ing as the recurrence is regular and periodical, or irregular and as it were accidental. Those which ordinarily belong to the first class are few in number, the principal being intermittent fevers. In these, the type being once known, we are able to foretel the appearance of the next fit. The prognosis must, however, be formed with some limitation, since not only may art interfere, but there appears to be very often a natural tendency in these fevers to cease spontaneously after a certain though variable number of paroxysms. Some neuralgic affections, especially headach, frequently assume a periodical character, observing the ordinary periods of intermittent fevers, and that even when they cannot be referred to malaria. The only other diseases which are often observed to return periodically are gout and spasmodic asthma, and in these the periods of recurrence form no part of the general character of the disease, but vary in each particular case. There are besides numerous other affections which occasionally observe very exact periods of return. The principal are hemorrhages, especially hemorrhoids; profluvia, as diarrhea; and some functional disorders, as mania, epilepsy, and jaundice. But as these peculiarities belong to the individual, and not to the disease, they are of no general interest in prognosis.

The liability of diseases to return irregularly and accidentally may in general terms be ascribed to the continued influence of some circumstance which stands in the relation of a cause, either predisposing or exciting, but more commonly the former. Such causes may be thus classed:

a. Organic disease frequently gives rise to the repeated recurrence of other diseases, and these may affect either the part in which the organic disease is seated, or others more or less remote. Of the former we have examples in the liability to repeated attacks of pleurisy, peripneumony, bronchial catarrh, and hemoptysis, which attends the presence of tubercles in the lungs; in the tendency to spasmodic stricture, where permanent stricture exists; in the frequent occurrence of partial peritonitis and ascites, when the liver is organically diseased; of menorrhagia, in cases of scirrhous uterus; and of affections of the intestinal mucous membrane, in disease of the mesenteric glands. We have examples of organic disease in one part causing repeated morbid affections of other parts, in the anasarca and various hemorrhages which attend diseases of the heart, and in hematemesis and melana accompanying that of the liver.

b. Nearly allied to the preceding description of cases is the well-known tendency of chronic affections to assume more or less frequently during their progress an acute character. Perhaps this is most conspicuously seen in the serous membranes, as in the pleura, peritoneum, and arachnoid membrane.

c. In many cases the liability to a particular disease on the application of slight exciting causes seems referable to some defects, not

amounting to notable disease, in the vascular or nervous apparatus of a part, the result of previous attacks. It is most conspicuously seen in affections of the skin and mucous membranes, as for example in ophthalmia, cynanche tonsillaris, catarrh and bronchitis, diarrhoea and dysentery, gleet and leucorrhoea, diseases which, if they have once occurred, often leave a manifest tendency to their reproduction. In numerous other cases, however, the tendency in a disease to re-appear seems to admit of no such pathological explanation, nor indeed of any other satisfactory one, however we may attempt to conceal our ignorance by the use of such terms as mobility, excitability, and the like. In many of these affections the vascular system is prominently disturbed. Such are erysipelas, biliary calculi and jaundice, gout, rheumatism, hemorrhoids, puerperal hemorrhage, amenorrhoea, dysmenorrhoea, phlegmasia dolens, and calculous affections of the urinary organs. In others, as palsy, epilepsy, insanity, neuralgia, palpitation, angina pectoris, spasmodic asthma, hiccup, dyspepsia, colic, and hysteria, the nervous system seems to be most affected.

d. Repeated attacks of the same disease often originate in the presence of some constitutional diathesis or depraved state of the general health. Hence the frequent recurrence of constitutional syphilis and of scrofulous affection of the glands and joints, the formation of successive crops of tubercles in the same or different organs, and the liability to scirrho-carcinoma, medullary sarcoma, carbuncles, &c.

e. Affections peculiar to certain periods of life are liable to recur during those periods, as epistaxis in childhood, and cerebral hemorrhage in old age.

f. Affections which may be traced to the interruption of some function, as hysteria and vicarious hemorrhages to suppression of the menses, may of course be expected to recur as long as the interruption continues.

The practical application of our knowledge of the liability to the recurrence of disease under the several circumstances now enumerated, consists chiefly in the avoidance of the occasional and exciting causes, since the permanent and predisposing ones are for the most part beyond our reach.

By the term relapse is properly signified the renewal of a disease during the period of convalescence, or before the effects of the preceding attack have entirely disappeared. Hence it is almost exclusively applied to acute diseases, especially fevers and febrile affections generally, including acute inflammations. The liability to relapse may be said in general terms to be in an inverse proportion to the completeness of the recovery. In epidemics it appears to depend in part upon their prevailing character and tendency, being much greater in some than in others; and it seems to be a general rule that when an affection, which ordinarily terminates by some marked crisis, has receded without such an occurrence, or when it has

disappeared early and suddenly, without running its usual course, there is a more than common danger of relapse. It is also laid down as a maxim by Hippocrates and other writers who treat of critical days, that when fevers end on non-critical days the patients are peculiarly liable to a relapse.

II. Of the prognosis of disease as deduced from the particular circumstances of individual

cases.

Our judgment of the future in many cases of disease is greatly influenced by the consideration of their being primary or secondary, idiopathic or symptomatic. The question of the curability and probable duration of a secondary or symptomatic affection is commonly very much involved in the prognosis of the primary one. This general rule, however, requires some limitation. Thus dropsical affections, which are symptomatic of organic disease of the heart, are not unfrequently removed, at least for a time, though the primary affection be wholly incurable. There is, however, in such cases, as has been formerly observed, great liability to a recurrence of the secondary malady.

The principal cases in which prognosis is influenced by the secondary or symptomatic character of the disease may be classed under the following heads.

a. Fever which is symptomatic of local inflammation of an acute character cannot be removed while the inflammation subsists. With regard, however, to the febrile state which attends local diseases of a more chronic and passive nature, and which often assumes the form of hectic, the same position cannot be assumed, except with considerable modification. Here we not only often meet with great spontaneous variations, the causes of which are mostly but little known, but we even find the hectic fever, to a certain extent, under the controul of remedies. Thus the power of sulphuric acid to diminish the sweating is generally admitted, and the influence of bark is attested by high medical authority.

b. When local inflammation or other dis ease arises during the progress of continued fever, it is by no means necessary that the primary affection should cease before the secondary one can admit of removal. Indeed, when the local affection does not proceed to disorganization, it more commonly disappears before the cessation of the primary fever. It may perhaps be assumed as a general rule that the symptoms of a local affection arising in fever are more prominent and severe than those of an idiopathic affection of the same character and tendency. The treatment of fever appears to be generally influenced by this rule, and its bearing upon the question of prognosis is obvious.

c. What has been above stated in regard to hectic fever is also applicable to other affections which are symptomatic of organic diseases; that is to say, the secondary affections are not only subject to great spontaneous variations, but may often be mitigated or re

moved by medical art, though the primary disease be permanent and incurable. As illustrations of this we may cite those symptomatic affections which are common to organic diseases in general, namely, hemorrhages, dropsies, and affections of the bronchial and gastrointestinal mucous membranes, and many others which are more proper to particular ones, as pleurisy and peripneumony to tuberculous phthisis; dyspepsia, pyrosis, gastrodynia, and obstipatio, to organic diseases of the stomach; dysentery, to those of the liver; and dysuria, tenesmus, &c. to diseases of the urinary and genital organs.

d. Affections which are symptomatic of a deranged or interrupted function are mostly very unmanageable till the latter is restored. The most remarkable examples are furnished by the various diseases which attend amenorrhea, such as hysteria in all its forms, regular and irregular, hematemesis, obstinate vomiting, suppression of urine, &c. While the menses are absent or defective, these affections are very little under the controul of remedies; but though they often assume a threatening aspect, experience teaches us that there is very little danger to life. For our knowledge of the great and extensive influence of derangements of the digestive organs in producing or maintaining various morbid affections, we are very much indebted to the sagacity of Abernethy. These affections sometimes present a formidable aspect, such as violent palpitation of the heart or interruption of its action, angina pectoris, palsy, and even a state like apoplexy; others, though less alarming, are very distressing, as neuralgia and asthma; and all of them, however generally exempt from actual danger, can only be treated with success by means which act upon the primary disorder.

e. Besides the above principal varieties of symptomatic affections, there are some more anomalous ones which deserve notice; especially worms and teething, which give rise to convulsions and various other diseases of children; and pregnancy, the origin of a long list of disorders, as vomiting, indigestion, costiveness, &c. These are all more or less subject to the general rule, that the removal of the symptomatic affection is in a great measure dependent upon that of the primary one.

f. When one disorder succeeds to or takes the place of another, the prognosis does not appear to be in general different from what it would have been if the secondary affection had occurred primarily. Dr. Cheyne, however, states that hydrocephalus supervening upon and displacing enteric disease, is more dangerous than when it occurs primarily. On the other hand, insanity is found much more often to admit of recovery when it is induced by some preceding affection, as fever or pregnancy, than when it arises spontaneously.

g. When primary and secondary diseases subsist together, the complication generally makes the prognosis additionally unfavourable; as, for example, when ulceration of the intestinal mucous membrane is superadded to

It seems to be a general rule that epidemic disorders are more tedious, unmanageable, and dangerous, than affections of the like nature and intensity which appear sporadically, and arise from some known causes peculiar to the individual, such as exposure to cold, intemperance, &c. This is very observable in regard to affections of the bronchial and gastro-intestinal mucous membranes. There seems to be an exception to this rule in some diseases which are traceable to the influence of marsh miasmata; as, for example, neuralgic affections, which are then more curable, supposing the future action of the cause be avoided, than when they arise from cold, &c.

Local inflammations, abscesses, and ulcers, when originating from an external injury or other cause which affects the part only, generally afford a much better prognosis than when they appear spontaneously; because in the latter case they have generally a constitutional origin, often of the nature of a cachectic diathesis. Tetanus, however, is more fatal when the affection is produced by a local injury than when it is referable to a cause acting on the system at large, as cold. We may here advert to the well-known fact, that in fractures or other severe local injuries, the prognosis is more unfavourable when the violence done to the part is accompanied with a general shock to the system.

In some affections of the nervous system, the prognosis appears to be partly influenced by the nature of the exciting cause, though in a way which cannot easily be explained. Thus epilepsy and insanity are said to be peculiarly intractable when they have been first brought on by fear or terror.

The mode of invasion is a point of much importance in the prognosis of many acute diseases, as fevers and febrile disorders generally, including the exanthemata. The first shock is sometimes so violent, or the progress of the disorder so rapid, that before remedial means can operate, life is extinguished, or irreparable disorganization produced. This is often seen in severe epidemic diseases, as plague, spasmodic cholera, &c.; and, among local inflammations, in meningitis and ophthalmia. If we except cases of the above description, it may be laid down as a general rule, that in proportion as the first invasion of an acute disease is well-marked and decisive, it will be found not only more controulable by remedies and shorter in duration, but also less likely to terminate fatally, or to cause permanent disorganization. On the other hand, where a disease is insidious and imperfectly developed in its commencement, remedies are

generally less efficacious; and even were it otherwise, the early diagnosis is often so obscured as to prevent their being resorted to with sufficient promptitude and energy. Chronic affections are generally more or less indistinct at their commencement, and are very often so much so as to baffle all attempts at precise diagnosis. In proportion as this is the case, the prognosis is commonly unfavourable, the efficacy of remedies being mostly less decisive, and the event often revealing an extent of disease little suspected in its earlier stages.

Regularity or irregularity of progress, as a guide to prognosis, is applicable only to disorders which have a pretty marked and determinate course, as especially to the exanthemata. In these affections, any considerable deviation from the accustomed course, as a premature disappearance of the eruption, furnishes an unfavourable augury; such cases not unfrequently ending fatally, even when there has been no peculiar severity of symptoms, or other circumstances, to excite alarm. Gout is another disease in which irregularities are often the precursors of dangerous and sometimes of fatal consequences. There is one disorder which affords an apparent rather than a real exception to the preceding rule. It is well known that, in intermittent fevers, changes in the accustomed hours of access of the paroxysms, whether they occur spontaneously or are caused by the use of remedies, often predict the approaching cessation of the malady.

In

In many diseases, especially those of a chronic character, the prospect of recovery is much influenced, and in general unfavourably so, by the length of their past duration. This influence seems to result from various causes, of which what may be called the force of habit is perhaps the most considerable. Its operation is conspicuously seen in many of those affections which are chiefly referable to the nervous system, as well as in others in which the occurrence of some secretion or other form of evacuation indicates disorder of the vascular apparatus of the part affected. Of the former we have examples in epilepsy and the neuralgia; of the latter in hemorrhoids and leucorrhoea; while spasmodic asthma and gout are cases of a somewhat mixed character. all these affections, and in many others of the same kind, the hope of recovery is in general small in proportion to their duration, and to the influence of habit which that duration implies. Another cause which renders the duration of a disease unfavourable to the hope of recovery, is its tendency to produce changes in the organization of parts. Perhaps all the affections commonly called nervous have more or less of this tendency, as, for example, epilepsy and asthma. It is, however, more conspicuously seen in some other diseases, as ague, gout, and rheumatism; in all of which the inveteracy of the affection is found to be increased by the production of organic changes. A third mode in which diseases become more intractable by continuance, is by diminishing the vigour of the system, and consequently its powers of re

sistance. This is illustrated in many kinds of chronic discharges.

The cases in which the prospect of recovery is improved by the duration of the disease are chiefly those in which it is observed to have a natural tendency to exhaust itself after long continuance. Examples are furnished by some of the chronic cutaneous diseases, as porrigo, and perhaps lepra. A tendency of the same kind is in some instances connected with age. Thus external scrofula and dyspepsia, however intractable during the earlier periods of life, are often found to diminish or disappear in mature and middle age.

With regard to the influence of the duration of disease upon its danger, it is obvious that all those affections which have a tendency to destroy life, either by inducing fatal disorganization, or by exhausting the vital powers, become increasingly dangerous in proportion as their continuance is prolonged.

Of particular symptoms. In the infancy of pathology a great number of symptoms which, either singly or in conjunction, are now known to indicate certain kinds of disease, merely served as guides to predict the event of indidual cases. Thus, much of what Hippocrates has said on the subject of prognosis more properly belongs to that of diagnosis; and it is probably in a great measure owing to the change above noted in the relative position of these two branches of medical science, that while the latter increasingly occupies the attention of physicians, and has given birth to many valuable systematic works in our own times, the former has, for the last half century, almost ceased to be the subject of distinct treatises. That part of prognosis which is independent of diagnosis being thus restricted in its materials, will not require a large proportional space in this article. It will be found that in local affections generally the most prominent symptoms are essentially diagnostic, and therefore foreign to our present object. In affections of a more general nature, such especially as fever, the case is different; and numerous symptoms present themselves which do not appear to be diagnostic of any particular state of disease, but which greatly influence our judgment of the event. These will necessarily occupy a prominent place in the following enumeration. It must, however, be borne in mind that in many cases our knowledge is too imperfect to enable us to determine with certainty what symptoms are properly diagnostic, and what are merely prognostic.

It is a general rule that the disappearance of the several morbid circumstances in the condition and functions of the body which constitute disease marks the approaching return of health; and, in fact, great part of the pro

In a list of fifty works appended to the article Pronostic, in the 45th vol. of the Dict. des Sciences Médicales, which was published in 1820, thirty-five are of dates prior to 1700, (a majority of them being rather comments on Hippocrates than original treatises,) fifteen between 1700 and 1777, and none later.

gnosis of particular diseases, as stated in systematic works, is of this kind. It seems, however, useless to extend an article like the present by an enumeration of points so selfevident. The chief exceptions to the above rule are to be found in the disappearance of one or more morbid circumstances while others remain. Indeed, in a large proportion of cases of disease, the prognosis is rather deduced from a general consideration of all the symptoms than from changes in particular ones; and hence arises an imperfection inseparable from this branch of the subject.

As the consideration of every individual morbid symptom would be at once tedious and unprofitable, it will be sufficient to particularize those which are most important and of most general application to the subject of prognosis.

Symptoms chiefly referable to the nervous system.-Delirium being one of the most common symptoms of fevers and febrile disorders generally, cannot in itself be considered unfavourable. In two of its forms, however, it indicates a threatening state of disease; namely, the delirium ferox, which perhaps mostly implies meningeal inflammation; and the muttering delirium which is one of the characters of typhus and adynamic fevers. An access or increase of delirium sometimes precedes a crisis in fevers; and, on the other hand, its cessation, though a favourable occurrence when conjoined with other marks of lessening disorder, is not unfrequently but the commencement of stupor and coma, or a part of that delusive calm which has been already adverted to as sometimes taking place before the fatal termination of many acute affections. In encephalic inflammations generally, including acute hydrocephalus, the violence and duration of the delirium is one measure of the severity and consequent danger of the disease. In acute pulmonary affections and also in jaundice, the occurrence of delirium has always been regarded as more or less alarming. That which frequently follows some local injuries does not appear to denote peculiar danger. In chronic diseases generally, particularly in phthisis pulmonalis, its occurrence is one of the most unequivocal indications of the approach of death.

Besides delirium, there are other modifications of mental disorder very common in fever and encephalic inflammations, which, when they are prominent, generally denote a severe and formidable disease. Such are, an expression of great confusion in the countenance, corresponding confusion of thought, and want of any recollection of things said or done immediately before.

The expression of great anxiety in the countenance and manner is a very unfavourable symptom in acute affections; while hope and cheerfulness, when not arising from delirium, are of good omen, being at once a cause and an indication of amendment. In many chronic affections, however, these indications are reversed. Thus in dyspepsia, jaundice, hypochondriasis, &c., anxiety and depression of

spirits by no means imply any well-founded alarm; while, on the other hand, in phthisis pulmonalis there is often confidence of recovery even to the last period of existence.

A strong presentiment or anticipation of death is at all times ominous, since, apart from every consideration of its foundation, it often appears to be the cause of its own fulfilment. The same may be said of a confident anticipation of recovery, whatever be its source; for whether connected with religious impressions, or excited by the prognostics of pretenders to the healing art, it often produces the most extraordinary effects.

The opposite states of preternatural susceptibility and complete insensibility of the organs of the external senses are alike unfavourable symptoms in fevers and febrile diseases. Hence, a very contracted or dilated and immoveable condition of the pupil, as well as strabismus, and that state of the eye in which it remains constantly half closed with only the white part visible, have always been considered of bad omen in such affections. It is, however, to be observed that deafness is a frequent occurrence during convalescence from fevers; and that extreme sensibility of the eyes and of the whole surface are not uncommon in hysterical affections, and of course of little

moment.

In febrile disorders, sensibility to suffering, with complaint of pain, are generally favourable, while the total absence of both is always a bad symptom. Severe attacks of local pain are not unfrequently the precursors of a crisis; and a peevish sensibility to uneasiness of any kind is proverbial as an indication of approaching convalescence.

In acute inflammations severe pain in the affected part cannot in general be considered as alarming. The principal apparent exception is found in enteritis; in this case, however, the severity of the pain seems chiefly owing to a spasmodic affection of the muscular coat of the intestine. Throbbing pain is a well-known precursor of suppuration.

With regard to local pains, severe headach is an unfavourable symptom in peripneumonia notha, and perhaps in pulmonary affections generally. A sudden and violent attack of pain in the head, preceding apoplexy, denotes a very dangerous form of that disease. Very severe pain in the loins has been observed to precede the confluent form of small-pox, and at the invasion of febrile disorders in general, mostly portends an attack of considerable

violence.

Pains which are prone to shift their seat, as in acute rhematism, are generally less manageable than such as are fixed.

The sudden disappearance of pain, without any known or satisfactory cause, is always alarming, as is seen in ileus, enteritis, and hernia, although in these cases it has been too exclusively regarded as an indication of commencing gangrene.

The sensation of pricking in palsied limbs often precedes the recovery of their power.

In

In fever, constant lying on the back, with the legs drawn up, a continual tendency to sink down in the bed, or general rigidity of the trunk and limbs, are all unfavourable symptoms; while recumbency on the side, with occasional changes of position, and a flexible state of the muscles, are of good omen. peritoneal inflammation great retraction of the lower extremities upon the trunk indicates a severe affection; while their occasional extension, together with the capability of sitting upright, are sure signs of the subsidence of the inflammation.

Convulsions and spasmodic affections are much worse symptoms in the advanced than in the early stages of fevers, and are generally less alarming in women and children than in adult males. Indeed, in young children (as Sydenham remarked in small-pox) their occurrence at the invasion of febrile disorders is often rather favourable than otherwise. In general it is not so much their severity as their continuance and frequent recurrence which imply danger. Among the different forms of convulsive movements, subsultus tendinum, picking at the bed-clothes, &c.; tremors of the hands and lips, and grinding of the teeth, are more peculiarly alarming, as being common indications of approaching dissolution.

A propensity to keep the hands and feet out of bed, and the trunk uncovered, commonly denotes a state of severe disease. Any form of paralysis occurring in fevers and acute inflammations is generally more or less alarming. Severe rigors are not ordinarily unfavourable in acute affections, as they tend to produce speedy reaction. In chronic diseases they are much more often so, mostly implying internal suppuration.

Extreme debility, or loss of muscular power, almost always justifies alarm.

Somnolence, occurring at an advanced stage of febrile affections, if it be associated with other indications of their decline, and especially if it follow some form of crisis, is highly favourable. In other circumstances, however, it is often but the beginning of a state of torpor, eventually passing into fatal coma. Sleep which is hurried or disturbed by convulsive startings, or in which the eyes are half open, shewing the white part only, or in which the lower jaw drops, is of bad omen. Constant wakefulness is always an unfavourable symptom.

Yet

Of all the indications of approaching death, and of all the forms in which it takes place, perhaps none is more general than coma. coma does not invariably portend death. In fevers attended with much cerebral disorder, and in idiopathic affections of the encephalon, more particularly in children, it is not unfrequently recovered from. In pulmonary affections it is almost always a fatal symptom.

Circulating system. The prognosis deduced from the action of the heart and arteries varies greatly in different diseases and under different circumstances. Extreme weakness, with great frequency, and perhaps irregularity of the