Death two months after the onset of symptoms in a case in which one of the capsules presented an old tuberculosis, while in the other there were only recent granulations. Death hastened by inter current erysipelas. Mouisset (Lyon Med., May 27, '94).
Diagnosis.—The presence of increased pigmentation of portions of the skin or mucous membranes, with progressive asthenia. frequent gastric disturbances, and cardiac weakness constitute the chief diagnostic features of melasma suprar enale, or Addison's disease. Increased pigmentation alone is not sufficient to justify a diagnosis of this affection.
Possibility of diagnosing Addison's disease when the characteristic discolor ation of the skin and mucous membranes is absent: high-tension pulse or a very striking difference in tension between the peripheral pulse and that in the abdominal aorta. Neusser (Med. News, Sept. 18, '97).
Case of Addison's disease in a phthis ical man in whom hot applications or mustard plasters caused pigmentation. These applications, kept up a week, caused marked pigmentation upon the abdominal wall, the right hip, the shoulders, and the calves. Slight pig mentation appeared spontaneously upon the patient's forehead before these ex periments were tried. The same ex periments produced pigmentation upon a patient with Pott's disease, in whom the autopsy showed tuberculosis of the suprarenal capsules. Jacquet and Tre molieres (Bull. et Mem. de la Soc. 316d. des Hilpitaux de Paris. July 25, 1901).
Case in which there was no tendency on the part of the discrete pigmented area to run together and become diffuse. The patches of pigmentation remained isolated throughout up to the time of death. These cases might be mistaken for various affections in which pigmen tation occurs: idiopathic multiple sar comata of Kaposi, xeroderma pigmen tosum, pigmented lesions following syph ilis, and lentigines. Treiiitsch (Zeit. f. klin. Med., B. 32, S. 163, '97).
Pigmentation of mucous membranes generally considered diagnostic of Addi son's disease seems to be found under other conditions. It appears to occur in some eases as mere accident without ob vious cause; it may also be associated with chronic gastric diseases, such as car cinoma. Two cases of abdominal disease in which pigmentation was found on mucosa of mouth. In first case diagnosis
lay between cirrhosis of liver and chronic peritonitis; in second there was cholan gitis due to gall-stones, with tubercular disease of lung and testicles. In neither could Addison's disease be absolutely ex cluded, but group of symptoms by which it is distinguished did not occur. Nor can occurrence of this group be relied on as sure indication of disease of supra renal bodies. Case noted in which weak ness, anorexia, vomiting, and diarrhoea were all present, but autopsy showed only chronic gastric catarrh without affection of suprarenals. In this ease there was no pigmentation. Schultze (Deutsche med. Woch., No. 46, '98).
Addison's disease is not the only dis ease in which the condition of body presents discoloration of skin. A fair percentage of cases also runs its course without bronzing. Addison's disease must be diagnosed by exclusion of ab dominal cancer. tubercle or lymphoma, tuberculosis of peritoneum, pernicious amtmia, and others, as sun-bronzing, vagabond's disease. sma ,g•avidarum. amyloid kidney, pulmonary tuberculosis, yellow fever and malarial fevers, heredi tary arsenic long continued, diabete bronze of the French, pellagra in the chronic pigmentary form. Hodgkin's disease, chronic hepatic disease, and con stipation in sedentary patients. A. J. Lartigan and 'W. H. Happel (Albany Aled. Annals, Feb.. '99).
On the other hand, a few cases have been recorded in which there was pro found asthenia, severe gastric disturb ances, irregular and weak pulse, and early death from syncope, when the au topsy revealed both suprarenal bodies much enlarged from caseous and tuber culous degeneration, but no pigmenta tion or bronzed spots on either skin or mucous surface. Letulle reported a case of this kind in 1894. The patient was supposed to be suffering from malarial cachexia, but died suddenly from syn cope, and "the autopsy showed the two capsules to be transformed into fibro caseous blocks as large as a mandarin orange!' There is at present no known Bronzed spots have been found in con nection with a variety of malignant and other growths, especially in the abdomen and pelvis, with some cases of diabetes, exophthalmic goitre, and also in cases of pulmonary and peritoneal tuberculosis.