adopted; which after all is the end to which accurate diagnosis is the means. A copper-coloured spot on the forehead will often clear up the nature of a very puzzling form of hemiplegia in a young person, just as will a tubercle on the iris; a scar at the corner of the mouth will reveal the secret of a case of malnutrition in a child which has hitherto resisted all remedial measures, but which becomes suddenly tractable, when mercury is added to the chalybeate; a little puffiness under the lower eyelid may indicate the chronic Bright's disease underlying the bronchitis which is the prominent trouble for which the doctor is consulted; the hue of the skin will often furnish the clue to the malarial neuralgia, which is very troublesome; just as a tortuous visiblypulsating temporal artery will tell in all but articulate language of the gouty heart and its associated conditions. These are a few instances of what the eye can do in the way of diagnosis; it gives the direction to physical examination, and guides the line of treatment when otherwise a trackless waste appears to lie before the puzzled youthful therapeutist. It is all very well to treat symptoms; but in the numerous maladies which are but the special manifestation of the general condition, the treatment of the general condition is that of the special manifestation, as is so well seen in gouty and syphilitic affections. A coppertinted blush on a baby's bottom may throw a flood of light upon the otherwise obscure lung mischief in its father, and furthermore suggest the appropriate specific treatment.

At present the remarks apply to a patient as seen with his or her clothes on; at a later period something will be said about patients when first seen in bed. When a patient walks into the consulting room, whether private or at the hospital, or into the general practitioner's surgery, the first thing to be done is to look at him. Look him or her carefully over; and my young friend the reader, if you will only do this sufficiently carefully, you will soon be surprised to find how much you can see. The more the eye learns to see, the more it can see, and will see. Because you cannot see all at first, you must not be cast down. A juggler will keep six balls in the air at once: you see him do it, but that will not enable you at once to do the same. As he

learnt to do it with much patience, long and determined per. severance, so must you, if you wish to do it. There is nothing worth knowing that is got without trouble. So it is with the education of the eye. Robert Houdin, the famous French conjuror, set himself to see how much he could note of the contents of different tradesmen's dressed windows in walking past them. In a little time he could note an almost incredible number of objects in an apparently brief passing glance. We all remember the interesting child's story of 'Eyes and no Eyes.' The educa tion of the eye is most important to a medical man: it cannot be forgotten or mislaid, like an instrument; it is of incalculable value when the patient is unconscious, or deaf; or a foreigner whose language the doctor does not know, and who does not speak the doctor's language. The careful education of the eye is invaluable in all these cases. Further, it spares much waste of labour often, and puts the practitioner on the right scent in many obscure cases. Especially is the information so furnished valuable as to certain diathetic (inherited) and cachectic (acquired) conditions, which underlie the malady of which the patient mainly complains. The reader will see, as the matter is unfolded, that the semeia we note tell chiefly of gout, struma, syphilis, and anæmia, all underlying conditions of the greatest moment in treatment; the hue of the skin in jaundice and Addison's disease being indeed the chief indication of the malady. The physiognomy of Graves's or Basedow's disease forms the diagnosis almost. The blurred outlines of some faces tell of mitral disease, just as surely as the pallor of other faces tells of the large white kidney. All this, when learnt, is of the greatest service every day in practice. Froude says truly enough: "The knowledge which a man can use is the only real knowledge; the only knowledge which possesses growth and vitality and converts itself into practical power. The rest hangs like dust about the brain, or dries like rain-drops off the stones.' Some varieties of information may be safely left in the library, and it is quite enough for the busy practitioner to know where to find it when he wants it; but there is other information which is required several times every day, and of such nature is

this which I am now essaying to furnish to the student-with how much success it would not be judicious to say. The subject has not been systematically handled before.

The late Professor Laycock, of Edinburgh, was the first person to insist on 'physiognomical diagnosis,' and on diatheses and their indications; Jonathan Hutchinson has told us much about the teeth; the late Marshall Hall wrote an excellent article on 'Symptomatology' in the 'Cyclopædia of Practical Medicine;' S. Wilks has written on 'Temperaments;' Professor Austin Flint has an excellent section on the subject in his 'Clinical Medicine;' Dr. Southey, of St. Bartholomew's Hospital, has written a series of articles in the Lancet, Vol. I., 1878, on 'Diatheses;' and Dr. Finlayson, of Glasgow, has written on the subject in his 'Clinical Manual for the Study of Medical Cases;' and I myself have written on the subject in 'The Maintenance of Health,' and in 'The Practitioner's Handbook of Treatment, or the Principles of Therapeutics.' So far as I know, the list given comprises the bulk of what has been written on the subject. Lavater's work was related to physiognomy, and so are the numerous phrenological works, and not to physical indications. Professor Laycock's work stands out in bold relief, and is by far the most important contribution on the subject. His 'Medical Observation and Research' ought to be in every student's hands, and before long will be so; for its practical value is much greater than the student at first sight will be led to suppose. Perhaps what is said here will stimulate him to peruse Dr. Laycock's writings for himself, especially the lectures in the first half of 1862 in the Medical Times and Gazette.

Making all allowances, then, for the immaturity of the subject, and remembering that it is but in its early infancy, the plunge must be essayed.

GENERAL APPEARANCE.-The first object to note is the general appearance of the patient; which tells the sex certainly, the age approximately. If obese, there is no question of wasting disease; if florid, there is no anæmia; if pallid, there is no vascular fulness; if emaciated, then phthisis, dyspepsia, diarrhoea, cancer, or female troubles are probably present. There

may be dropsy present, as seen in the swollen feet or bloated features ; or if it be abdominal, the unfastened gown or gaping waistcoat tell us quickly in which direction to pursue our inquiries. The general appearance will tell us whether the patient is fairly well generally, whether broken down by disease, or how far enfeebled-will, indeed, tell us rudely how 'ill' the patient is, and direct our examination.

THE ATTITUDE.—The attitude is often suggestive. The patient may be bowed by sheer debility, or by abdominal pain, or spinal disease; or bent to one side, in order to give some part rest, as in pleurisy, when the patient bends to the affected side, so as to lessen the friction of the two inflamed serous surfaces. Then the tout ensemble is often most instructive. There is the pale, thin, cast-down and unhappy-looking young woman with dyspepsia, and trouble of various kinds in her reproductive organs; there is the panting patient with raised shoulders, who has chronic bronchitis and emphysema simply written legibly upon the figure; there are the liniments of struma as distinct as a written page, especially in children; the snuffles of a syphilitic baby are pathognomonic! It is well for the student to study types, or well-marked varieties of disease, which spares much time, in out-patient practice especially; as, once the type wellrecognised, it is easy to find out the peculiarities of the individual patient. The eye learns a certain type of person with persisting lithiasis, and this will often guide one safely through a perfect maze of symptoms and statements of subjective sensations otherwise unintelligible. This is very common among elderly patients; and is as marked as that of the anæmic young woman. There is a certain attitude and carriage which tells one, in no doubtful accents, that there is pulmonary phthisis, and leads one to examine the patient's chest without more ado. Then the bearing is very different A consumptive is often abnormally acute, and will note a piece of paper on the floor under the table, and dive for it before one is well aware that he is in the room; whereas patients with chronic bronchitis and emphysema, or with fatty degeneration of the heart, appear bewildered and stupid. Then in chorea the movements make the diagnosis;

sometimes, however, the arm is quiet, and looks as if paralysed, and so the practitioner is set off on a wrong scent. In paralysis agitans the movements of the forearm are indicative of the changes in the nervous system. Then there is tremor, which is well seen in anæmic women who take tea to excess. It is also well marked in chronic alcoholism, when the tremor of the different muscles, and the unsteadiness of the carriage, often tell what the patient endeavours hard to conceal.

PHYSIOGNOMY.-Then the physiognomy is not without value. There is the bowed-down look of cerebral anæmia; the depression of melancholia; the excitement of mania; the elation of general paralysis; and the worn look of mental worry or anxiety are all visible enough. There are the general evidences of nutrition and a well-fed nervous system, usually with a full pulse; and the muscular listlessness of malnutrition, and a soft, compressible pulse.

PARALYSIS.-This may be partial-the hand and arm being fixed-the remains of a whilom hemiplegia. This condition, however, may be simulated by some accident or affection of the bones; or the patient may have slept with the arm over the back of a chair, as men when drunk are apt to do, and the pressure on the brachial nerve be the cause of the paralysis.

Then there are the differences in gait, attitude, and walk produced by different forms of nervous disease and osseous changes. There is, first, the walk of ordinary hemiplegia; where the patient circumducts the affected leg, trailing the shoe-toe on the ground, sometimes the outside, sometimes the inside, so that the toe of the shoe becomes irregularly worn. Often, the shoulder of the opposite side is thrown outwards at each step, so as to tilt up the pelvis on the affected side, and thus make it easier to circumduct the leg. Here the knee action is lost. Often the arm of the affected side hangs down rigid, with the fingers closed. In paraplegia the feet are not lifted up, but shuffled along the ground; in advanced cases there is never a distinct interval betwixt the feet, and each attempt at a step does not reach the length of the shoe. In hysterical paralysis the feet are dragged along, usually one more markedly than the other; while the patient is apt to