It is right to note here that Dr. Rados, of Tours, expressed the opinion that Addison's disease was clue to a general poisoning of the body by pigmentary matter which had not been destroyed by the ad renals.' But in opposition to this view we must take note of the fact that cases of acute Addison's disease, ending fatally within a few months, are, as a rule, unaccompanied by characteristic melasma. This point will be referred to later.
The occurrence of rheumatoid pains in the loins and abdomen has been noted with some frequency.
The appetite is capricious, and there may be loathing for animal food. Profuse diarrhoea may supervene toward the end of the malady. There may sometimes be complaint of lumbar pain and of epigastric distress.
With this series of symptoms, every intelligent physician would suspect the onset of adrenal disease, and his opinion should hardly be shaken by the absence of one or more of them.
With the progress of melasma, the patient becomes greatly changed in appearance, assuming the color of a mulatto or of one of the dark races. It varies in degree and in depth of hue on various parts of the body, being usually more pronounced on the exposed parts such as the face, neck, and back of the hands. But it is also found well-marked on the genitals, a sooty hue of the penis and scro tum being very common and characteristic. The groins and the nipples and areolffl are apt to become very dark. The tint is never quite uniform all over the body even in an extreme case of "bronzing." As in eases where pigment is apt to be deposited from any cause, points of pressure and those exposed to friction become the seats of greatest attraction in this respect. Thus, the friction of a collar or of braces, constriction by garters, irritation of blisters or sinapisms, or of skin-eruptions, all lead to greater intensity of pig mentation in the sites affected. The patches of varying depth shade off gradually, and have no abrupt margins.
It is well to take note of this fact, because it helps to distinguish Melasin a from another morbid condition known as melano derma, where the pigmentary outlines are sharply defined, and con trast markedly with pale patches void of natural pigment. It is very common to find small spots of dark pigment scattered over the trunk and limbs and on the face, like flat pigmented moles. The contrast of
the pearly conjunctive with the melasma as seen on the face is very remarkable in a well-developed case of Addison's disease.
This peculiar pigmentation is not, however, confined to the integ uments of the body. It occurs ou mucous membranes, and is espe cially to be looked for on the buccal surfaces. Along the inner sur faces of the prolabia and opposite the lower incisor teeth may be noted dark pigmentary patches, and the same are seen on the inner surfaces of the cheeks along the teeth, and on the margins of the tongue.
These much resemble the deposits of pigment met with in the same situations, but more extensively and especially on the palate, in many dogs, when they are reckoned marks of good breeding; they occur in some dark races of men. It is doubtful whether pigment is ever de posited in any internal organs in Addison's disease. The pia mater was once noted to be darker than usual over the medulla oblongata by the late Dr. Carrington of Guy's Hospital.
There is nothing specially noteworthy about the anatomical posi tion of the pigment in these cases. It occurs just where it is usually found in dark races, that is, in the deep layers of the rete mucosum, and it is deposited in the form of yellowish-brown granules.
There are many causes for undue pigmentation of the skin. Those commonly recognized are exposure to the air and the rays of the sun. These affect chiefly persons of dark complexion. Life in the open air with free exposure to all vicissitudes of weather, such as is led by gypsies, tramps, and vagabonds, will induce this, and the covered parts of the body are also affected in such persons owing to long-con tinued irritation from dirt and varieties of vermin. Dr. Greenhow directed attention to this condition, and named it "vagabond's dis ease," and showed how it might simulate Addison's disease.' The pigmentation met with on the limbs in stokers and women may also suggest a true melasma. It is, however, commonly reticu lated in appearance, and is due to exposure to fire. Dr. Pavy had under his care a case of Addison's disease in a woman in which the pigmentation assumed this form. Phthiriasis of long-standing may induce great deposition of pigment over the body, the face, however, escaping in such a case.