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under the stimulus of light. He is slightly deaf, but his intelligence is unimpaired. He sleeps badly owing to pain in the loins, which he says is more intense by night than by day. There is frequent uneasiness on pressure over the epigastrium and one or other hypochondrium, and always great tenderness on pressure, and severe pain on percussion, over several of the lower dorsal and upper lumbar vertebræ; but he has neither difficulty in micturition, nor yet pain, numbness, nor formication in the lower limbs. The pulse varies from 80 to 100, is exceedingly feeble even when the patient is in a recumbent posture, and becomes almost imperceptible when he is raised up in bed. The percussion resonance over the anterior and upper part of the chest is slightly deficient, and the respiration is tubular below the right clavicle and harsh below the left. There is also increased vocal vibration on the right side. The percussion resonance is somewhat deficient over the base of the right lung posteriorly, and the respiration is somewhat harsh over the back of both lungs, but there are no moist sounds. The patient has slight cough, and is subject to catarrh. The heart’s impulse, though feeble, is comparatively stronger than the arterial pulse, and the sounds are healthy.
The history and progress of this case render it, as I have said, a typical example of Addison’s disease; for, although it is true that, besides the caries of the vertebræ to which I have already alluded, there exists apparently some slight inactive pulmonary affection, I need not tell you that neither of these would account for the peculiar constitutional symptoms and discoloration of skin which I have described, and which present, in an unusually striking and fully developed form, all the features recognised as belonging to this remarkable malady.
As regards the assumed vertebral disease, I am led to diagnose it, both by the local pain and tenderness in the lumbar vertebræ, and also by the sense of constriction around the abdomen and the difficulty in stretching out the legs. Lumbar pain and obscure pain on percussion over the loins are indeed common in this disease; but here the pain is more severe and better defined than in simple cases of Addison’s disease, and is accompanied by the other symptoms I have enumerated, which are by no means usual features. I have no doubt that the injury to the back, received so nearly four years ago, produced some mischief which set up slowly progressive inflammation, with, as I have said, probably caries of the bone and formation of an abscess; and, if we should hereafter have the opportunity of examining the state of these parts, I expect that we shall find the cellular tissue around the