294 BENSON A. COHOE 



As a rule the pigmentation deepens with the progress of the disease, 

 but not uncommonly remissions in its intensity have been observed. A 

 decrease in the melanoderma, following suprarenal gland therapy, has been 

 recorded by numerous observers. In a few instances, it has been re- 

 ported as having entirely disappeared under such treatment. 



The gastro-intestinal disturbances constitute a prominent feature of 

 the syndrome, but are, perhaps, the least constant of the triad of cardinal 

 symptoms. They are variable both in occurrence and in intensity, 

 throughout the course of the disease, and in occasional cases are entirely 

 wanting. At times the disease may be ushered in with some digestive 

 disturbance, either loss of appetite, or abnormal hunger, epigastric dis- 

 comfort, nausea, eructations, and vomiting. As a rule, however, the as- 

 thenia has become well established by the time the gastric disoTders make 

 their appearance. The anorexia may be pronounced, or in other rare 

 instances the appetite may be voracious and accompanied by polydipsia 

 and polyuria. The vomiting may occur with or without the taking of 

 food, sometimes spontaneous in character, and in the 'later stages fre- 

 quently uncontrollable, with the presence of blood, mucus or bile in the 

 vomitus. The gastric symptoms are irregular in their occurrence and 

 in the earlier stages show frequent remissions and exacerbations. Con- 

 stipation is more common than diarrhea early in the disease, but the 

 two conditions may alternate. Late in the disease, a profuse diarrhea 

 is a common feature, at times occurring in crises and simulating a cholera 

 nostras. The stools may contain excessive mucus, but rarely blood. Tenes- 

 mus has been occasionally noted although, in general, the diarrhea is not 

 especially painful. Meteorisin is frequently associated with the gastro- 

 intestinal disturbances. 



Abdominal tenderness and pain are common symptoms. The pain 

 may be diffuse, or localized in the epigastrium, or loins, or elsewhere in 

 the abdomen. Occasionally the pains are paroxysmal, suggesting gastric 

 crises, or lead colic, and at other times gastric ulcer, or cholelithiasis, ac- 

 cording to the localization. In a few cases, rigidity of the abdominal 

 wall, associated with these pains, has produced the clinical picture of an 

 acute peritonitis, a condition which has been observed to be followed 

 within a few days by an exitus lethalis. 



The symptoms referable to the nervous system may be slight at first, 

 but almost invariably a psychic adynamia develops concurrently with the 

 myasthenia. A striking apathy, and a loss of interest in the ordinary pur- 

 suits of life, and undue mental fatigue, are early features of the syndrome. 

 Such patients are often classed as neurasthenics. An obstinate insomnia 

 may prove troublesome, although in rare cases somnolence has been ob- 

 served. Almost always the memory becomes defective. Mental depres- 

 sion, or mental excitation, and increased irritability and ill-humor, are 

 common manifestations of the altered psyche. The mental deterioration, 



