292 BEFSOK A. COHOE 



with a gradual increase in severity. Frequently, however, the mode of 

 progress is paroxysmal, with remissions and intermissions in the severity 

 of the symptoms. 



The adynamia, or asthenia, is very generally regarded as the most 

 characteristic and constant symptom of the disease. In almost all cases 

 it occurs as the earliest indication of the onset. It is a psychic as well 

 as a physical asthenia. In the early stage the patient complains of extreme 

 lassitude, and of abnormal fatigue following physical or mental ex- 

 ertion. He may experience a constant fatigue, and become disinclined, 

 or unable, to carry on his ordinary occupation. Langlois has laid stress 

 upon the fact that while the patient, with this disease, may be able to 

 make a short series of movements with considerable energy, he becomes 

 almost instantly fatigued, in contrast to the patient with chronic pul- 

 monary tuberculosis, who is able to carry on a sustained effort for a 

 much longer period. When the disease becomes well established, the as- 

 thenia, as a rule, steadily progresses in degree of severity. In the earlier 

 stages, however, it may occur over periods of varying length with inter- 

 vals of remission, in which the patient may be able to resume his usual 

 vocation. Fainting spells frequently occur, and are regarded as an ex- 

 pression of the asthenia. The muscular development and general nutri- 

 tion of the patient frequently exhibit a marked contrast to the extreme de^ 

 gree of muscular prostration. In the later stages, the asthenia becomes 

 extreme and forms an essential feature of the disease. The patient, 

 sooner or later, becomes confined to his bed, and may be unable to rise, 

 or in some instances, to feed himself, or to speak, or perform movements 

 of any kind. A marked grade of asthenia may precede the appearance 

 of the pigmentation by many months, rendering a diagnosis difficult. In 

 exceptional cases muscular weakness may not be a prominent symptom. 

 Tieken has recently observed a case with all the characteristic signs of 

 Addison's disease, except asthenia, in which the muscular development 

 and power were noted as fairly normal until within a few days before 

 death. 



The pigmentation of the skin is an important and striking sign of 

 the disease, the presence of which some authorities have come to re- 

 gard as a sine qua non of the Addisonian syndrome. It is believed to 

 be rarely absent during some stage of the disease. Lewin, however, found 

 it present in only 72 per cent of his series, a proportion which is generally 

 regarded as lower than the true incidence (Bittorf (a)). In the chronic 

 forms of the disease it is almost invariably found present in varying de- 

 gree, but in the acute cases it is commonly absent. The discoloration of 

 the skin begins inconspicuously, usually following the initial asthenia, 

 and the gastro-intestinal symptoms. Not uncommonly, however, the pig- 

 mentation- constitutes the earliest sign of the disease, and may first attract 

 the attention of the patient or of his friends. At times it may be present 



