Synonyms:—Bronzed skin; melasma suprarenale.
Definition:—A chronic disorder in which, with pallor of the skin and loss of strength characteristic of some forms of anemia, there is a peculiar pigmentation of the skin, which presents a characteristic bronzed appearance. With this there is oppressed circulation, feebleness of both the body and mind, and irritation of the gastrointestinal tract, and important changes in the suprarenal capsules.
Etiology:—As with the anemias, no specific cause has been found for this disease, but in more than half of the cases which have been examined post-mortem, disease of the suprarenal glands has been found to be present, and among these disorders tuberculosis is by far the most common. However, it is observed that these glands may be seriously diseased with no appearance of the characteristics of Addison's disease. On the other hand, Addison's disease may be present with no disease of the suprarenal glands. The disorder is more common in males than in females in the proportion of nearly two to one, and occurs in early middle life, usually before the age of fifty. It has followed blows upon the back or severe injury to the trunk of the body sufficiently often to cause all writers to believe that it may result from traumatic causes. Injury to the semilunar ganglia of the abdominal sympathetic nervous system, interfering with its control of the function of the suprarenal glands of the kidneys, is thought by most writers to be the actual cause.
Symptomatology:—Ready exhaustion from any effort, increasing prostration or general asthenia are the first symptoms of this disease. There is lassitude and a persistent sense of fatigue, which is brought on not only by physical, but by mental exercise. There are symptoms common to anemia, such as tinnitus aurium, sighing respiration, shortness of breath or difficult breathing, vertigo, syncope, and more or less severe and persistent headache. There is no leucocytosis, but some reduction in hemoglobin. Anemia is present and occasionally it is quite pronounced, although it is usually mild. These patients are not greatly reduced in flesh, but retain their weight, and the abdominal fat is quite often fully preserved. As the prostration increases in its progressive character, the patient becomes despondent, is careless of his habits, is interested in nothing, and becomes peevish and irritable. Quite early in the history of the disease there is loss of appetite and nausea, and ultimately vomiting, which does not seem to be due to a disordered stomach, occurs with increasing frequency and severity. This is undoubtedly due to the wrongs of the sympathetic nervous system. There may be some diarrhea, and pain in the stomach or in the bowels present as a common symptom. The heart is feeble almost from the first, and the pulse, is small and easily compressed, and there is a gradual reduction in the blood pressure, which becomes quite apparent in the later stages. The general temperature of the body is usually subnormal, and the extremities are cool. Ultimately increasing dullness, mild delirium, stupor and coma may occur, with perhaps convulsions, which usually precede death but a short time.
The characteristic pigmentation of the skin, is often one of the first evidences of the disease. While it is described as of a bronze color, it may vary from a dirty yellowish tinge to a dusky brown or greenish yellow color, and in extreme cases may be described as dark or of a deep greenish brown. There is no uniformity in distribution of this pigmentation; it is more plainly marked wherever there is a normal increase of pigmentation on the surface of the body, such as in the areola of the nipples, and in the axillae, groins, on the abdomen, and on the genital organs, but it is deepened first upon the exposed parts. There are also pigmented areas of a dark or bluish color on the mucous lining of the mouth and lips. This may be also discovered in the vagina. The pressure of the clothes seems to interfere with the pigmentation, as lines corresponding to the pressure thus applied are easily observed in the coloring.
Occasionally with disease of the suprarenal capsules, as a natural consequence there is also disease of the kidneys. In other cases it would seem that the renal disorder is the natural result of a fault in the arterial tension or as a result of some cardiac complication.
Diagnosis:—In the earlier stages of this disease the diagnosis is sometimes extremely difficult. Several other conditions have a more or less mottled pigmented discoloration of the skin, such as congestion of the liver with jaundice, or cirrhosis. Cancer and tubercular disease in the abdomen will also result in altered condition of the skin. It occurs in goitre also, in pregnancy, or in chronic uterine disease. After well defined cases are fully developed, the characteristic pigmentation is readily distinguished. Discoloration from the continued use of the salts of silver produces a peculiar discoloration, but to a close observer there is no similarity. In these cases it is plainly a discoloration, and in a number of cases which have come under the observation of the author the discoloration was uniform on all surfaces exposed to the light. The association of a peculiar bronze pigmentation, with progressive weakness, persistent vomiting, which is plainly reflex in character, and of feeble pulse, with usually pain in the loins, will determine this condition.
Prognosis:—This disease usually results in death. It runs its course in from two to four years; rarely a patient will live from five to seven or even ten years. In other cases the disease will terminate within a few months.
Treatment:—Prior to a positive determination of the character of the disease, these cases will be treated symptomatically, and often there will be satisfactory results from the use of remedies calculated to increase the vitality of the patient, to improve the function of the blood-making organs, and restore the tone of the blood. Any exertion should always be short of fatigue. The patient should be surrounded with all of those favorable conditions named for leukemia, and the treatment will be very similar. The use of specific remedies should not be overlooked whenever the indications are plainly apparent.
Much has been written during the last ten years concerning the use of the suprarenal gland of the sheep in the treatment of this disease, and theoretically considered it should be beneficial, but in practice its use has not been productive of satisfactory results. Much attention should be paid to the stomach and the digestion, although the probabilities are that treatment directed to the nervous system will allay the diarrhea and vomiting more quickly than that administered for its direct influence upon the stomach. Electricity and the X-ray should be tried in order to determine their influence. Results have not as yet established confidence in any form of treatment.
The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.