the cases correspond with those of Dr. Addison, except the
appearance of the skin, and  the emaciated condition of all the
patients, except Bishop.  The emaciation is not as  great as
is noticed in phthisis, though it is very distinct.  Dr. Addison's
plates represent a dirty brown  or mulatto or West Indian
color, and all his cases  have the scalp tinged except case 9,
which appears to have been free or not continued to the face
by the lithographer as the whole face  is not lithographed.
  Dr. Jonathan Hutchinson, in his series of cases published
in the Medical Times and  Gazette, for December 1S55 and
1856, has  appropriated the term " bronze" to the discolora-
tion, which, as he conceives, " conveys a good idea of the
exact character of the appearance of the  skin in the disease.
He compares it " to the  color of a bronzed statue from which
the gloss has been rubbed off."  This, it appears to my mind,
and many of my professional friends who have seen  them, as
inapplicable  to the cases  I have reported; and I  think it
would have a tendency  also to cause the disease to  be over-
looked in its early stage,  if that appearance of skin was sought
for and expected to be found as diagnostic of the disease in its
early stage.  From the  cases reported by Dr. Addison and
others, and my own, it  will be  remarked that this  affection
may spring up whilst  another  disease is progressing; and
that it may, and generally  does  exist as  a disease by  itself;
that the disease, judging from the number of cases that have
come under my observation in the course of two  months'
service  in  the  hospital, cannot  be very  rare; that it  must
have existed in many cases which have never been recognized;
that the discoloration may take place  in rather a rapid man-
ner, when the disease may be of an acute character,  and that
the  discoloration may be gradual in its appearance, and be-
come extensive when the disease is of a chronic nature, and
exist for, it may be, years, owing to the  peculiar diathesis of
the  patient,  whether of the  tuberculous or  cancerous or
fibrous, as nearly allied  to  the rheumatic ; that it requires a
longer time for the development of  the pigment  when it
becomes of the mulatto or West Indian hue, and more univer-
sal, while in the early stage it is like a person who is sun-
burnt, and further, that the result of .all the cases have pro- 
15
ceeded to a fatal issue, though there is one case reported by
Dr. Peacock, in which it is stated by the clerk who made the
post mortem,  that  the supra renal capsules were healthy
(this statement, I find, according to Dr. Hutchinson, in the
Medical  Times and  Gazette,  May, 1856,  page  519, was not
correct, and that the organs alluded to were not examined),
so there is, therefore, no  instance, thus  far, in all  the  cases
that have been  recorded,  amounting  with my own to
thirty-seven, and in which there were eighteen post mortem
examinations; that in all these eighteen cases, fourteen of
which both the supra renal capsules were diseased, and in
four only one of the capsules was  diseased; and  there has
been no case  recorded, where this morbid change occurred,
and the discoloration of the  skin existed, of a recovery; and
not a single case has been noticed where these bodies were
diseased and the discoloration did not exist also.
   Respecting  the diagnosis of the discoloration of the skin in
this affection,  there might be some  difficulty in arriving at a
correct decision in the instances  of persons who  have been
sunburnt.  But in cases of this nature, the ears and the hair
have undergone  some  change—which does not, in this dis-
ease, exist, in its early stages—as we have seen in all the
instances I have recorded, and as many medical  gentlemen
have also observed, where  the sunburnt  appearance  from
nature exists.   The general health is good, and the nervous
system not impaired;  the lips  free from the pigment which
all of the patients in this affection have.  In the case of Bon-
nel, who appears at present to enjoy tolerably good health,
even at this early  stage, the pigment of the  lips is clearly
marked, when stretched distinctly so.  If the pigment on
the face  does not  extend,  or grow much darker,  though
otherwise having the characteristic marks, it is possible that
only one of the capsules may be affected, and thus it may
remain in this form for a great length of time, and the disease
may be prolonged even to two or more years.
   In pityriasis versicolor the patches are smaller, not as dif-
fused, show themselves  on  the breast, shoulders, partly on
the neck, and  existing sometimes slightly on the face—not un-
like the freckles or discoloration in females during gestation
—itches at times,  and has also, sometimes, a slight, furfur-
ous scale; and, lastly, the presence of a microscopic fun-
gus, similar in structure to the parasite  of tenia  favosa, and
to other myeodermatous growths, which discovery has been
made by Eichstadt, and where this is sought for and  found 
16
 no doubt could exist;  the history of the case must here be
 taken into consideration.  Another source of difficulty might
 seem to be the dirty,  sallow appearance of the skin in mias-
 matic, and in the various forms  of malignant  cachetic, dis-
 ease, but to the early stage there can be no comparison ;  and
 in  the advanced stage, the color is so marked that it would
 not admit of error.
   The  microscopic  examination of the skin, by Prof. J. C.
 Dalton, jr., in the case of Drs. Bulkley and Smith's patient,
 showed the coloring matter found to be deposited in a granu-
 lar form, and could not be distinguished from a mulatto,  and
 it is believed that it is recognized that the color in the mulatto
 is dependent upon a special arrangement in the organization
 of  a certain tissue of the  skin; that pigment cells of a dark
 color is secreted in the form  of fine granular matter, instead
 of being uniformly diffused through the tissues.
   Respecting the anatomy of these  organs, we know  that
 different  opinions have  been entertained  regarding their
 structure and the relation they bear to other organs and their
 physiological action.
   In their structure  they approach nearest to the blood vas-
 cular glands ; they are composed of two different substances,
 cortical and medullary; the form is compact, and is of fibrous
 aspect, and  tears  readily; its color, of a whitish yellow, or
 yellow in the innermost third, passing into a brownish yellow,
 or  brown, so that when  a transverse section is made, two
 layers may be distinguished an external, bright-colored layer,
 and an internal, ifarrow, dark border.  The medullary sub-
 stance is  of a  grayish white with a tinge of red, although
 when its veins are full  of  blood it may assume a darker and
 more venous hue.  Its  consistence is softer than the cortical,
 though not so much  so as is generally believed.  In the dead
 subject, the cortical substance readily becomes detached from
 the medullary, when  the supra renal gland presents a cavity,
 according to Kolliker,  occupying the entire organ  and con-
 taining a dirty pultaceous substance, derived from the half dis-
 integrated  brown  layer of the cortex, mixed  with  blood,
 together with the less altered medullary substance, and which,
 however, in more rare instances, also becomes broken up. If
this is the appearance of the result of death, as described  by
 Kolliker, it will appear difficult to recognize whether in some
instances it results from disease in the organ in its acute form
or early stage.  It has, however, been shown by Dr. Wilks,
of London, that in persons who have been killed by accident 
17
the central  medullary portion has nearly a  grayish white
color, and on those who have been the subjects of cardiac or
pulmonary obstruction, or in those  long dead, the centre has
been generally red and soft.  This,  however, is not sufficient
to account for the different appearance met with, and it still
remains to be decided, whether this be due to disease, age,
or post mortem changes.
   Some anatomists have supposed they had no excretory
ducts, while others, such as  Bartholin, Vauquelin, Peyer,
etc., believed they had, and accordingly they  communicated
with the testicles and ovaries ; with  the thoracic canal, by
Kulmus;  with the pelvis of the kidney, by Heuerman and
Bendt.  Cassan and others have asserted that the supra renal
capsules were larger in the Negro than the Caucasian race,
and their medullary substance darker ; and Meckel has found
this  to  be the case in  the  negress but not in  the negro.
Those who admit an  excretory duct to  the genital organs,
necessarily connect the renal  capsules directly with them,
and Meckel  has observed their simultaneous and considerable
development in several orders of mammalia, and this has sug-
gested  the  same  idea  to himself, but  he  was unable to
describe the mode in which the supra renal capsules and the
general organs cooperated.
   Vauquelin has found the capsules ossified  in  a cat from
whom the ovaries had been extirpated.   Lobstein,  that of
the left capsule triple the size, by a chalky mass, in a  man
who had long been affected with syphilis;  and in two indi-
viduals, according to Meckel, who were addicted to  venery,
they were unusually large ; and in  a deformed female, after
parturition,  in whom the uterus and ovaries were atrophied,
they were also atrophied.   Otto has  seen them twice  the
usual size in one case, where the ovaries were much develop-
ed.  Treviranus considers them as imperfect rudiments of
the genital organs.   Sometimes there is  but one  capsule,
and sometimes they increase  in number and resemble  the
spleen  in this respect; but it  is believed to   be  difficult to
determine whether this state be only a simple division, or as
a real increase of the capsule.  Rokitansky  has observed
that accessory supra renal capsules, indicating an apparent
excess  of development, are of  frequent occurrence, and sev-
eral flattened accessory capsules are then found on the renal
and solar plexus, and on  the ganglion of  the latter nerve,
varying in size from a millet to a hemp seed.
   In the morbid anatomy of the cases reported by Dr. Addi- 
18
son and the series of Mr. Hutchinson, and in the two  cases
published since in  the Med.  Times and  Gazette, for June,
1856, and the two cases of my own, it will be observed that
these bodies undergo  the  same process of disease from  an
inflammatory action through its regular changes, suppuration
and induration, and also through the various organic changes
incident to lymphatic glands, and glands  of this nature, such
as tubercle, cancer, cystic degeneration, and, as supposed by
one or two authors lately, having a  form of  degeneration
peculiar to the gland itself.  But from the evidence before
us of eighteen post mortem cases, there have been more of the
tuberculous degeneration than any other, and as a general rule
I am inclined to believe that if not of an acute nature, this
result will characterize most frequently that form of degen-
eration, as this form  of cacchexia prevails more extensively
than any other, except the cancerous, for the history, pro-
gress, and termination of the disease, shows a  cachetic con-
dition, and not anaemic, as described by Dr. Addison.   On
account of their vascularity, haemorrhage not unfrequently
occurs.  But it is rare to see a case in the inflammatory state,
according to Rokitansky,  as, in consequence of inflamma-
tion, they become adherent to the kidneys. It is also rare to
find  a congenital union of the  kidneys and capsules, and in
that instance the same tunica albuginea invests the two, and
they are united by only a  cellular tissue.
  It is very evident,  from the results of investigation of the
cases brought before the medical profession, that these small
bodies, when diseased, play an important part in the economy
of man, undermining the constitution and  hastening  on to
dissolution ; and as we perceive, where both of the organs
are involved, no treatment has been of any avail, for when
the visible and prominent coloration of  the  skin presents
itself, an unfavorable issue would seem to be indicated.
  At the  present day the function of these organs is not
recognized, nor  has any light been thrown  on their physi-
ology, although Kolliker has given more attention to them
than any of the prominent physiologists of the present time.
The conclusion  to which he has arrived, is  that in  view
of the absence of all physiological indications, and so long
as the course of the nerves in them is not more  accurately
known, only very general deductions  can be offered.  But
he considers " The cortical and medullary substance as physio-
logically distinct."  The former may provisionally be placed 
19
with the so termed " blood vascular organs," and a relation
to secretion assigned to it;  while the latter, the medullary,
on account  of its extremely abundant supply of nerves,
must be regarded as an apparatus appertaining to the nervous
system, in which the cellular  elements  and the  nervous
plexus either exert the same reciprocal action as they  do in
the gray substance, or stand in a relation as yet wholly
unascertained towards each  other.  Leydig joins with Berg-
man in believing that these capsules are closely related to the
nervous system and that these  organs  bear the same rela-
tion to the ganglia of the sympathetic nerves, as the pitui-
tary body bears to the brain.
  In connection with the present subject of the pigment which
we notice  existing on the  skin of patients laboring under
disease of these capsules,  and  the great  impression  made
on the nervous system, as we perceive through  the marked
impairment of the physical constitution, the weakness and
feebleness of the powers of the body,  the  general lassitude
that exists, the feeble and slow action of the mind, the stupid
manner and expression of thought, the unearthly and sickly
aspect of the eye, the method of death, either by exhaustion,
as in cases of advanced anaemia, or through the cerebrospi-
nal axis, or by coma, we are disposed to entertain the belief
or opinion, that if the suggestion of  Prof. Kolliker be true
" that the  cortical and medullary substances are  physiologi-
cally distinct,"  it may, or  will, in the course of time cast
much light  on the  subject, and aid in solving the principal
 feature of the case, why and how this pigment is deposited,
 and its relation to the supra renal capsules.  Now, if, as we
 perceive, in this disease, the nervous system is so much in-
 volved, the body and mind both  impaired and  depressed,
 when the  affection  has  existed for a  few months, and the
 medullary substance is considered as being nearly allied in
 its  function and relation  to the nervous tissue,  I would
 suggest this part as being physiologically distinct from the
 cortical, and to be  the  "fons et origo,"  of. this depressed
 and impaired state of the  nervous system.  On the  other
 hand, as the cortical substance is believed to belong to the
 " blood vascular organs,"  may this  not  be the  "fons et
 origo" of the pigment we  see  so distinctly evident  on the
 skin ?  It seems to give color to the appearance of a tendency
 to an elucidation of the difficulties involved in the relation
 the discoloration bears to the disease of the supra renal cap-
 sules.  But we leave this point  for  further investigation, 
20
 though the idea may be entertained, as the physiology of the
 organs  is considered  not  yet determined, and its function,
 according to the latest authority on the subject, unknown.
 From  the facts, therefore, lately presented to our attention
 by Dr.  Addison, and which have in  so  many instances thus
 far been verified, that there appears to be a relation or con-
 nection between the discoloration of the skin and the capsules
 the thought presents itself to my mind, whether it may not
 be possible that a still further application of the subject in
 the discoloration of the skin,  which we  see in gestation,  on
 the face, hands, around the nipple, the abdominal line, navel,
 vulva, etc., etc., may  not  have some connection with these
 bodies,  though  of  a  temporary nature;  I  think  the  sug-
 gestion has so'-T?» bearing,  when  we  come to reflect on  the
 connection or relation pregnancy has with the kidneys,  pro-
 ducing  in them a temporary congestion, and  to such  an
 extent that albumen  may be deposited in  the  urine, and
 produce convulsions as is sometimes the case.   Now this
 temporary congestion  of the kidney,  during  gestation,  may
 exist as early as the first  week, and therefore proceed  not
 from mechanical pressure on the principal arterial and venous
 vessels as is generally  supposed.  An instance of this nature
 has lately  came under  my  observation, where the  skin
 had continued to be deprived  of its natural function for two
 months, and  albumen was discovered to exist, though  the
 lady was only advanced two months and one week, and while
 under treatment in the course of two weeks, ceased to exist
 and still continues free from it.  If, therefore, when the
 kidneys  become congested during  gestation, even  in its
 very early  stage, may it  not be possible, from the conti-
 guity  of the supra renal capsules, they may become involved
 or may they not themselves become slightly affected, as we
 perceive other organs  do in this state, sufficiently so to allow
 the discoloration, incident  to pregnancy, to exhibit itself'(  It
 seems to me there is a feasibility in the suggestion that  may
 admit of further illustration from the remarks we have made ;
 and from the  investigations of Meckel on the mammalia, and
 his observations on the human subject, and the case of Otto
 and others, shewing the relation they  both bear to the genital
 and uterine  organs; the  case of Comb,  where it  occurred
 during renal  disease;  but  the further, and as I conceive, the
more valuable, suggestions of  Kolliker, respecting the plivsio-
logical action of the  two portions  of  these bodies being
 distinct, and which we are disposed to think may in  future 
21
tend much to  explain the reason how this  pigment is de-
posited, and its connection to the supra renal capsules.  Now
if this should prove to be the reason why this discoloration
exists, and in gestation also, may it not explain  the reason
why the nervous system is affected when albumen is discov-
ered in the urine, and that  instead, as some have  believed,
and which I have not yet been disposed to be fully convinced
of, that, instead of urea being the cause of the convulsions,
it may be possible that the  medullary part of the supra renal
capsule is involved.
  My object in publishing the cases which have so recently
come under my notice,  of  the  disease of the supra renal
capsule, is to aid in the dissemination of facts  that  bear so
evidently on the early stage of the disease, 1   the  sunburnt
appearance of the skin, and which has been .  faithfully and
correctly depicted by Dr. Addison, as I think, in the advanced
stages, and to whom the profession are so much indebted for
the very valuable monograph he has presented them on the
subject, and in which he asks for all the facts that may have
a tendency to corroborate his views, or that may tend to con-
tradict them.   It was not my intention to have occupied so
much time and space, but if there is but one fact which has
advanced  the elucidation of the subject, my object will have
been  obtained.   The subject  requires close  and patient
investigation, aided by morbid anatomy, through microscopic
investigation and physiological induction. 
{, 
I