* * * * *
These seem to me to be points eminently worthy of consideration, and
the best mode of obviating the objections they involve, is a greater
attention to natural theory and arrangement.
But, in order perfectly to remedy these great defects, the cultivation
of physiology is primarily necessary. As far as the accumulation of
facts goes, it has, however, already been cultivated, and that most
assiduously. But before these accumulated facts can afford a principle of
medicine, they must afford a theory of physiology, and, before they can
afford this, they must be arranged according to their relations to each
other.
I may here observe, that the sciences alone afford theories, the arts
admit merely of principles upon which these reasonings or theories are
applied to the wants of man. Thus, in every step of their progress, the
arts must implicitly depend upon the sciences.
Now medicine is purely an art and admits of a principle derived from
physiology by which the theories of that science may be applied to the
cure of diseases.
As, however, no general theory of physiology exists, it becomes necessary
to inquire what systematic arrangement can be given to its facts, as
strictly founded on those of anatomy, in order to obtain one. And I know
none so unexceptionable as that arrangement which I have already publicly
delivered, nor any general theory so rational as the one which results
from it.
I shall now, therefore, restate these arrangements, and then try their
applicability to the medical art.
* * * * *
Anatomy I divide into three parts, namely, that which considers the
mechanical or loco-motive organs, that which considers the vital organs,
and that which considers the intellectual organs.
Under the mechanical or loco-motive organs, I class, first, the bones
which support the rest of the animal structure; second, the ligaments
which unite them; and, third, the muscles which move them.
Under the vital organs, I class, first, the organs of digestion, the
absorbent surfaces, and the vessels which absorb from these surfaces;
second, the heart, lungs and blood-vessels which derive their contents
(the blood) from the absorbed lymph; and, third, the organs of secretion
which separate various matters from the blood.
Under the intellectual organs, I class, first, the organs of sense, where
impressions take place; second, the brain or organ of judgment, where
these excite ideas; and, third, the nerves, where volition results from
the last.
This is a natural arrangement of the anatomy of animals, and its peculiar
simplicity is illustrated by its involving, in application, that of
minerals and vegetables, and by its being capable of instant adaption to
physiological science.
In order to arrange animal physiology, it is only necessary to substitute
the term “functions” for “organs;” and that science will likewise
involve, in application, the physiology of mineral and vegetable bodies,
and be, in its turn, capable of instant adaption to medical science.
Thus, the functions also are divided into mechanical, vital and
intellectual.
The mechanical functions are subdivided into that of support, that of
connection and that of loco-motion.
The vital functions are divided into that of absorption, that of
circulation and that of secretion.
The intellectual functions are divided into that of sensation, that of
mental operation and that of volition.
In order to arrange medical science, for the term “healthy functions,”
the subject of physiology, it is only necessary to substitute the term,
“diseased functions.”
The classes of disease are, therefore, like those of anatomy and
physiology, three, namely, diseases of the mechanical or loco-motive
functions, diseases of the vital functions, and diseases of the
intellectual functions.
The orders of the first class, as affecting the functions of the bones,
the ligaments and the muscles, are three, viz. diseases of support,
diseases of connection, and diseases of loco-motion.
Those of the second class, as affecting the functions of the absorbent,
circulating and secreting vessels, are likewise three, viz. diseases of
absorption, diseases of circulation and diseases of secretion.
Those of the third class, as affecting the functions of the organs of
sense, of the brain and of the nerves, are also three, viz. diseases of
impression, diseases of judgment and diseases of volition.
The genera, under each order, consist of diminished, irregular and
increased function.
This arrangement of disease likewise involves in application, that of
minerals (if we choose to maintain the analogy and to give that term
to mere injury of structure) and of vegetables, as well as animals.
The first have what may be termed diseases of mechanical structure;
the second have diseases of mechanical and vital functions; whilst the
third have diseases of mechanical, vital and intellectual functions;
corresponding with the observation that animals exist, vegetables exist
and live, and animals exist, live and think.
Precisely in the same way, would I class the articles of the materia
medica; first, as operating upon the mechanical, vital or intellectual
organs, and then as either increasing, rendering irregular, or
diminishing their action.
In this natural arrangement, I must again remark, that all its parts
correctly correspond and beautifully flow from each other; while anatomy
is the basis of physiology, physiology, in its turn, is the basis of
medicine; the classification of one is applicable to the rest, and all of
them at once involve mineral, vegetable and animal nature.
Such arrangement, as it lays the foundation of a new system of each,
will, I trust, soon shed some light over anatomical, over physiological,
and particularly over the dark paths of medical science; but it must be
remembered, that this exhibits merely a sketch of the application of my
general arrangement to medical science, and that sketch necessarily brief
and deprived of every illustration. Yet, even after this sketch, I think
I may add, in the words of Lord Bacon, that “the harmony of a science,
supporting each part the other, is and ought to be the true and brief
confutation and suppression of all the smaller sorts of objections.”
I shall now, however, further explain the principles upon which the
natural system is constructed.
* * * * *
The correctness of this arrangement, as strictly founded on physiology,
is confirmed by the following observations.
Disease is change of the healthy state and of the healthy action of
parts. It is change of the state as well as of the action of parts,
because action depends on state, life itself on organization, and it is
only by affecting this state—the structure of the objects acting, that
change of action can be produced. In fracture, as far as the bone is
concerned, the action peculiar to it—loco-motion is affected; as the
blood-vessels are ruptured, their action is affected; as the nerves are
injured, their peculiar action is also affected.
Thus each has its peculiar action, and the action of each is affected
through the medium of its structure; but the affection of the state and
action of the vessels or nerves is not, in fracture, the primary disease,
but only an extension of it to other parts or other functions, or, more
properly, they are new diseases, because they affect new functions, and,
though dependent upon it, are, in their nature, entirely different from
fracture—the primary disease.
The action, for instance, of vessels in absorbing, circulating and
secreting, so far as, in vegetables, for instance, the form and
arrangement of their capillary tubes are concerned, or the continuation
of the action commenced in these tubes, or the effusion of their
contents when ruptured, is evidently independent of nerves; and I
believe, were this principle traced further, it would be found to account
for many of the actions of animal as well as vegetable parts. Whether
true or false, however, it cannot materially affect the system. For
whether their action is dependent on nerves or not, it is, strictly
speaking, their own action, and, by injury, they are rendered incapable
of performing it.
Disease may thus properly be defined, any change of the healthy state
and healthy function of parts. If any one urge, that disease implies
the action, not the state of parts, I grant it; but must observe that
_change_ of state is action, and change of healthy state is evidently
morbid action or disease, whether it arises from within or without,
whether suddenly from external and accidental causes, or more slowly
within the body and in dependence upon other previous derangement.
Indeed to trace any disease back through previous derangement is actually
to trace out other diseases, and to define any disease from others
thus traced out, is to abandon those distinctions which separate the
termination of one disease from the commencement of another.
If any one still assert, that disease is not change of the state but
change of the action of parts, and urge that those accidents which
depend on external causes, as fracture, considered in themselves, are
not disease, I should say, were this even proved, it could only affect
my arrangement by giving the term injuries, instead of diseases, to the
first class. As, however, it seems to me that they may justly be named
diseases, and that practically considered they are precisely the same,
I shall retain that term. Thus, we shall have a fairer view of the
interesting analogies which, as will be seen, exist between the animal,
vegetable and mineral worlds.
Now, if disease consist in change of function, different diseases must
either consist in different changes of the _same_ function or in the
changes of _different_ functions; the former, viz. different changes of
the _same_ function, as being a more minute division, making evidently
the genera which are subordinate; the latter, viz. changes of different
functions, as being more general, forming the orders which include these
genera.
From the inspection of the table, and a consideration of the nature of
disease, it will appear, that whatever is commonly reckoned one disease,
is generally, perhaps always, three; thus fracture is always accompanied
by inflammation and pain; and while the simple fracture is a disease
of diminished support, the inflammation caused by it is a disease of
increased circulation, and the pain caused by it a disease of increased
impression.
As individual diseases are not arranged under the table, I may, in order
to render my meaning perfectly obvious, give one or two examples of
this mode of classification. Thus with regard to the classes or first
and most general divisions of disease, _fracture_ is a disease of the
mechanical functions, _syphilis_ of the vital functions, and _mania_ of
the intellectual functions. With regard to the orders or second and less
general divisions of disease in the last of these classes, _amaurosis_
is a disease of impression or sensation, _mania_ of mental operation,
and _paralysis_ of expression or volition. And with regard to the genera
or subdivisions of disease in the second of these orders, _fatuitas_ is
a disease of diminished mental operation, _mania_ of depraved mental
operation, and _vigilia_ of increased mental operation. Farther, with
regard to the combination of disease under the last class, (sleep
itself consisting in the quiescence of almost all the intellectual
functions), _dreaming_ consists chiefly in the quiescence of sensation,
_somnambulism_ chiefly in that of mental operation and _incubus_ chiefly
in that of volition.
With regard to the articles of the materia medica, or rather with
regard either to external or internal applications, the correctness
of my arrangement, as indicating their influence upon the different
classes of organs, will, on the slightest consideration, appear equally
evident; pressure, for instance, affects the mechanical, mercury the
vital and opium the intellectual system. But, like the diseases which
they remedy, it will appear, that each of these also affects all of the
functions, though in a less direct manner than that which I have just now
particularly pointed out as its object, and upon which the exact place of
each in a systematic arrangement ought to depend.
It cannot, therefore, be a just objection to this arrangement, that it
throws each of what are commonly called diseases under these different
classes, as, in reality, each of the common diseases is more properly
three, and exists under three natural classes. Even in this way, does
every physician, though unaware of it, consider them, and therefore,
instead of giving any new complexity to nosology, it merely explains
and simplifies that complexity which ever has existed in the nature of
disease. In other words, it is natural, and developes and simplifies only
the combinations of nature.
Thus, no one disease, properly so called, can, with the slightest truth,
be said to fall under three different classes, as inflammatory and
suppurative phthysis, which are even commonly reckoned distinct stages,
or as fracture, inflammation, &c. which are essentially different in
their nature and may actually be combined in every possible form. Thus
it can serve no useful purpose to reckon them one disease, while it
destroys every natural arrangement and all the invaluable consequences
dependent on it, and absolutely leads first to confusion, next to false
reasoning and then to the most fatal errors in actual practice.
Although, however, nosology must thus, in any thing like a natural
arrangement, be fixed most accurately upon the basis of physiology,
the classification of every disease may be derived from the particular
derangement of that individual function which occasions the derangement
of all the rest, and not from the derangement of all the three functions
which would render names uselessly complex.—I say uselessly, because, as
the whole of any one disease, commonly so termed, is primarily dependent
on the derangement of one function, so health is to be recovered chiefly
by the restoration of that function, and the mode of cure is chiefly
indicated by the name of genus under which the disease is _primarily_
arranged. This last is one of the most important consequences of such a
system.
If, however, the names of diseases and their classification are not thus
made dependent most strictly on each specific change from the healthy
state described in physiology, they are at once arbitrary and unnatural;
the pathology and nosology of which they constitute a part, have not
their foundation in physiology, nor is the practice constructed upon them
indicated by the reasonings it delivers.
To reckon a series of occurrences which entirely differ in their nature,
consequences and mode of cure, as one disease, may serve the purposes of
common language, but by no means those of medical science and medical
arrangement.
In considering the natural arrangement of medical science exhibited
above, it will be particularly necessary to avoid substituting the term
“organ” for “function.” The term “diseases of organs” expresses merely
the seats of disease, whilst the term “diseases of functions” expresses
their nature. Nevertheless a reference may also be made to the various
organs, as it is evident that there may be disease of the vital or
any other function in a mechanical organ. Thus a tumour in a bone is
a disease of secretion, or an ulcer in a similar situation a disease
of absorption; both being orders of the class—Diseases of the vital
functions.
The first principle of the medical art, therefore, is founded upon a
knowledge of the relations subsisting between the various states of
the animal functions and the power of medicines, as exhibited in the
preceding sketch of a natural system; and it consists in the application
of the articles of the different genera of medicines (exhibited in the
last column of the table) to the cure of the corresponding genera of
disease (exhibited in the third one).
* * * * *
One of the most beautiful results of the principle I have proposed is,
that, by its adoption, it will be possible for the physician to lay his
hand upon the several columns of a table, each of which, with regard to
the diseases which it enumerates, is precisely similar in its nature from
commencement to end; indicates correspondingly arranged articles of the
materia medica, and requires precisely a similar mode of cure.
As the same arrangement is applied to the articles of the materia medica,
the corresponding medicine will evidently, in every case, readily present
itself to him.
But the most signal advantage resulting from it is, that, by merely
assigning to any disease its place in nosology, the physician will
instantly indicate the mode of cure which ought to be adopted for it.
I shall now then, Gentlemen, conclude by this important remark, that
happily the tendency of this natural system of disease is not to
controvert one established fact, but, by pointing out their relations,
to simplify, consolidate and if possible to increase the amount of our
knowledge on all the subjects of medicine.
SECOND PRELIMINARY LECTURE TO THE COURSE OF PATHOLOGY AND THE PRACTICE OF
MEDICINE; EXHIBITING A FUNDAMENTAL PRINCIPLE OF SURGICAL OPERATION.