ADDISON'S DISEASE 293 



for months before the asthenia becomes noticeable. The melanoderma 

 represents an exaggeration of the normal pigmentation of the skin, and 

 while pervading more or less completely the entire integument of the body, 

 occurs most markedly in those regions of the body which are normally pig- 

 mented, or in parts exposed to light or pressure. It is usually first evi- 

 dent on the face, neck, backs of the hands and fingers, especially on the 

 knuckles. The areolse of the nipples, the axillary folds, the extensor sur- 

 faces of joints, the genitalia, and the groins, may show a marked intensifi- 

 cation of the normal pigmentation. Areas of the skin exposed to pressure 

 or friction, as the waist line, the regions over the spinous processes and the 

 ischial tuber osities, or parts of the skin pressed upon by the collar button, 

 suspenders, belt or garters, become darkened. An area of scar tissue may 

 become pigmented, or be surrounded by a dark areola. The Nnea alba, in 

 pregnant women, frequently becomes a black line. The hair does not 

 usually show pigmentary changes but cases have been reported in which 

 it became darker. The skin of the scalp and other regions covered by hair, 

 commonly escape pigmentation. The nail beds, palms, and soles are usu- 

 ally free, but pigmentation of the palms, with intensification along the 

 folds, has been observed. The flexor surface of the phalangeal joints, in 

 rare cases, shows pigmentation. 



The nature of the discoloration of the skin has been variously de- 

 scribed. Addison pictured it as a "dingy or smoky appearance, or vari- 

 ous tints, or shades of deep amber or chestnut brown." It has commonly 

 been described, in the earlier stages of the disease, as a dingy yellow tint. 

 Straub(fr) observed a general redness of the skin preceding the appearance 

 of the pigmentation. As the disease progresses, the tint deepens from 

 a light brown, or bronze, to a darker brown, in some cases assuming the 

 dark hue of the negro. At times, a bluish or greenish tint has been noted. 

 Although diffuse as a general rule, the melanoderma is rarely distributed 

 uniformly over the trunk, but assumes a mottled or patchy character, 

 frequently showing small areas of intense pigmentation resembling moles. 

 Areas of leucoderma are frequently interspersed between the pigmented 

 areas. 



Pigmentation of the mucous membranes is almost constantly present, 

 and is regarded as an especially important sign of the disease. It is 

 usually distributed in the form of small spots or streaks, of a bluish black 

 color. It occurs on the lips at the margin of the skin, sometimes spread- 

 ing out from the angle of the mouth in a distinct streak; on the border 

 of the tongue, the buccal mucosa, the gums, and soft palate; on the eye- 

 lids, and, rarely, the conjunctiva. The vaginal and rectal mucosa are 

 occasionally pigmented. A patchy pigmentation of the serous membranes, 

 occurring in the form of small black spots beneath the peritoneum of the 

 mesentery and omentum, as well as pigmentation of the pia mater, has 

 been noted in some instances. 



