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he is to another who has been deprived of sight or speech by a lesion, locally and pathologically very nearly resembling his own. Again, the sufferer from dyspnoea, cough, and expectoration, supposing his maladies, to all his own feelings and all practical purposes, limited to those three derangements,-is more closely related to another whose distresses are the same, although from widely different remote causes, than he is to a third person whose complaint is swollen legs and general debility, although these may arise from structural disease very like his own. The right arm may lose its power by injury to the nerves, to the spinal cord, or the brain; by venous or arterial obstruction; by rheumatic, lead, or other poisoning; by accident, or operation; and on the other hand tumour of the brain may cause amaurosis in one, imperfect speech in another, and paralysis of the right arm in a third. So the thoracic symptoms mentioned above may be due to chronic bronchitis, to heart disease, or to morbus Brightii, &c.; and patients suffering from them are more nearly related to the victims of slow phthisis, and of old pleurisy, than they are to others in whom the renal disease or the morbus cordis has produced ædema of the extremities and general weakness.

The sufferers from occasional convulsive paroxysms form a natural group,-limited in similar manner as regards their vital capacity, their social position, their prospects of life, in all its phases, except in that which is the lowest of all, viz., the probable duration of physical existence;-yet the conditions upon which those convulsions remotely depend are as various as are the organs of the body, and the varieties of change which they may undergo. Allowing this, we have the strongest objection that can be urged against the principle of classification that I propose. Yet this objection is, I think, feeble to the last degree when compared with that which can be raised against adopting either organ or anatomical change as the primary basis of classification. In regard of organ, let it be remembered that, for example, tumour of the brain may induce no symptoms except in the digestive organs;* that it may produce headache as almost its sole exponent, or blindness, convulsions, hemi

*

Abercrombie's "Pathological and Practical Researches in Diseases of the Brain and Spinal Cord," p. 472.

plegia, anesthesia, vomiting, general emaciation, dementia, or insanity. Further, that disease of the heart may cause no symptom, or it may produce convulsions, dyspnoea, palpitation, swelling of the legs, ascites, headache, vertigo, or absolute incapacity for all exertion, through physical or moral causes, or the two combined. If, instead of organ, we regard pathological change as the primary basis of division, we have only to remember the different effects of inflammation, or oedema, or tubercle of either the lung, the glottis, or the joints; and to compare these in their several combinations and permutations in order to be convinced that it also is quite unfit for the purpose of primary classification.

Upon the system which starts with difference of organ as its basis of primary division, we arrive at special diseases, which have then to be described as assuming various clinical forms; thus Abercrombie details the different types of cerebral hæmorrhage, and thus Durand-Fardel describes several forms of softening of the brain.†

The system which should commence with primary groups, formed by their having in common particular pathological conditions, would arrive at the same difficulty, or be encumbered by one still greater. Whereas the clinical arrangement is free from this fault, its peculiar evil being that diseases similar anatomically have to appear in two or more clinical groups. This was admitted and exemplified in my own work on Diagnosis.

The latter evil, however, appears to me the least of the three, because it represents in the book the condition of the facts of practical experience, and the order in which, as a rule, we advance from their simple observation to their interpretation. The patient complains of pain, of paralysis, of fits, of cough, of short breath, or of swollen legs; this is his first communication; and, from his symptom or group of symptoms, the physician advances to a discovery of the organ affected, and of the nature of its change.

Upon the principles laid down-viz., that disease is the sumtotal of modifications in structure and function; that its measure is that of the degree to which life is limited or its actions perverted, and that its classification is most naturally based upon the

* Op. cit., p. 208, &c.

+ Traité du Ramollissement du Cerveau.

mode in which it effects this limitation or perversion—we come to regard "special diseases" as groups of modified function and structure, although the names by which they are denoted sometimes express only the one and sometimes the other.

Chronic convulsive diseases are a very definite group; they are, with few exceptions, readily recognised as such; and I propose in the following work to treat of them all, pointing out wherein they differ and wherein they agree, and advancing, by the discovery of the conditions upon which they depend, to a knowledge of the treatment which is appropriate to each.

§ IV. The symptoms of disease are the phenomena, or the feelings by which it may be revealed to the observer, or to the sufferer. Some of these may be appreciated by both, such as heat of skin, or an eruption; others can be recognised by the latter only, as, for example, pain, or numbness.

Symptoms resolve themselves into modifications of structure, such as hypertrophy, variolous pustules, &c., and of function, as, for example, paralysis, convulsions, flux, and the like. So that the symptoms are in reality part of the disease; and the problem of Diagnosis may be stated thus:-Given certain of the phenomena of a disease to find the others. This involves the discovery of the organ primarily affected, and the recognition of the nature of its change. The latter discovery is based upon a knowledge of Pathology; it is indeed the deductive application of that science. Hence Diagnosis rests upon Pathology, and the two support each other.

There was

a period in the history of Medicine when disease was regarded as some mysterious entity taking possession of the body, and producing its various results; but although this period has long since passed, we should find it difficult to discover any resting-place between that view of disease and the one stated at the commencement of this chapter. The names by which different maladies are called, are often intended to express the essential facts in their existence; but a nomenclature constructed upon this principle would be exposed to unceasing change, or would soon become an unmeaning jargon. It is far easier to recognise a case of Bright's disease, than to say what is its essential condition; and the same is true of a large number of affections. Again, it is no less difficult to

determine the primary fact in many groups of diseases. We go backwards from effects to causes, from functions to organs, and may repeat the process almost ad infinitum, or until we find the line of causation returning into itself; and we know not at what point in the circle of life, and of our knowledge about it, the first irruption took place. We often cannot separate proximate causes of symptoms, or even remote causes of disease, from the disease itself, and are driven to accept the latter as a whole, and as a fact, some part of the order of whose events we may trace, but the first starting point of which, and the essential fact of which, we cannot positively determine. In the meantime symptoms must be regarded as parts of the disease, and the discovery of their relations as the problem of Pathology.

§ V. Some of the phenomena or symptoms of disease are physical, chemical, or textural alterations which may be immediately perceived; as, for example, heat of skin, urinary changes, enlargement or hardening of organs. Other physical or textural changes may be inferred from the effect they produce upon the mechanical action of organs. In this way auscultation and percussion elicit truth with regard to the state of lungs and heart. But there are other symptoms which we must term vital,—such as modifications of contractility, sensibility, and the like,—because, although we may express some of their results in physical or chemical terms, we do not by such terms express all the facts. We may detect excess of sulphates, phosphates, urea, or uric acid in the urine; we may perceive changes in the temperature of the body and in the excretion from the skin; but we can discover no structural change in the nerves, muscles, or brain of the patient who has suffered from chorea, delirium tremens, or mania; and we cannot express by either chemistry or physics the changes we have witnessed in mind, motion, or sensation.

§ VI. All vital actions, however, are accompanied by, and depend upon, some physical change in the living organism. In health, waste and repair balance each other, and there is a persistent textural result. The process of nutrition is interstitial, and too fine for our microscopes and test-tubes: but the vital actions of the organ depend upon, and are in proportion to these finer changes; and when the actions are abnormal in

degree or kind, it is because nutrition is, in like manner, different from that of health.

It is in thus regarding the relation between function and structure that we find, as it seems to me, a solution of the much-vexed question of functional disease. Thus, in 1855, I wrote, "If all that is intended (i. e. by those who assert the non-existence of functional disease) is that some physical change in the intimate organic processes of the tissues in question must take place as the essential conditions of their activity, and that some diminution or perversion of these processes must attend the increase or alteration of their functions, there is not only à priori evidence, and the deductive application of general laws, to warrant such an assertion, but there is direct clinical evidence of its truth. But these changes are totally distinct from those which are ordinarily meant by structural lesions, and are, as I have already said, conditions of vital activity, and not its cause.

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"This mode of viewing the subject is of importance, not only in relation to those diseases in which no structural changes can be detected, but in reference to those which are connected with distinct pathologico-anatomical alterations. The immediate conditions of all such symptoms as result from modified functions being the intimate organic (vegetal) processes of the tissues, we can understand why similar symptoms arise from anatomical conditions, presenting coarse differences, and vice versa. The mechanical changes, such as hæmorrhage, congestion, softening, &c., do not cause the symptoms directly, but by the intervention of secondarily induced alterations in the minute organic processes."*

If it is asked, which of the two, function or structure, is primarily affected? I reply, Neither; for the two are correlated, and are mutually dependent.

The application of these views to the interpretation of convulsions I attempted in a paper read before the North London Medical Society, and subsequently published in a provincial journal,† from which I quote the following:

"Many of the 'symptoms of discase' are merely modified Diagnosis of Diseases of the Brain," &c., p. 224.

"The Liverpool Medical and Chirurgical Journal," Jan. 1858, p. 1 et seq.

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