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met with from shrewd and sensible observers of symptoms alone, who have often had occasion to conduct through many years of safety individuals who had been stethoscopically condemned to an early death.
There is frequently not only a want of correspondence between symptoms and physical signs, but contradictions between these two kinds of evidence will be found so striking as to weaken the confidence of the unreflecting in either of them. The patient with cavity, who is therefore physically in the last stage of phthisis, may preserve for years a fair degree of health, and in colour, flesh, and appearance forbid even the supposition of disease ; while others in the first stage (by auscultation) succumb to the constitutional disorder attending an extensive tubercular deposit, and the blood depravation which has been its cause. Individuals die in all stages of phthisis, and with infinite variety as to the extent of lung disease: they also perish with much variation as to the mode, and therefore as to the existing symptoms, the progress of few of such cases when watched with a discerning eye being exactly alike. The physical signs and the concurrent systemic events often · advance pari passu, but by no means invariably; the one set of phenomena does not necessarily imply the other; and while neither should be neglected or overlooked, it becomes the highest office of the physician to regard and carefully balance the evidences to be derived from both sources. The one cannot be weighed against the other, but the neglect of either would be unphilosophical. The man who in the present day pretends to despise physical aids, is in darkness while surrounded by light; the auscultator who condemns his patient from certain sounds in his lungs, and neglects to regard the rounded limbs and rosy colour, the tranquil pulse and unimpaired digestion, by which the same individual evidences a healthy sanguification on which the system may draw for its supplies for years to come,
is in the position of one who declares that the building CHAP. is falling because a wintry storm has displaced some bricks from his roof.
That a disease whose earliest organic manifestations and latest destructive results are most prominently seen in the lung should be capable of detection by that inost certain kind of evidence which appeals to our senses, is indeed of great value. To measure the exient and appreciate the stage of mischief in the pulmonary structure was a great achievement of the preceding generation of observers; but in our later refinements and additions to physical knowledge we must beware of attaching to it too high or too exclusive a value. Vital phenomena are of primary importance; systemic disorder, waste of tissue, blood depravation, kill the patient, who in rare cases only can be said to have perished from destruction of pulmonary structure, as an analogous amount of local disease is often tolerated for years in other individuals.
For merely diagnostic purposes we are now possessed of means and knowledge which, applied by competent observers, are sufficient to establish the nature of our case, and the extent of existing local mischief, the negative evidence also derived from physical signs being very satisfactory and valuable.
Diagnosis, however, whose perfection is so desirable to the scientific observer, and which must be established as the basis of his treatment, falls very far short of the requirements of the patient from his medical attendant ; and if the individual himself is satisfied that the nature and extent of his disease is known, and its treatment scientifically arranged, his friends have a reserve of questions to be answered, and appeal to the physician for a higher knowledge than even that which he has exhibited in his recognition of the affection. Is it to be fatal? How far can life be prolonged? Are the remedies of removal to foreign
CHAP, climates admissible ?-and an infinite number of social I.
problems connected with the habits, engagements, and relations of the patient arise, which cannot be answered by a statement of stethoscopic information. The whole history of our case and its relative standing in the great history of the disease are here appealed to ; and while mistakes involve, on the one hand, not only the character of the medical adviser, but the far higher consideration of painful anxiety and apprehensions to others, and domestic events of vast importance ; on the other, a correct appreciation of the probable future strengthens the uncertain-minded, saves pain of the deeper kind, and lends a confidence to our treatment which enhances its actual value to the sufferer, and gains merited approbation for his adviser.
The importance of prognosis cannot, therefore, be over-estimated, whilst its very meaning involves an acquaintance with all the knowledge which can be accumulated on the disease and on the individual, from a study both of physical signs and of symptoms.
The experience of a very large number of cases must be brought to bear in elucidating these interesting problems, and the actual as well as the relative value of auscultatory and vital phenomena ascertained, in order to arrive at even an approach to truth in this investigation.
It is not proposed to write a history of Phthisis, nor to weigh the merely diagnostic value of signs and symptoms, but to offer facts derived from the experience of the writer, and in some instances from that of others, which, by illustrating the ordinary history and progress of the disease, its varieties and anomalies, shall furnish us with data for a method of prognosis which shall not be empirical.
GENERAL CONSIDERATIONS ON CHRONIC ORGANIC DISEASE.
As we have been led by investigation to recognise CHAP. that all healthy functions are performed in accordance with a pre-arrangement, and exhibit an invariability in action evidencing the presence of an exciting cause, so it is of disease. Disease is something more than a negative condition, or simple departure from the laws of health. It is true that there is a disturbance of normal actions, but there is no merely chaotic and confused result. The new state of things is not nature let loose, vital condition overturned, and disorganisation resulting from the annihilation of previously existing forces. Properly speaking the word disorder' cannot apply to disease. The new condition is simply a substitution of one set of actions for another; and this is not the less true because the transition is productive of mischief to the economy as a whole.
So far as natural laws are concerned, the morbid process is as much under their influence as the healthy. There is never one moment of interregnum ; such a cessation of government would be death; that is, the cessation of all vital law. There can be no action without law; in other words, without a defined, limited obedience to governing power. Disease is therefore only another phase of nature's processes—a new form—but equally subservient to rules as health. When a machine is broken, its action as a whole is put an end to till the same train of movements is restored by re-instating its component parts exactly as they were. If it continue to act partially after an injury, its motions are only im
CHAP. perfect continuations of the original force, not new
actions, obeying other laws. It is not so with vital actions. Here, too, there is often imperfect performance of functions ; but, when once organic disease is established, new laws come into play and new forces. The difference between the machine and the animal is vitality. The former is made to represent one train of uniform action dependent on a single force ; the latter represents many forces capable of conjoint, independent, or successive actions, whose obedience to natural laws never ceases.
We can thus view disease as a defined series of actions in accordance with equally definite causes ; and if in morbid conditions we can only recognise disorder, the failure is in our powers of observation or of reasoning
It is a great help thus to study diseased action as we regard other vital phenomena, and on this foundation alone can our advances be made.
The characteristic features of all chronic organic systemic resistance. affections as contrasted with acute diseases, are derived
from the length of time through which they may be prolonged, and from the resistance of the system to their progress. The nature of the structural changes undergone may not be widely different from those in more rapid affections, but the systemic disorder assumes
a different attitude. System
The system may resist and throw off the structural disease and recover its own balance; or, after a period
of violent reaction, it may tolerate and sustain the local tolerates,
disorder as an irremediable injury, continuing the functions of the body with diminished power, but with
out much manifestation of disturbance to the general or yields. health; or the vital powers may gradually yield, and so
exhibit the phenomena which constitute the final stage of all organic changes.
The individual organ primarily affected will, of neces