'300 BENSON A. COHOE 



less deliriunij from which the patient lapses into a stupor or deep 

 coma. 



Diagnosis. The diagnosis is readily established in the typical case, 

 in which the cardinal symptoms asthenia, digestive disorders, and 

 pigmentation are outspoken. In the atypical cases (formes frustes) 

 with absence of one or more of these symptoms, a positive diagnosis is 

 sometimes rendered impossible during the life of the patient. Cases of 

 the disease, without melanoderma, are known to occur, but are prob- 

 ably less common than the older statistics would indicate. In such in- 

 stances the diagnosis is extremely difficult and the disease may pass unrec- 

 ognized. In these atypical forms Barker (a) has emphasized the importance 

 of noting: (1) the presence of constitutional anomalies corresponding to 

 status thymicolymphaticus; (2) exact studies of the pigmentation of the 

 body ; (3) careful analysis of any digestive disturbance present. 



The critical survey of the anamnesis is of equal importance with the 

 physical examination in arriving at a proper diagnosis of the disease. If 

 there can be obtained a history of progressive weakness, gastrointestinal 

 disturbances (nausea, vomiting, gastralgia, constipation or diarrhea), and 

 of neuralgic pains localized in the lumbar region, or in the abdomen, from 

 a patient, in whom the physical examination shows pigmenting of the skin 

 and of the mucous membranes, and an absence of any organic disease of 

 the viscera, or of a blood dyscrasia, a positive diagnosis of Addison's 

 disease may be regarded as well substantiated. 



Pigmentation of the skin occurs in many other pathological conditions, 

 but is rarely so pronounced as in the extreme Addisonian melanoderma. 

 It is the less severe grades of pigmentation which give rise to difficulty 

 in diagnosis. The more important pathological states, in which increased 

 pigment deposit may occur and from which the Addisonian pigmentation 

 must be differentiated, are: 



(1) Ilemochromatosis (glycosuria, enlarged liver, absence of 

 marked asthenia: pigment contains iron). 



(2) Argyria (pigmentation slate colored: history of silver nitrate 

 medication). 



(3) Arsenical pigmentation (usually history of prolonged arsenical 

 medication: hypertrophic processes in the epidermis). 



(4) Pernicious anemia (color of skin usually lemon colored, but 

 pigmentation here may be due to prolonged taking of arsenic: 

 mucous membranes not pigmented: blood examination). 



(5) Pellagra (seasonal appearance of a rash: marked asthenia ab- 

 sent ) . 



(6) Jaundice (icterus of scleras: bile in urine: history of cholelithi- 

 asis, or obstruction from a mass). 



(7) Cachexias, accompanying tuberculosis, carcinoma, malaria, 



