

ADDISON S DISEASE 347 



administration of tryptophan, so it would not be unlikely that an increased 

 production of tryptophan has been brought about in the body by the ad- 

 ministration of adrenalin. Further it should be mentioned that Neuberg 

 demonstrated in the tumors of the cases of melanoma of the suprarenal 

 cortex a ferment which let a pigment formation be recognized after the addi- 

 tion of adrenalin or oxyphenylethylamin. Further Jaeger has obtained 

 from a melanoma an enzyme that decomposes adrenalin with pigment forma- 

 tion. Jaeger supposes that adrenalin is the mother substance of the iron-free 

 pigment of the organism. Finally, according to Meirowsky, freshly excised 

 pieces of skin show in the incubator an increase of pigmentation, and accord- 

 ing to Konigstein this increase of pigment is greater in the skin of dogs without 

 their suprarenals. Therefore it would not be unlikely that the cortex as well 

 as the chromamn takes part in the pigment formation, the first furnishing the 

 mother substance of the melanogen (tryptophan), the latter the further de- 

 composition. Increased formation of pigment may occur under the most 

 diverse circumstances, as in Basedow's disease, when the production of ad- 

 renalin is increased, or in Addison's disease when the production of adrenalin 

 is absolutely lessened, or perhaps less disturbed than the function of the corti- 

 cal system. Thus may also be seen why pigment formation often remains 

 away entirely in acute destruction of the entire suprarenal apparatus. This 

 should, however, be regarded merely as a hypothesis that still requires 

 experimental support. 



Differential Diagnosis. For differential diagnosis, of great importance 

 are the pigmentations. The number of cases of Addison's disease without 

 melanoderma is, as Bittorf has emphasized, less than the older statistics 

 would lead one to expect. Similar pigmentations are found, however, in 

 normal individuals. Also in itching skin affections and [those due] to ver- 

 min, during the use of arsenic, in pregnancy , f in chronic heart affections and in 

 phthisis pulmonalis; in slight grades of the latter the thought of Addison's 

 disease may be erroneously awakened on account of the emaciation and the 

 slighter hypotonia; it is hence important to remember that in all conditions 

 enumerated the mucous membranes remain free. In persons cachectically 

 tuberculous the pigmentations may become quite similar to those of Addison's 

 disease. Here indeed it is questionable whether the pigmentations might 

 not be referred directly to a damaging of the suprarenal function, an opinion 

 that is upheld by Lavignel-Lavastine. 



In cirrhose bronzee the coloration of the skin is more blue-gray; here also, 

 the mucous membranes are affected only rarely and more in a diffuse form 

 (Heller). Here we should consider the liver lesion and the eventual compli- 

 cation with pancreatic disease (diabetes). Naturally it should be taken into 

 consideration that combinations of cirrhose bronzee and Addison's disease 

 may occur, if the sclerosing process in cirrhose bronzee also involves in strong 

 degree the suprarenal apparatus (Fod, Bittorf}. As is known, pigmentations 



