no uniform connection with emaciation or atrophy. Consumptive patients are not always pale. According to Andral, the composition of the blood is altered in anæmia by "the diminution of its globular element; occasionally, however, we see the albumen and the fibrin of the serum diminish also with the globules." It usually attends or produces dropsies. It affects girls of feeble constitution, at and just after puberty, when the changes of that critical period have been imperfectly gone through. The elaboration of blood is a complicated and delicate process, which, if interrupted or much impeded, is apt to be abandoned altogether by the organs concerned, as respiration when for a time suppressed or suspended.

Hyperaemia, or mere general superabundance of blood, I do not know how to recognize, and can scarcely regard as possible; notwithstanding the views expressed by some pathologists, who seem disposed to identify it with plethora. Local hyperæmia, indeed, is one of the most familiar symptoms of disease, being, of course, met with in congestions of every source and character, active or passive, irritative or inflammatory. But I am not aware of any test by which a "general redundance" of blood can be shown to exist, or any circumstances from which it can logically be inferred. There is no standard by which we can measure or even approach the measurement of a normal or regular proportion of sanguineous fluid in the vessels of a sound and healthy body; we cannot then pronounce upon the limit of such quantity. We know when any organ or organs are oppressed or deranged by undue determination and accumulation of blood; but we never find all the organs thus oppressed at the same time.

Plethora, a term perpetually recurring, but ill defined, is always, I think, to be used relatively rather than absolutely; implying a loss of harmony, a want of proportion between the condition, the tone of the heart and vessels, and the quantity or quality of the blood. "The blood of plethoric persons," says Andral, " differs from ordinary blood in the greater quantity of globules, and the much less quantity of water it contains." On the contrary, Becquerel and Rodier announce as "an incontrovertible fact the existence of plethora in cases where there is a diminution of the globules," and attribute it to simple "increase in the mass of blood.". Plethora was looked on by the older writers as of several varieties; they recognized plethora ad molem, ad spatium, ad volumen, ad vires. The first, ad molem, contemplated the absolute superabundance of the vital fluid; the general hyperæmia of which I have already spoken. Plethora ad spatium expressed the quantity in reference to the contracted state of the vessels; a condition which, I think, may be shown to exist as a part of the early history of congestive and malignant fevers, perhaps, indeed, of every febrile rigor. Plethora ad volumen regards the supposed expansion of the blood itself; and, indeed, it is by some such effect on the actual mass, subject as it must be to the universal law of increase of volume with elevation of temperature, that we shall most easily account for the common headaches of spring and early summer, apoplexy and insolation, and the frequent hemorrhages of that season. Plethora ad vires. denotes the condition of the system in which the mass of the fluids

and the force of circulation are disproportioned to the tone of the vessels containing them, or to their power of resisting the impulse incessantly acting upon them. These distinctions seem to be natural enough, and we may keep them still in view with advantage; nor do I see any difficulty in admitting a combination of the three last as constituting a not rare and very forcible predisposition to a great variety of forms of disease.

2. Of the DIGESTIVE SYSTEM, the disorders are shown: 1. By alterations in the condition of those parts which we can palpably examine; 2. By derangements of the function manifested in any obvious way; 3. By uneasiness, pain, discomfort, referable to any of the organs concerned in the function; and 4. By changes in the results of action of these organs, diseased secretions and excretions.

1. The tongue and mouth exhibit the influence of almost all forms of disease, and of fevers especially, undergoing alterations of appearance, supposed to be correspondent with and indicative of the morbid impressions made upon the interior portions of the tube. I know that this correspondence is denied to exist by Louis, the most minute of medical notemakers, whose patient industry is worthy of all praise and imitation. But I cannot help thinking that he has laid too much stress upon exceptions and anomalies, and must adhere still to the opinions founded upon a long experience. I am pleased to find this view confirmed by the sagacious and philosophical Holland who says: "Among the external indices of change within the body, the tongue is, perhaps, the most valuable. Scarcely can the pulse compare with it in the extent, variety, and accuracy of these indications, which are not limited to disorders of the membranes and secretions of the alimentary canal, or to the presence of fever in its various forms, but extend also to the various states of the nervous power, the sensibility, the voluntary powers, and even the more intellectual functions. The physician cannot better study any set of signs, than those afforded by the tongue, the palate, and the fauces; the terminating portions of that inner surface, along which so many actions are carried on, both of health and disease. The observations of Dr. Beaumont on the precise and uniform relation of the tongue and stomach in the case of St. Martin might justify this remark, were it needful to seek any other authority than that of daily experience."

The tongue is cold in bad cases of cholera. It is dry in typhoid fevers, and such as present a paramount derangement of the sensorial system. When the gastric and intestinal secretions are defective from inflammatory irritation, it assumes a fiery redness, and is pointed, and hard, and dry. When these secretions are abundant and vitiated, it becomes soft and swollen, and a nauseous and offensive mucus is effused in the mouth. When the mucous tissue or its glands have ulcerated, it also ulcerates or is aphthous. Hepatic affections cause it to put on a yellowish fur, and to be affected with a bitter taste. The mere color of the surface, which grows darker as danger increases, is a symptom of importance in the fevers of our climate. When covered with a black sordes, which also gathers upon the teeth, and adheres to

the lining membrane of the mouth, we infer the state of the patient to be truly critical. This sordes, though first seen on the teeth and gums, is said also to be exuded upon the internal surface of the bronchi, and of the pulmonary cells, impeding of necessity, the results of the function of respiration, and preventing the proper changes of the blood, which hence is always black in typhus.

We account for these and all other similar facts, on the principle of direct and continuous sympathy; identity and continuity of structure, and community of function connect the internal seats of morbid action with the external extremities of the tissues affected, and give rise to similar disturbance from the application to any part of a whole so indissolubly connected, of an agent capable of an injurious impression. By exploration of the abdomen, we also arrive often at inferences greatly instructive, and indeed essential to a correct intelligence of the case before us. We distinguish by resonance upon percussion, such enlargements as depend on air within; by fluctuation, the fluid effusions; by pulsation, the vascular, as in aneurisms; and by the resistance, and weight, and position, the physconiæ or visceral enlargements of spleen, liver, &c., and other tensions and swellings.

2. Derangement of the digestive functions arises sympathetically in a great many forms of disease of which it is not essentially a part. It shows itself in the first instance by anorexia, or loss of appetite. Next, there is a sense of oppression, aggravated into nausea, and vomiting, which seems excited to rid the stomach of some load. We are not, however, always to infer the presence in that organ of any noxious matter from these disturbances-a mistake which has done much harm. They occur under very varied circumstances; being produced not only by irritation and inflammation of the mucous coat itself, but also by determination to the brain-as in approaching apoplexy, and in sea-sickness, and some headaches. In fever, this state of the stomach is very general, and arises from both the conditions above alluded to-the irritation of the abdominal viscera, and the disorder of the cerebral and sensorial system.

3. The digestive organs, unconscious and insensitive in health, become, when diseased, or when deranged sympathetically, susceptible of many forms and degrees of pain and discomfort. Some of these seem purely neuralgic, and are consistent, as in dyspepsia, with the performance, somewhat impaired perhaps, of their important functions. Others arise from inflammation, or from distension, pneumatosis, or from the pressure of the neighboring parts enlarged or indurated.

4. The results of morbid action, as shown by the changed appearances of the secretions and excretions, always demand our attention. Matters vomited are of exceedingly varied aspects. Some of them seem capricious or insiguificant; others are characteristic, as produced by, or associated with, certain diseased states or known lesions. Of the first, are the foul and porraceous matters thrown up in the first stages of fever, and in some indigestions; bitter, oily, rancid, acid, and alkaline; of strange hues-white, green, brown, and blue. Of the characteristic, we may mention the black vomit, so often spoken of as diagnostic of yellow fever. To this pestilence, however, it does not

belong exclusively, although it occurs so generally in its fatal progress that it may fairly be regarded as one among its regular symptoms. It may and does happen in fevers of every type, and in many other maladies as enteritis and gastritis. It has been met with in the unterrifying vomitings of pregnancy, and comes on before death in the lamentable cases of rupture and laceration of the uterus. The rice-water discharges of cholera, generally considered albuminous, are almost peculiar to that horrid pestilence. Dysenteries and diarrhoeas are marked by certain well-known qualities of the alvine evacuations, which it is not necessary here to describe.

3. RESPIRATORY SYSTEM.-Dyspnoea may be continuous or paroxysmal; may arise from mechanical impediment, or spasm, or disorganization, or muscular debility. The use of the word orthopnoea indicates that the difficulty of breathing is increased in a recumbent, and relieved more or less in the erect posture. This is assumed to depend upon a movable effusion, but incorrectly; for it is also met with in asthma and other diseased states, in which no fluid is imagined to be effused.

Special slowness or hurry of breathing in fevers, especially if protracted, should be carefully noted. The first may indicate oppression of the brain, or exhaustion of the vital energies; by the latter we are led to fear the occurrence of pulmonary congestions, or of such changes in the condition of the pulmonary mucous surface, as shall prevent the due action of the air upon the blood. This happens in typhoid cases, where the bronchial tubes are coated with a dark, tenacious sordes.

Yawning and heavy sighing betoken an imperfect circulation through the lungs. They attend upon the cold stage of all fevers, even the slightest intermittents, but mark the congestive forms so often fatal.

Cough, and the expectoration which it effects, are often characteristic. The sound of cough shows laryngeal disease-croup in the child, and phthisis in the adult. Tubercular cells, pus, offensive sanies, rust-colored mucus, show inflammation in its various modes, and the presence of morbid deposition, and must be observed attentively. The physical exploration of the thorax by auscultation, mediate and immediate, percussion, and other methods, constitute a very important addition to the modern course of medical study, which will require to be frequently referred to.

4. SENSORIAL SYSTEM.-Every morbid alteration of structure or of function implies pain, with exceptions so few that the rule may be laid down unhesitatingly. Pain, however, varies much, both in kind and degree, not only in relation to the intensity of the disease with which it is connected, but also both to the general susceptibility of the patient and to the peculiar sensibility of the part in which it is seated. All these circumstances must be taken into consideration, before we proceed to deduce any inferences either from the nature or amount of pain suffered. Nothing can be more embarrassing than the complaints often made to us of extreme pain, when the closest examination does not de

tect any cause adequate to account for it. This is the history of many obscure cases of neuralgia. We are apt, in dealing with certain classes of patients, to become uncharitable, and to suspect soldiers, sailors, convicts, and servants of malingering, when we find no objective signs of corresponding disease, and are called on to listen to loud and long descriptions of suffering. Let us be cautious here. It is possible that pain may exist, not as a symptom, sign, or manifestation of disease, but as a primary, idiopathic, insulated morbid condition. An instance, apparently of this sort, is given us on no less authority than that of Foderé, who tells us the story of a young man dying under his care, as he alleges and affirms, of pain, and pain only. "After his death," says Foderé, "I anxiously explored, by means of the scalpel, all the seats of the pains, but could discover nothing in the muscles, the nerves, or the viscera; and I was forced to believe that life had been destroyed by the long continuance of the pains."

Pain generally points out the locality of disease; a nice and patient examination should always be made of the part to which it is referred. Yet the exceptions to this law are numerous, and some of them highly impressive. We have a pain at the top of the shoulder when the liver is inflamed, so uniformly that I have never met with a case in which it was absent; though I am aware that both Stokes and Andral-names always to be mentioned with respect-deny its regular coincidence. When the hip joint is diseased, the pain is often in the knee. There is severe pain in the urethra and in the testicle when a calculus is present in the kidney, or passing from it through the ureter. A gall-stone in the biliary duct excites harsh pain in the stomach. Many intestinal disorders afflict children with itching of the nostrils, and adults with tenesmus and pruritus. Verminous and hepatic irritation sometimes excite a harassing uneasiness in the larynx and trachea, with ceaseless and violent cough. A nerve, affected at any point of its course, may convey its peculiar sensation, ascribed always by the mind, with misled consciousness, to its peripheral extremity, this being the normal seat of its characteristic sensibility. Hence traumatic neuralgia, in which those who have undergone amputation feel pain in the fingers and toes. Of these misplacements of pain, sympathetic and otherwise, experience has, in many instances, taught us the significance; in many others, they are still obscure and ill understood.

Pain is more or less modified by the nature of its cause and origin, and thus becomes indicative of the kind of morbid change upon which it depends; such as inflammation, distension, compression, spasm, or cramp. To this law, also, of the relevancy of the modes of pain to their causes there are many exceptions. Acid in the stomach will create a sense of heat, heartburn, as vehement as gastritis; sharp, lancinating pangs occur in cancer, fissures of the sphincter ani, and some glandular ailments, as irritable breast and testis, as well as in distension from colic; the flashes of electrical agony which startle the neuralgic, belong promiscuously to a large class of disorders, mechanical as in calculous affections, inflammatory as in gout, and undefined; and aching is a term applied alike to the ineffable torments of cephalalgia,