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rounding skin, corresponding with the sites of blisters which had been applied, some months previously, for the relief of pain in those parts. The knuckles likewise were more deeply coloured than the rest of the hands. But for the thoroughly English cast of the man’s features, the peculiar tinge of discoloration might have easily caused him to be mistaken for a person belonging to one of the darker races of mankind. The white pearly hue of the conjunctivæ contrasted strongly with the dusky complexion; and this is a peculiarity almost invariably noted in genuine cases of this disease. Upon the face were several small black specks, which might have passed for congenital marks had not the patient’s wife assured me that they had appeared since the commencement of the illness; a statement corroborated by the fact that they have manifestly darkened and increased in size, if not in number, since he came under observation. Lastly, there was a dark stain upon the right edge of the tongue, near the tip, and the lips and buccal mucous membrane were mottled with brownish discoloration.
In this description, noted nearly a month ago, I have not found it necessary to make any alteration; for the only change that has occurred in the discoloration is the general deepening of the hue, characteristic of the later stages of the disease.
The patient has complained more or less, ever since his admission, of pain in the loins and right side, and of occasional pain in one or other hypochondrium, but most frequently in the right. He also complains of difficulty in stretching out his legs, when he has been lying for some time on his back with his feet resting on the bed and his knees raised; and he says that this difficulty is caused by a sense of tightness, as though the extension of the legs were restrained by cords situated between the flanks and the groin. He has, moreover, a feeling of weakness in the back, as if it were broken or had a loose joint, and a sense of constriction round the lower part of the abdomen, which seems to start from the weak and painful portion of the spine. He rarely now attempts to leave his bed, but, when he does so, suffers from vertigo with dimness of sight and sickness, accompanied by such extreme prostration that he is afraid of falling, and when he sits down in a chair can scarcely rise again. He has an anxious, exhausted expression of countenance, which is increased by sitting up in bed; is breathless on the slightest exertion, and has a tendency to yawn, especially at nights; has frequent retchings, and rarely passes a day without vomiting. His appetite is bad; bowels confined, the fæces being dark coloured and dry; urine normal. The pupils of his eyes are large, and act sluggishly