ADDISON'S DISEASE 301 



syphilis and arthritis deformans. In both tuberculosis and car- 

 cinoma the chromaphil tissue may be involved but the asthenia 

 is rarely so extreme as in Addison's disease. In malaria (his- 

 tory : finding of plasmodia in the blood : enlarged spleen) : 

 syphilis (history : Wassermann) : arthritis deformans (char- 

 acteristic joint changes). 



(8) Certain skin diseases; vagabond's disease; chronic eczema, 

 scleroderma, melanosarcoma of the skin, vitiligo, xeroderma 

 pigmentosum (absence of cardinal symptoms). 



(9) Neoplasms, especially abdominal forms: melanotio carcinoma, 

 melanosarcoma, lymphoma; benign tumors of the uterus and 

 ovaries ; pseudoleukemia ; neurofibromatosis, in which diffuse 

 bronzing and pigmentation of the mucous membranes may occur 

 (subcutaneous nodules). 



(10) Exophthalmic goiter (symptoms of hyperthyroidism). In 

 rare instances the two diseases may be associated in the same 

 patient. 



(11) Pregnancy (pigmentation usually limited to the face: tumor). 



(12) Gastric disease gastric ulcer and dilatation of the stomach 

 are sometimes accompanied by a pigmentation of advanced grade 

 (gastric findings: radiogram). 



(13) Cardiovascular disease arteriosclerosis, chronic heart disease, 

 and chronic interstitial nephritis, may at times show pigmenta- 

 tion (physical examination: blood pressure: electrocardiogram: 

 urinalysis) . 



The presence or absence of an asthenia is regarded by many authorities 

 as the most important factor for consideration in establishing the diagnosis. 

 In the absence of this symptom in a patient with melanoderma, in whom 

 other possible causes for the pigmentation have been excluded, it is be- 

 lieved that a diagnosis of Addison's disease should only be tentatively ren- 

 dered, until such time as this symptom develops. 



The pigmentation of the mucous membranes is a further valuable diag- 

 nostic aid, but is not pathognomonic of this disease. It occurs physio- 

 logically in some races, negroes and certain yellow races (Japanese), and 

 also occasionally in such pathological states as chronic stomach disease, 

 and neurofibromatosis. Further, it is sometimes absent in Addison's 

 disease. 



In every suspected case, an examination of the patient for the pres- 

 ence of lymphatic anomalies associated with status lymphaticus should be 

 carefully made, since Wiesel(e) and Hedinger have shown this condition 

 to bear a close relation to hypofunction of the chromaphil system. Neus- 

 ser has called attention to the great difficulty of making a diagnosis of 

 status lymphaticus intra vitam, but the finding of enlarged tonsils, enlarged 



