CLINICAL PICTURE OF ADDISON'S DISEASE 201 



which more frequently leads to diarrhea than to constipation. With this 

 very often, even early, there are marked pains in the abdomen especially in 

 the epigastrium, in both lumbar regions, and in the right and left hypochon- 

 drium, intermittent at first, subsequently often becoming continuous. All of 

 these symptoms increase late in the course of the disease, and often become 

 so severe that after a time the gastrointestinal disturbances, with- stubborn 

 vomiting and often steady diarrhea, rapidly decrease the strength. 



The symptoms which may be referred to the nervous system are slight at 

 the onset of the disease, of a general character, and limited for the most part 

 to psychical apathy, tendency to headache and the like. Later, attacks of 

 vertigo and syncope are usually observed, not infrequently also epileptiform 

 attacks and somnolence. Death occurs most often after coma and convulsive 

 phenomena. 



The most conspicuous symptom of the disease in all well marked cases is 

 the discoloration of the shin which has given- the affection the designation 

 of " bronze disease." Like the other symptoms, this usually develops gradually 

 from a light yellowish brown up to a dark brownish black (mulatto color, 

 negro color). It often begins simultaneously with the general asthenia, but 

 may precede this, in some cases even by a long time (in one recorded case 

 twelve years). The bronzing appears most often on the places which are 

 exposed to the air (face, neck, hands), and on those which normally show 

 most pigmentation (the axillse, the areola of the nipple, the linea alba, the 

 genital region), and thence distributes itself over the rest of the skin. Upon 

 the uniformly pigmented surface there often develop later circumscribed, still 

 darker areas ; in some cases, on the other hand, we find zones which are without 

 pigment (leukoderma). 



The simultaneous involvement of certain mucous membranes in this pig- 

 mentation has very properly been emphasized throughout the literature of 

 Addison's disease as especially important in- the differential diagnosis from 

 other discolorations of the skin. Almost invariably the mucous membrane of 

 the mouth is affected, usually in the form of irregular bluish black spots, 

 their seat being chiefly upon the mucous membrane of the lips and palate. 

 According to my experience, the tongue deserves more attention than is usually 

 given to it. In the cases seen by me it often shows in different areas a very 

 conspicuous inky stain. Sometimes pigment areas are found upon the vaginal 

 mucous membrane; exceptionally also upon the conjunctiva palpebrarum and 

 scleras and upon the vocal cords. 



The pigmentation, as a rule, gradually increases in intensity throughout 

 the course of the disease. Only exceptionally has a diminution been noted 

 prior to death. Somewhat more often transitory remissions of the bronzing 

 have been reported. I myself have seen in two cases a bleaching of the skin 

 lasting several months (with a simultaneous general improvement) and later 

 increased discoloration. 



The course of the symptoms just mentioned is decidedly chronic; only 

 exceptionally is the onset acute and progress rapid. The severer symptoms 

 follow the milder ; not infrequently they come on some months or weeks prior 

 to death, with a certain suddenness. Two years may be mentioned as the 



