b. Aspect and expression are to be studied in their relation to the physiognomy of disease, of which they are most important elements. The former especially points to physical conditions; the latter the sensations of the patient, as revealed by the fea tures. They are both of much value, but nothing further can be done here than to indicate the direction in which they must be studied.
Aspect tells of a general state--cacheitia, the existence of tubercle, scro fula, anaemia, &c., that which accompanies cancer is frequently called malig nant: it may be that of ill-ventilated blood, of dissipation, or of exhaustion.
Expression, on the other hand, has more distinct reference to the nervous system. It may be tranquil, or indicate *n or anxiety; it may be listless, depressed, wandering, unmeaning, excit4 or maniacaL But further, it is of use as a test of the reality of complaints made by the patient, or, at least, of their exaggeration; and the rapid transition from smiles to tears in the hys terical female is often a valuable sign.
Both are to be noted with as much precision as possible, because they have an important bearing on the particular form which any malady has taken or may The mind will naturally revert to them in confirmation of an opinion formed on other grounds, or as a cause for modifying a conclusion which other symptoms might seem to warrant; and the observant practi tioner will always let them have their due weight in the treatment of the case. It is scarcely necessary here to remark that, of the two classes, those having reference to aspect are less liable to mislead than those derived from expression ; the former belong to objective, the latter are in great measure subjective phenomena.
c. Alterations in color are in some respects more specifically diagnostic ; sometimes inseparable from aspect, as the waxy complexion of chlorosis, the pale puffiness of advanced albuminuria, the sallow hue of malignant disease, or the particular blueness of the nose and lips with dark-colored unaiirated blood ; sometimes distinct from it, as the yellowness of jaundice, the muddi ness of enlarged spleen, or the blueness of Asiatic cholera, and the eruptions of measles and scarlatina.
Local changes may result from a general state, as in scurvy or purport', and the blue line of colica pictonum, or the specific color of syphilitic erup tions ; from one partly local, partly general, in erysipelas or erythema, and the red patches over the joints in acute rheumatism or gout; or from a purely local state, as in the formation of abscess.
Cutaneous diseases are all more or less associated with local changes of color, which must be particularised when this class of diseases comes before us.
§ 3. The fact that a patient is first seen in bed, or going about his usual business, serves to give a vague impression of greater or less severity of the attack, which may turn out to be very false.
a. Position in bed is to be considered with reference to its being horizontal, or more or less erect ; to the position of the limbs, whether flexed or extended, fixed in one position or moved freely about ; to the quietude or restlessness of the patient in lying, or the maintenance of a constant posture, whether on the back or on one side. These circumstances have reference chiefly to the state of the respiration, or to sensations of pain, which are aggravated by one position and relieved by another.
In many instances the breathing is felt to be much easier when the head is elevated, and occasionally the horizontal position cannot be tolerated at all ; to this last the name of orthopnms (erect breathing) is frequently applied. It is independent of frequency of respiration, which may attain to three times its average rate without any consciousness of dyspnara, and while the patient prefers lying perfectly flat in bed ; but it is generally accompanied by a certain degree of hurry of the breathing. Such a distinction is often to be seen in the effects of disease of the heart or aorta upon the respiration, as compared with those of lung disease in phthisis and pneumonia. Occasionally the frea.
dom of breathing is more interfered with by inclining to one side than the other, and this generally when one lung 'is from any cause obstructed, and free movement of the ribs on the opposite side is sought to be obtained by elevat ing the shoulder ; this is seen in cases of extensive consolidation of one lung or effusion into one pleural cavity. But, on the other hand, pain on the dis eased side may be aggravated by such a position, and therefore this indication is by no means a certain one.