This condition of the vascular system, and of the secreting and intestinal functions, is often combined with a foul and diseased state of the cutaneous surface: and there is perhaps nothing which more completely proves the co-existence of full and gross feeding, with many of its consequences-namely, plethora, diminished or morbid secretion, and a constipated or an irregular state of the alvine evacuations-than the presence of some one of the numerous family of cutaneous eruptions. The co-existence of external eruption with plethora and imperfect secretion and excretion, is often indeed a fortunate circumstance for the patient, inasmuch as the external disorder may, with the greatest propriety, be looked upon as one of the chief means of preventing the particular state of the vascular and secreting organs now insisted upon, from being productive of disease in some internal and vital organ. How often, indeed, do we find, that those who take narrow views of the origin of external diseases, and by local means endeavour to shut up this outlet of disease, which nature opens upon the surface, for the preservation of the individual, in spite of his own imprudencies, are productive of mischief, and thereby endanger the life of the patient when they accomplish their object, by causing the consequences of the states of the system now described to fall upon an internal viscus? In the majority of cases, the most rational and successful treatment does not depend upon external means; or if in any degree they are benefited by them, it is only in a subsidiary manner. The most safe, and at the same time the most efficient mode of cure is, to deplete generally or locally, according to circumstances: to act decidedly and sufficiently upon the great secreting viscera and upon the intestinal secretions and excretions; to promote the cutaneous functions by warm bathing, vapour baths, and every other means usually resorted to for that purpose; and to put the patient upon light and spare diet, with sufficient exercise.

The debility which often accompanies a plethoric state of the system has been a frequent cause of serious and mischievous mistakes on the part both of patient and practitioner. It is generally the necessary result of an engorged or congested state of the vessels, particularly of the veins, and is almost always so combined in the first days of disorder following the impression of the exciting causes of intertropical diseases. It should be looked upon as the earliest symptom of commencing disease; but its cause ought also then to be well understood. There is, doubtless, at the time a depression of the vital and nervous energies; but they are merely kept down by the vascular load which presses upon them, and will

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spring up again as soon as that load is removed. The heart and the blood-vessels, particularly those of the secreting viscera, are engorged beyond their impelling powers, and the sinuses and veins of the brain and lungs are in a similar state,-thus pressing upon the great nervous centre, and thereby diminishing nervous energy, and interrupting those necessary changes which the blood undergoes in the lungs, and which, if not performed fully and healthily, become the source of further disorder, inasmuch as the circulation of imperfectly purified blood throughout the body and in the brain lessens the activity of the nervous influence and the powers of the system. Debility, moreover, co-existing with plethora, and depending upon it, tends also in a most eminent manner to diminish secretion and excretion, and thus to prolong, and even to increase, the plethoric condition from which the debility arises. The lowered energy of the frame is here merely a necessary sign of the plethoric state, although it also assists in continuing and augmenting this Much mischief has consequently arisen from the circumstance of debility being viewed as the only evil, with the removal of which all disorder would cease; and many, acting upon this view, have given tonics and stimulants, have increased the appetites thereby, and thus augmented the original evil, viz. plethora and congestion, until the state of simple fulness of the vascular system, either locally or generally, and the resulting debility, have been converted into inflammation of some important organ, or an attack of fever. How very different would the case have been, had active and repeated purgatives been given with gentle stimulants and sudorifics in the intervals; and the requisite depletions, either generally or locally, according to circumstances, with a properly regulated diet and regimen, been instituted. It is true that in many cases of debility, resulting from vascular fulness, and constituting the early stage of intertropical diseases, the powers of the nervous system require to be roused at the same time that the fulness must be removed; but the means of accomplishing the former must be gentle, and the least calculated to convert congestion into inflammation, a termination to which congestion is extremely prone in warm climates. The debility, therefore, which accompanies a loaded state of the vessels, and characterises the early stages of disease, is not curable by tonics and astringents, but by evacuants and by those medicines which increase secretion and excretion, which establish a regular and active state of the alvine functions, and which increase cutaneous transpiration; and by a regulated diet and due exercise.

Besides the foregoing conditions, characterising incipient disease, and tending to hasten its progress and aggravate its nature, there are others which require remark. The liver, is perhaps, that organ which feels most the effects of full living, deficient exercise, and the consequent plethora of the vascular system, and which evinces the earliest derangement. Attention should therefore be always directed to this viscus, both by the patient himself, and also by his physician; and a careful watch should be kept over the functions and condition of the organ, by observing the frequency and appearance of the stools, the sensations experienced in the region of the viscus at the pit of the stomach and about the right shoulder. The expression and colour of the eye, and appearance of the countenance and skin, should also be observed; and as soon as any circumstances or sensations indicating disorder make their appearance, judicious means should be resorted to, to avert the consequences which neglect would allow infallibly to supervene. Congestions in the substance of the liver, consisting either of blood in the vena portæ or in the hepatic vein, or of bile in the biliary ducts or gallbladder, are amongst the earliest consequences of full living on animal food, in warm climates, and insufficient exercise,―are those states of this organ most frequently supervening during the few days which first elapse after the impression of the exciting causes of disease upon the system,-are always attended with an imperfect and disordered state of this secretion, and almost necessarily are followed, if not judiciously treated, by acute, sub-acute, or chronic inflammations, by bilious diarrhoea or dysentery, or by bilious remittent and continued fevers, as the nature of the predisposition of the individual, or the exciting or co-operating causes, may determine. The bad effects of resorting to stimulants or tonics, in this condition of the biliary apparatus, must be apparent; and the ill consequences now enumerated are more readily brought about by such means. On the other hand, those remedies which unload the liver, either by moderately withdrawing blood, or by eliciting secretion, and by promoting the discharge of such secretions as oppress the parts in which they have accumulated, or by occasioning a flow of the circulation to the surface of the body, are the measures which will, together with spare or moderate diet and due exercise, most certainly restore the healthy functions of the organ, and arrest the impending disorder. What the particular means are, which should be adopted in order to fulfil these intentions, will be stated at length in the sequel. It sometimes, however, happens, owing to peculiar states of the organ threatened with

disease, that the best means which can be used, in order to unload the vascular system when it is greatly oppressed, are followed by increased action, to an extent which threatens the worst conse. quences but this cannot be prevented by the adoption of any other measures better calculated to prevent it, than a steady perseverance in their employment, directing them, combining them, and varying them, according to the particular circumstances in which we are called upon to employ them. Reaction will sometimes arise in the system generally, and in that organ particularly which has been more immediately oppressed, soon after the load has been removed. But such reaction will be less detrimental when it supervenes upon the judicious plan of diminishing vascular fulness, and increasing the whole circle of the secretions and excretions, than when induced by the imprudent exhibition of heating stimulants and tonics. The former will merely bring about a salutary reaction, which, if not guarded against, may indeed lead to inflammation of the predisposed organ; the latter plan will more certainly induce inflammatory action, which will be less readily controlled, and will more rapidly run into abscess, and thus actually occasion what in the former instance we have only to guard against, or at most to dread.

The state of the tongue is one of the most sure criteria by which our judgment is guided respecting the condition of the abdominal viscera and the commencement of disease. When it is foul or loaded, it may then be inferred that the alvine secretions and evacuations are not adequate to the wants of the system, and that they require to be increased, in order to avert impending disorder. It is not sufficient that the tongue shall appear clean over its more anterior surface, but that it shall also be so at its base. It very frequently will be observed, at the commencement of febrile and inflammatory complaints, that, in addition to a foul state of the tongue, the fauces are red and fiery, and the uvula relaxed. These appearances are not only indicative of threatened disorder, but also require the employment of alvine evacuation. In conjunction with the foregoing states, the papillæ on the surface of the tongue are often early in disorder, large, prominent, and excited, and the surface white. This particular condition is frequently connected with a plethoric state of the vascular system and general excitement, and, in the majority of instances, indicates the propriety of general and local evacuations. Not unfrequently the tongue is darkcoloured and of brown appearance. This is usual at the commencement, and indeed through the progress, of diseases where

great prostration of the energies of the system exists, and which are characterised by congestions, particularly in the liver, brain, and lungs, and by a previously neglected state of the alvine functions. Early in disease, also, the tongue is often covered with a slimy mucous coating, which is generally indicative of a foul and loaded state of the mucous surfaces throughout the intestinal canal. This appearance most obviously requires the institution of active purgation, which in many cases should be preceded by the exhibition of an emetic, particularly in cases of approaching fever, and before the febrile excitement is fully formed. There are other states of the tongue and fauces which require attention, as indicating the commencement and progress of disease,-such as, dryness of the tongue and pharynx, redness of these parts, particularly the edges of the tongue: but these mark more frequently the advancement of disorder, and will be noticed more appropriately hereafter.

The state of the pulse, as indicating the heart's action, and the general condition of the vascular system, is deserving of the most intimate attention, in the early stages of disease, as one of the best means of ascertaining the existence of plethora, of congestion, and of several of the consequences to which they lead. When the pulse is slower than natural, our attention is at once directed to the state of the functions more immediately dependent upon the brain. But although the pulse is often slow for the first few days after the causes of fever have operated upon the system, and before the febrile symptons are developed, yet the slowness in such cases seldom is the result of oppression of the brain, but rather of deficient energy of the nervous and vascular systems. At the same time that the pulse is slow during the premonitory stage of fever and inflammatory diseases, it is also then often irregular, and even intermittent, and such is more frequently the case when the commencement of the disease is attended with congestion or impeded circulation in the vessels of the liver. An irregular and intermittent state of the pulse is often met with in individuals who make little or no complaint, and whose only disorder is a plethoric condition of the vascular system and slight signs of derangement about the biliary organs. When this state of the pulse is thus noticed, such curative means should be resorted to as are calculated to meet the exigencies of the case. Generally the pulse, at the same time that it is irregular and intermittent, and particularly when the intermissions are only occasional, and not depending upon organic disorder about the valves of the heart, is also obviously oppressed. This latter state of the pulse should, perhaps, more than any other,