the anguish of a decaying tooth, and the oppressive annoyances of lumbago and sciatica.

Pain differs in different tissues, by virtue, as we may suppose, of their intimate structure. The serous tissues suffer acutely; when inflamed, they assume a new and exquisite sensitiveness. Mucous membranes and parenchymata, generally, are, on the other hand, liable to dull uneasiness, comparatively speaking. In cerebral affections, we suppose the keen piercing pain to be meningeal; that of the neurine or brain proper, to be heavy and oppressive. So in hepatic inflammations; that of the investing membrane being acute, while the reverse is true when the substance of the liver is attacked. Inflammation of the digestive mucous membrane may proceed almost unfelt to a fatal extent of disorganization, as in typhoid fevers, with their follicular ulcerations, and in chronic dysenteries, and sometimes in gastritis and in enteritis; but if the investing membrane be invaded, as in perforation, or forcibly distended as in colic, or strictured closely as in hernia and intussusception, the agonies of the patient become unendurable. There is a peculiar modification of pain met with under certain circumstances, consisting in alternate inflictions and remissions or intervals, such as give the name to tic douloureux, which may be regarded as the type. These "tics" are commonly considered as characteristic of neuralgia, properly so called; but they are met with in catarrhal inflammation of the frontal sinus and antrum, and in the passage of a calculus from the kidney along the ureter.

The intensity of pain is modified, as I have already said, by the general sensibility of the subject, and the special sensitiveness of the part; it is often regarded as the measure also of the violence of disease, of its rapidity of progress, and the degree of change occasioned, and of the specific malignity of the morbid action. All these points must be attended to. Some persons are nearly insensible to ordinary inflictions, and complain little under any circumstances. There are national or tribal differences, in this respect, as well as individual idiosyncrasies. We would expect a delicate and refined lady to suffer more in any malady than a laborer. Nor would we wonder at the degree of pain in disease of the eye, the mamma, the testis, which are normally sensitive and exquisitely perceptive. We are well aware, too, that the most destructive processes may go on slowly without great uneasiness, comparatively speaking, while any considerable change in a part occurring promptly shall cause severe distress. Lastly, we know that cancer and lupus, gout and rheumatism, angina pectoris and syphilitic nodes, are in their own nature methods of indescribable torture. But we are also familiar with the fact that certain parts, entirely insensitive in their normal state, become, when inflamed in their simplest and least destructive manner, keenly alive to pain of the highest extremity, as has been already noticed in reference to the serous tissues, and is equally true of the membranes investing bones and joints, and some of the glandular and parenchymatous structures. The pungent stitches and keen lancinating stabs that announce the inflammation of the pleura and peritoneum; the agonizing spasm, heat, and laceration that attack the heart when diseased, are but too well known. The brain, which in

its normal condition may be cut or torn to pieces without consciousness, will, under the most transient and slightest disturbances, functional and organic, idiopathic and symptomatic, arising mechanically, as from the movements of a swing or a ship; from sensation, as when the eye is subjected to unaccustomed light; from all forms of mental emotion or intellectual action, ache oppressively and insufferably. The kidney, too, that most obtuse of the viscera, will, in nephritis and nephralgia, be filled with anguish unspeakable. Do such parts acquire, in these new morbid states, a new power or faculty not inherent or previously belonging to them-the faculty of receiving impressions and conveying them, the power of generating nervous force? If so, how is the impression made upon them transmitted to the brain and converted into a sensation? If by nervous cords of communication previously existing, why were the parts previously insensible or unconscious? Or can such cords or nerves exist, capable of sensitive impressions, yet conveying none in health? Or can sensation be aroused independently of them as a local function, without the necessity of communication with a central sensorium? These are questions which seem to be worthy of a more profound investigation than they have yet received.

On the other hand, the absence of pain in some diseases of sensitive parts, and in violent cases of general disease, is among the worst of symptoms, as indicating the subversion of the ordinary nervous sensibility of tissue, or the general impairment of nervous power. This occurs not very unfrequently in certain malignant disorders. A patient dying of yellow fever or typhus will sometimes affirm that he is quite well. It is also met with in cholera and the plague. A degree of it is often evinced by inattention to blisters and sinapisms.

Disordered perceptions, from a morbid condition of the organs of the special senses, give reason for unpleasant inferences. The appearance of motes before the eyes, dimness or confusion of sight, strabismus, vertigo, blindness, betoken, usually, some cerebral derangement. Permanent contraction of the pupil is generally attributed to inflammatory irritation of the brain or its membranes, and is usually coincident with sleeplessness, pervigilium. Dilatation of the pupil is the effect of compression, either vascular or extra vascular, of that organ, and is for the most part attended with drowsiness, stupor, coma, and convulsions. Double vision is a curious phenomenon, occasionally arising in disorders affecting the digestive organs; it is sometimes met with in hysteria. Some vegetable poisons produce it; as a drunken man is proverbially said to see double. When unassociated with strabismus, it is inexplicable; it is most probably occasioned, in a majority of instances, by the unequal or disassociated action of the muscles of the globe of the eye, by which their axes are directed abnormally, and two images are seen instead of one. Tinnitus aurium is, in middle and advanced life, a warning often of undue determination to the encephalon, and of a tendency to apoplexy and palsy.

The chilliness which ushers in so many fevers is a very obscure symptom. Some ascribe it merely to internal determination and congestion; but it bears no relation to them in degree, being often severe in the least dangerous attacks, and slight in the most malignant. I

have seen patients die promptly of congestion without complaining of cold; and, indeed, in cholera, they sometimes complain loudly of heat, while the surface is of icy coldness.

MOTORY SYSTEM.-The muscles and joints are liable to certain specific modes of disorder, resulting also specifically. In rheumatism, the inflammatory process rarely gives rise to purulent effusion; but the symmetry and usefulness of the parts are impaired by induration and permanent tumefaction, irregular and deforming. In gout, there is deposit of earthy matter in the smaller joints, with ulceration. The most familiar and important of the affections of this system, however, are inseparable from derangement of the sensorial functions; such as paralysis, cramp, tonic, and clonic spasm, the great variety of forms and modes of convulsion. Paralysis depends on a suspension or loss of the supply of nervous force or influence derived from the cerebrospinal axis. Pressure upon any portion of the intra-cranial contents will occasion a loss of the motivity or the power of voluntary motion at least, on the opposite side of the body. Injury or disease of any part of the spinal cord, will produce the same palsy of the portion of the body whose nerves of motion arise below that point. Relaxation of sphincters is always an unpleasant symptom.

For the explanation of cramp, spasms, and convulsions, we must refer to the doctrines-best taught and illustrated by Marshall Hallof reflex-motory or diastaltic action, upon which depend so many of the physiological functions of the body. There are several modes of excitation of the morbid reflex movements, such as: 1. The merely impressional, a good example of which we find in the verminal convulsions of young children, and in some obscure and seemingly causeless epilepsies. 2. The sensational; convulsions produced by pain or pleasure, or, as is said to happen, by tickling. 3. Those of combined character, impressional and sensational, as in cramps from local injury, and, perhaps, in trismus and tetanus. 4. The emotional, as when convulsions ensue from violent passion, or chorea from fright. 5. Morbid changes in the brain and spinal marrow. 6. Morbid change in some portion of an incident excito-motor nerve, not necessarily at its extremity, as in the aura of epilepsy.

Cramps and spasms of great diversity connect themselves prominently with diseases of the digestive tube, as in colics and cholera morbus; and in epidemic cholera are well known to be among the most annoying symptoms, not only affecting, as in the above maladies, the muscles of the limbs and trunk, but, probably, the heart itself, thus proving sometimes suddenly fatal. Some of the poisons used as medicines produce severe cramps, by irritating the stomach; antimonials especially.

Hiccup, a diaphragmatic spasm or local convulsion, requires to be noticed here. It attends upon gastric disturbances of varied character, inflammatory and neuropathic. In fever it is a bad symptom, and by protraction, a source of great disturbance and ultimate exhaustion, preventing all rest or repose. Similar spasm, or subsultus of the muscles of the limbs, often precedes death, in fevers especially.

EXCRETORY SYSTEM-MISCELLANEOUS PHENOMENA. 145

EXCRETORY SYSTEM.-The skin and the kidneys are the organs chiefly engaged in the important office of eliminating effete and injurious matter from the system. The skin aids the lungs in getting rid of the carbon from the blood, as well as yields all the elements of perspiration. Its dryness and morbid temperature attract our attention in fevers, and seem to indicate the suspension of its necessary action. The heat which it attains in bad cases of yellow fever and of scarlatina, is very high, ordinarily. In congestive fever, of every kind, it is apt to be cold, as it is, strikingly, in cholera. This would seem to be caused by a paralysis of the minute vessels which carry on the capillary circulation. If long continued, it must be productive of evil, as well as indicative of a very unfavorable condition of the patient. A cool relaxed state of the skin, with profuse clammy perspiration, sometimes attends upon malignant fevers, and is almost always a fatal prognostic. Epidemics designated by this characteristic have happened from time to time. During the fifteenth and sixteenth centuries, there were several such, chiefly affecting the English race, whence their names of Ephemera Britannica, Sudor Anglicanus, or sweating sickness of the English. Contemporary writers, however, show that their exclusiveness was by no means complete; and in recent times some of the departments of France have suffered from similar epidemics, though of far less marked malignity, as the "Suette de l'Oise" of 1821, described by Rayer; that of 1849, observed by Verneuil. The sweat itself undergoes diversified changes in disease, acquiring a yellow color, an acid, or ammoniacal quality, &c. The yellow hue is indicative of the diffusion of bile; acid perspiration is said to belong to rheumatism and catarrh; and ammoniacal exudations to typhus. Many diseases may be known by their specific odors exhaled; smallpox, scarlatina, and I think several others.

The urine affords us, in its appearances, many instructive and important phenomena. Its quality should be noted; the suppression of its excretion is always attended with danger; the elimination of its nitrogenous elements is necessary to health. When very abundant, it is apt to contain sugar, a morbid condition much to be deprecated. In certain diseases of the kidney, granular or fatty degeneration, it exhibits the presence of an undue quantity of albumen. It presents much admixture with epithelial scales, broken down blood globules and pus, in nephrites and oxyluria, with crystals of oxalate of lime. Many other earthy matters are often found in it.

MISCELLANEOUS PHENOMENA.-The physiognomy of disease is often marked and characteristic. He who has once seen the countenance of malignant yellow fever will never forget it, or pass by, without startled attention, a similar aspect. The tense forehead; the muddy eye, suffused and watery; the dark flushed mahogany or bronzed cheek; the anxious expression of mortal terror, or the gloomy sullenness of despair, form a picture deeply impressive, as well as strongly indicative of fatal ailment; nor can we easily mistake the thin clear hectic cheek and bright eye of tubercular phthisis, or the haggard

and sallow aspect of malignant tumors and ulcerations. But it is not possible to go into full detail on this interesting part of my subject.

The "risus sardonicus" of the books is described as a grim sarcastic smile, evincing some painful hallucination of mind. It is said also to be occasioned by inflammation of the stomach and the diaphragm.

The "facies hippocratica" consists in a hollowness and sunken appearance of the eye; the nose being sharp and compressed; fallen temples; the forehead tense and pale; the visage thin and livid. It portends approaching death.

The decubitus of the patient-his posture in bed, is often significant. Confinement to any one position is unfavorable, and should prompt to an examination for its cause; still worse is it when very awkward or constrained, as when he can lie on his back only with his knees drawn up; or when from great weakness he is always sliding down to the most dependent part of the bed. Jactitation, and a restless desire to move from bed to bed or from room to room are very unfavorable-especially in children; towards the close of life, he often seems to see minute objects in the air above him, catching at them, and picking the bedclothes with his nails and fingers.

IRRITATION, CONGESTION, INFLAMMATION.

It is scarcely possible to discuss the simplest proposition in pathology or therapeutics, without repeated allusion to that condition of disease so familiarly known under the term inflammation. Affecting as it does, every tissue; modifying, as it may, every morbid movement in the general system: combining or concurrent, as so frequently happens, with every varied derangement, either of function or structure, it is perpetually before us, demanding our attention, as cause, or consequence, or coincident of almost every malady. And the same thing may be affirmed with equal truth of the general subjects of irritation and congestion so nearly allied, yet so definitely separable. A brief investigation into the nature and history of these states of morbid action is, therefore imperatively demanded of us, and must be entered into as preliminary to a due understanding of the long series of topics which are to engage us.

These words, congestion, irritation, and inflammation, are to be read upon every page of modern pathological discussion; but they have come to be applied, each of them, to so wide a class of phenomena, as scarcely to convey the same precise meaning on any two pages, whether of the same or different writers.

Irritation and inflammation are represented by some authors as identical in nature, though perhaps differing in degree; by others they are hypothetically assumed to affect exclusively separate tissues; and the idea is often suggested of their being contrasted both in mode and form. We cannot avoid, in pursuing our systematic course of inquiry into the history of disease-we cannot, I say, avoid entering within this labyrinth; let us hope that we shall not be utterly lost in its intricacies.