CHAPTER XIX. VOMITING. A tendency to vomiting not unfrequently occurs. We do not know that in the instances in which vomiting occurs there are evidences of any especial disorder of the stomach, and hence we do not think that the primary cause of it is associated with indigestion. We have already mentioned, that in many cases of early phthisis there are some evidences of dyspepsia-more frequently than is found in an equal number of persons in moderate health—and, therefore, if vomiting occur in any large number of such cases, it will be associated with dyspepsia, but we believe that usually the former is not due to the latter. As a general rule, the vomiting or retching is due to the act of coughing, and is therefore truly pharyngeal. The cough in such cases is commonly irritable, and possibly spasmodic, and the patient continues to cough until he retches. It also not unfrequently occurs after a meal, but even then it is always associated with cough. In such cases the food excites the cough either by its quality, its presence on the pharyngeal membrane, or by the distension of the stomach preventing the usual descent of the diaphragm, and in such con ditions as we have already stated there is commonly increased sensitiveness of the mucous membrane. Hence, there is a favourable conjunction of circumstances for the occurrence both of the cough and the retching, quite apart from any primary action from the stomach. The proportion of cases in which this symptom occurs in early phthisis is but small, and is almost restricted to such as evince much sensibility of the pharynx and the general system, or who have the habit of eating quickly, or of taking too much fluid or solid food at once. It is a symptom which, in the stage now under discussion, is never permanent, but passes away in a few days. During its continuance it is, however, a symptom of urgent character, and occasionally produces much prostration of the system. CHAPTER XX. THE LUNGS. THE RELATION OF THE LUNGS TO THE GENERAL SYSTEM IN PHTHISIS. We have now concluded our observations upon the state of the general system in the early stage of phthisis, and proceed to inquire into the condition of the organs which may be concerned or more essentially implicated in the disease in question; but, before doing so, it may be well to define the relations which exist between these two parts of the body in reference to the production of phthisis. It is evident, as we have already shown, that the lungs must share in any change in the general condition of the system, and also that they may have their own local deviations from health, which will implicate the general system in proportion as they are more or less extensive. Hence, whether the general system suffer first, the lungs will suffer also; or whether the lungs are affected first, the system will be affected also; so that whilst any disease may be said to be local, it might with equal truth be affirmed that no disease is local. What, then, is the state of the case in reference to phthisis in its early stage? In reference to phthisis in an advanced condition, we have no doubt as to its presenting local evidence of disease in the lungs, for the changes of structure are marked, and attract attention. In regarding the disease step by step in a yet earlier stage, we find less and less evidence of the existence of the material which is regarded as pathognomonic of phthisis, until it may be found only in a small portion of one lung, instead of its wider distribution over larger portions of one or both lungs. Having thus arrived at a point at which only the smallest amount of this recognised evidence of the disease exists, it is commonly presumed that we have found the earliest evidence of the lung disease-the commencement of the local disease; but knowing that there are conditions of the general system indicative of ill-health existing even prior to this period, we transfer our attention from the lung, where the disease would be regarded as local, to the general system, and connect this state of the general system with the local conditions, not by any necessary tie, but by an accidental one, and regard the general conditions as predisposing causes, from which the local disease may or may not issue. Hence the general conditions of the system are regarded as only predisposing to the local mischief, and the local disease is believed to begin, not during the whole period of action of these predisposing influences, but only after a certain duration has occurred, and a new substance has been deposited in the lung, which has been seized upon as the origin and essence of phthisis. So that, strictly speaking, phthisis is at no period a general disease, and as a local disease it com mences only when certain morbid products have been deposited in the lungs. This is, we believe, a correct statement of the belief at the present day; and it will be observed that it makes no account of the fact, that the general conditions which early occur, and which are called predisposing, are precisely those which are found through every subsequent stage of the disease, varying only in intensity; and also that the matter which has been deposited in the lung, and which marks the commencement of the local disease, must have had a source whence it was derived, and an antecedent morbid action by which it was created. How, then, can we regard a condition of the general system which exists throughout the whole course of the disease as a predisposing condition only, and in what way are we entitled to affirm that the local disease commenced in the lungs with the deposit of tubercle, when that deposit must have been due to preexistent changes. We ask if the distinctions which have been drawn as to predisposing and local conditions are not purely arbitrary, and have arisen from the defective knowledge of former times, by which tubercular deposit was regarded as the essence of the disease, both because it was the condition of the lung readily detected, and because it having been found in some, it was affirmed to exist in all stages of phthisis. Such a view might have been the best possible one under these conditions of knowledge, but now it must be admitted that, until we have satisfied ourselves that there is not an earlier condition of disease in the lungs than that marked by the deposition of tubercle, we are not |