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Stewart’s permission, to read you an abstract of the notes I have taken of the case.
C. S., aged 32, was admitted an in-patient on the 13th of February. In early life, he worked as an agricultural labourer in his native county of Herefordshire, but for the last thirteen years has been employed as a coal-porter at a London wharf. About three years previous to the commencement of his illness, he had strained his back severely in the lower dorsal region while shunting a loaded coal-truck, and had felt as if something gave way at the moment of the accident. For some days he suffered much pain in the part, and more or less every afterwards, though he was able to continue his work. He did not himself attribute the origin of the illness to this injury, and indeed, attached so little importance to it, that I only elicited the fact by careful inquiry. He stated his health to have been uniformly good until about eight or nine months before his admission to the hospital, when his illness began with headache, sweating, and debility, followed by loss of appetite, sickness, and breathlessness on exertion, with pain in the lumbar region and right flank. The symptoms of asthenia steadily increased; faintness supervened upon his making any muscular effort, and he had been incapacitated from labour for about two months, when he came under our observation a month ago. The gastric disturbance had also continued; he had frequent nausea and retching, and generally vomited after taking food; the pains in the loins increased in severity, and became associated with gastralgia and with pain in both hypochondria; and these symptoms were all much aggravated by any attempt to move about. Three or four months after the accession of the first constitutional symptoms, his wife had noticed a slight duskiness of colour, which, she believed, was at first confined to the face and hands, but which had gradually spread over the whole body and progressively deepened in hue.
On careful examination , a few days after his admission, I found the skin, generally, of an olive-brown colour, which was especially marked on the face, hands, and neck, the shade being deepest on the more-exposed parts, and least dark on that part of the forehead covered by hair. The chest, down to the fourth rib, was paler than the face and neck, but the nipples and areolæ were dark. From the fourth rib downwards the colour gradually deepened; the abdomen was very dark, but the colour faded away towards the legs, which were very lightly tinted. On the right flank, and also over the lumbar vertebræ, were well-defined oval patches darker than the sur-