BY CARROLL DUNHAM, M. D., NEW YORK.

The question of the Relation of Pathology to Therapeutics is one of exceeding importance, if for no other reason than this that, by a very large portion of the medical profession it is commonly held that the whole science of Therapeutics is based, in its general principles and in its special applications, upon the science and the facts of Pathology.

Before beginning the discussion of this subject, it is necessary to define the terms used in stating the question, as well as certain kindred terms.

The study of the tissues and organs of which the healthy human body is composed, constitutes the science of Physiological Anatomy. It may be pursued upon the living or the dead body provided the death resulted from violence and not from disease.

The tissues and organs of the healthy body are so fashioned as to perform, each a special work. This act of performing its special work is called the function of an organ. An organ can act only during the life of the individual. Functions, therefore, can be predicated only of living organs. The study of the performance of their special work by the aggregation of organs which make up the body, constitutes the science of Physiology.

Physiological Anatomy then is the science of the tissues and organs of the healthy body; Physiology is the science of the functions of the healthy, living organism.

When any or all of the tissues or organs of the body have suffered modifications of substance or of structure in consequence of disease, the study of these material changes, which are the results of disease, constitutes the science of Pathological Anatomy. This may be studied upon the living or the dead diseased organism.

When, in consequence of the action of a morbific agent, any or all of the organs of the body perform their special work in an abnormal manner — in other words, when the function of any of the organs of the body is perverted, the study of these changes and perversions of function, constitutes the science of Pathology, which, like Physiology, can be studied only in the living organism.

Pathological Anatomy, then, is the science of the morbid tissues and organs of the diseased body. Pathology is the science of the abnormal functions of the diseased living body.

Diseased tissues and organs being modifications of healthy tissues and organs, it is clearly necessary to understand Physiological Anatomy before we can understand Pathological Anatomy. Just as necessary is it, for the same reason, to understand Physiology before we can master Pathology. Indeed the latter might be said to exist only by comparison with the former.

If this be true of the details of these sciences, it is no less true of their essential nature and philosophy. If one would gain a correct notion of the subject, scope, limits and relations of the science of Pathology, he must first have a just and exact idea of those of Physiology. To the latter, therefore, I propose to devote a few words.

Dr. Carpenter defines the object of Physiology to be the study of “the phenomena which normally present themselves during the existence of living beings,” or, in another place, “the phenomena of health or normal life.”

Its object, then, is not, as it has been sometimes loosely stated, life itself but the phenomena which depend upon and result from normal life. The science of Physiology brings these phenomena into systematic form, classifies and compares them, analysis secondary and complex phenomena into their simple elements, and seeks the ultimate phenomenon in which the real elementary manifestation of simple life is made, uncomplicated by secondary or related chemical or mechanical phenomena.

Virchow says, “the chief point is to obtain a recognition of the fact that the cell is really the ultimate morphological element in which there is any manifestation of life, and that we must not transfer the seat of real vital action to any point beyond the cell,” (Cell. Path., Eng. ed. 3).

Dr. Carpenter says, “the cell lives for itself and by itself, and is dependent upon nothing but a due supply of nutriment and a proper temperature for the continuance of its growth, and for the due performance of its functions until its term of life expires. Its chief endowment seems to be that of attracting or drawing to itself some of the various substances which are contained in the nutritive fluid in relation with it This fluid is a mixture of a great number of components; and different sets of cells appear destined severally to appropriate these. As far as is yet known, however, the composition of the cell-wall is everywhere the same, being that of Proteine.”

Dr. J. H. Bennett says, “nutrition is now considered to depend upon an inherent vital property peculiar to the tissues themselves, which exercise a force at the same time attractive and selective. By its agency each tissue and gland attracts from the blood that amount of matter which is necessary to maintain in bulk, and at the same time selects from it the peculiar substance necessary for itself and for the secretion it is destined to produce.”

According, then, to the most advanced writers on this subject, we are to regard the organism as a complex which is capable of being analyzed into ah aggregation of cells of homogeneous structure, but each of which is endowed with a peculiar inherent vital power of “attraction and selection,” which we recognize only in its results and which constitutes the only “real action of life” that we are capable of observing. In the words of Virchow, “every animal presents itself as a sum of vital unities, every one of which manifests all the characteristics of life.”

Life, then, really consists in the exercise by each cell of its inherent peculiar attractive and selective power. Physiology concerns herself with the results of this exercise. A. cell by virtue of its inherent power abstracts from the nutrient fluid a substance which is to serve to nourish the organ to which the cell belongs, or to furnish the secretion of that organ. If the former, then the future history of that organ, its development, its functions and its interstitial decline and dissolution and the fate of its debris belong to the secondary and complex phenomena to which Physiology devotes herself. With these phenomena, life has no exclusive connection save in the primary exertion by the cell-wall of its “inherent attractive and selective power.”

Physiologists with great propriety attempt to explain by mechanical, chemical and electrical laws the secondary phenomena of the organism, the relations of different tissues and secretions to each other and their mutual reactions. But they make no attempt to explain the action of the cell-wall which is the ultimate and essential phenomenon of life. They accept this as an ultimate fact, they recognize a power peculiar to the wall of each variety of cell and different from that of any other cell, and they deal with the results of the exercise of this power.

Physiology having been defined as the science of the phenomena of normal life, Pathology has been declared by the same writer (Dr. Carpenter) to be the science of the phenomena of disease or abnormal life.“

If the mutual reaction of two secretions be different in any individual case from that which is observed in the healthy organism, one or other of the secretions must be of an abnormal character. This must have resulted from an abnormal exercise by the cell-wall of that inherent selective power, by virtue of which the secretion was made. The essential and ultimate act of disease is found, like that of life, to consist in some abnormal exercise by the cell-wall of its inherent vital power. As we recognize the existence of this power in the healthy cell only through its action and its result, viz., the function of secretion and the substance secreted, so we recognize disease which is an abnormal exercise of this power only through its action, viz., the perverted function, and through its result, viz., an abnormal secretion.

“Not unfrequently,” says Dr. Bennett, “this attractive and selective power in the tissues is deranged, producing increase or diminution in growth or secretion, general or partial. Not unfrequently the selective power appears to be lost, and the attractive power much increased,” etc., etc. From this alteration of these forces, diseased conditions of these fluids and tissues result. The secondary and complex phenomena resulting from the reaction of abnormal tissues are analyzed by Pathology and referred to this elementary deviation in the selective and attractive forces of the cell-wall. But the nature and intimate cause of this alteration, which is however the essence of disease, Pathology does not attempt to explain or apprehend; knowing it only by its effects.

As, therefore, Physiology concerns herself with the results of life, so does Pathology take cognizance of the results of disease. For it must be repeated that as the functions of healthy organs and the tissues of the healthy body which are respectively the subjects of Anatomy and Physiology are not life, but only results of life, so the abnormal functions and the altered tissues of the diseased body, which are respectively the subjects of the science of Pathology and Pathological Anatomy are not disease itself, but only the results of disease.

These distinctions, it will be perceived, have a direct and most important bearing upon the science of Therapeutics, which has for its object the cure of disease.

The process by which the secretion of any fluid of the body is accomplished, cannot be explained. It is an exertion of that peculiar vital power of which we have spoken as inherent in the cell-wall. The secretion of the gastric juice and of the bile, for example, is wholly inexplicable. But when, after being secreted, these or similar fluids are brought into contact with each other or with any foreign substance, whether within or without the body, the actions and reactions which ensue are explicable by chemical, mechanical or electrical laws and these explanations constitute the object of Physiology. It is obvious that these phenomena may be of great complexity and that the explanations may require to state the conditions of several successive series of reactions, which intervene between the external fact or symptom as viewed by the observer, and that ultimate action of the cell wall which Virchow declares to be “the only real vital action of the living organism” — or on the other hand the phenomena may be simple and the explanation may be complete by a simple and direct reference to the selective action of the cell-Trail. Thus, for example, the fact of salivation, as noticed by an external observer, is made up of the discharge of the salivary secretion into the mouth. The explanation refers us at once to that selective power of the cell-wall of the salivary glands which extracts from the nutritive fluids the constituents of this peculiar secretion which, as such, is not found any where in the body except in the salivary ducts as the result of the process we have just described.

On the other hand the fact of urination is made up, so far as the external observer is concerned, of the discharge of urine from the urethra and the emptying of the urinary bladder. The physiological investigation, however, shows the process to be quite complicated, and the explanation carries us through several series of phenomena, before we arrive at the ultimate fact. Thus, we trace the urine through its reservoir, the bladder, up the ureters to the tubuli of the kidneys, where it has probably received, if not the whole, at least a great portion of its watery constituents; and this contribution may require a further explanation by the mechanical laws of endosmosis and exosmosis whereby this constituent was separated from the blood. Not tracing this constituent further, for the present, by asking, as we should logically be required to do, how this substance came to be contained in definite quantity in the blood, we seek the other constituents of the urine and find the urea and possibly some other of them eliminated by the Malpighian bodies from the blood through the agency of the cell-wall. And yet even this can hardly be called the ultimate vital act, which will require to be sought by a still deeper analysis. For although the cells of the Malpighian bodies do separate the urea from the blood, yet they do not manufacture it from the constituents of that fluid. They find it there already formed, and an exhaustive analysis of the physiological fact of urination would require us to seek the origin of the urea in the blood. This would lead us to the study of the nutrition and decay of the nitrogenized tissues, and in the cell-walls of these we should first meet with that ultimate vital act, in which alone, of all the processes which urination involves, life, pure, simple and inexplicable, is concerned.

Physiology goes somewhat further than this analysis of the actual normal functions of the living organism. Under the name of Experimental Physiology she not only seeks to apply the test of Synthesis to her analysis, but she endeavors to solve her problems by the substitution of analogous substances for some elements of the nutritent fluid, or for some of the secretions of the organism, and thus light is thrown not merely on the processes of the living organism, but also contributions are made to the derived science of Pathology.

Let us now take a similar view of the science of Pathology which deals with abnormal functions as Physiology does with normal functions and which might almost, by a license of speech, be called the science of Morbid Physiology.

The fact of morbid salivation is, to the observer of objective occurrences, only a discharge of abnormal salivary fluid The pathological explanation, like the physiological, leads us to the selection from the blood by the cell-wall of the glands of the Substances out of which it fabricates the salivary fluid. If the blood be normal and yet the saliva be, as we have supposed, abnormal, then the mysterious power of the cell-wall must have been perverted, altered or impaired. This manifestation of life must have become a manifestation of abnormal life — which is disease. Here, then, is the seat of disease — just where we found the seat of life — in the inherent attractive and selective power of the cell-wall. This, then, is the nature of disease, a modification of that unknown and inscrutable power, life.

”Health,“ says Carpenter, “or normal life;” ”disease or abnormal life.“

“Not unfrequently,” says Dr. Bennett, “this attractive and selective power in the tissues is deranged. Not unfrequently the selective power appears to be lost and the attractive power greatly increased and thus,” after a few intermediate steps described,” the phenomena which we call inflammation ensue.“

To take, now, an example of a more complex series of phenomena, the fact of the evacuation of morbid urine, simple as it may appear to the observer of external phenomena only, yet leads us, in our search after the original act of “abnormal life” in which the morbid excretion had its origin, to examine first whether the change was purely a chemical change, originated and effected while the urine was retained in its reservoir, the bladder — for if so, it differs little from a corresponding change which occurs daily in the “vase de nuit” — secondly, whether the urine derived its morbid character from the admixture of morbid secretion, or effusion from the surface of the bladder, of the ureters, of the pelvis of the kidney, or from the tubuli; from each of which it might receive blood, or mucus, or pus, or, perhaps, liquor sanguinis alone holding fibrine in solution or finally solid fibrinous casts; or, thirdly, whether the morbid change in the urine came from a loss, on the part of the cell-walls in the Malpighian bodies, of their inherent vital selective power, whereby they are enabled to separate from the blood those substances which it is their province in the healthy body to separate; or, finally, whether the blood no longer contains, as in a normal state it should do, those elements which it is the function of the kidney cells to eliminate from it, in other words whether the whole train of processes which eventuates at last in the evacuation of abnormal urine, may be traceable to an abnormal interstitial nutrition and destruction of the nitrogenized tissues; all these are questions which it is the legitimate and very useful business of Pathology to solve.

Now, be it observed, whether the cause be traced to abnormal action in the cell of bladder, ureter, kidney, or in that of the muscular or cerebral tissue, we arrive always at the fact that as the action of the cell-wall in the healthy body constitutes the only real vital action of the organism, the only unmixed manifestation of life. So the modified and abnormal action of the cell-wall in the diseased body constitutes the only real action of abnormal vitality in the organism — the only unmixed manifestation of disease.

It may be objected that no account has been taken in what we have said, of the action of the nervous system, to which, nevertheless, both in the case of morbid salivation and in that of morbid urine, the alteration in the salivary gland and in the kidney respectively may have been attributable. Hut this objection simply adds another step to the analysis. For every action of any part of the nervous system involves an expenditure of a portion of nervous substance, that is, a process of interstitial destruction and reconstruction, and this process is effected only through the attractive and selective power of the cell-wall of the nervous tissue. Thus are we brought again face to face with this inevitable mysterious power, the abnormal action of which constitutes Disease.

We are now in a position to discuss the relations of this science of Pathology, which treats of the phenomena of the diseased organism to the science of Therapeutics which proposes to cure disease.

It has been stated that a large portion of the medical profession hold that the science and practice of Therapeutics are based upon the science and facts of Pathology. It is held that the explanation of the phenomena of the morbid organism which Pathology furnishes, gives the key to the procedures which should be adopted for the restoration of the morbid organism to a healthy condition. If, for example, it be ascertained through the investigations which Pathology makes for us, that a certain series of morbid symptoms may be traced to an abnormal constitution of the gastric fluid, a too great acidity, for example, “it is,” says Dr. Bennett, “the discovery and removal of such causes as this, that constitute the chief indications of the scientific practitioner.” Let us see in what way Dr. Bennett proposes that this “removal” shall be accomplished? He says, supposing another case, “the capillary vessels become over-distended with blood and the exudation of the liquor sanguinis to an unusual extent takes place, constituting inflammation. How is this to be treated? In the early stage, topical bleeding, if directly applied to the part, may diminish the congestion, and the application of cold will check the amount of exudation. But the exudation, having once coagulated outside of the vessels, acts as a foreign body and the treatment must be directed to furthering the transformations which take place in it and facilitating the absorption and excretion of effete matter. This is accomplished by the local application of heat and moisture — the internal use of neutral salts to dissolve the increase of fibrin in the blood, and the employment of diuretics and purgatives to assist its excretion by urine or stool.”

In this plan of treatment, we have a proposition to adopt mechanical measures — blood-letting — for the diminution of a congestion; chemical means — neutral salts — for the solution of the exudation; and mechanical means again — diuretics — for the removal of the dissolved exudation from the blood.

But it cannot fail to attract the attention of every reader that this plan proposes to deal only with the results of disease — not with the disease itself — for the congestion is a primary result of the abnormal action of cell-wall, and the exudation which results from the congestion is a secondary result of the same abnormal action of the cell-wall. This is clearly shown by Dr. Bennett's words already quoted, but which we again cite: “Not unfrequently the selective power of the cell appears to be lost and the attractive power so much increased that the liquor sanguinis is drawn out through the vessels, so that its fibrine coagulates in a mass outside of them. This result, preceded or accompanied by certain changes in the vessels themselves and more or less stagnation of the current of the blood, constitutes the phenomenon hitherto described as inflammation.”

It is here most distinctly stated, and most conclusively shown, that the cause of the phenomena of inflammation lies behind these phenomena of congestion and exudation, and is to be found in a modification of that mysterious vital power of the cell-wall. It follows from this that a treatment which is addressed to these resultant phenomena, and not to their cause must be but a palliative treatment. It can in no sense be called a radical or a rational treatment. To remove or assist in removing from the body or any part of it the results of morbid causes may alleviate suffering, may enable the patient to hold out longer under disease, just as pumping out a leaking ship may postpone the time when she will sink, may increase her chances of getting into port before she sink's, may thus in fact be the means of saving her. But as, certainly, pumping is only a palliative mode of treating a leaking ship — as the stoppage of the leak is the only radical treatment imaginable — so in the case of inflammation the only radical treatment would be one which addressed itself directly to the cell-wall, and in such a way as to restore to it the just amount and proportion of its now perverted “inherent attractive and selective power.”

It is evident that when this had been accomplished, congestion would cease to be produced, and in consequence of this cessation there would be no further exudation. It might now be within the province of Pathology to indicate some mechanical or chemical way of aiding, or hastening the removal of the results of disease, the congestion and exudation, but this would be only a sequel of the curative treatment.

A curative treatment, then, must address itself directly to the cell-wall which is the ultimate seat of disease. And every method which is directed to the result of disease, which are the proper subjects of Pathology and Pathological Anatomy, must, of necessity, be a, palliative method.

But, it may be objected, we are unable to plan any such curative treatment, for the reason that we do not understand the nature of this cell-force, nor the nature of its perversion, in any case. To recur to our simile of the ship; it is sometimes impossible to find the leak or, if its location be known, to stop it. Nothing remains but palliation. This statement, as applied to disease, is correct in only a few instances, the number of which is becoming continually diminished by the progress of science. It is true that we do not understand the nature of the cell force whether normal or perverted. — Neither do we understand the nature of chemical affinity nor the modus operandi of chemical reaction. Yet we have an experimental knowledge of each, and we know the peculiar chemical affinities and reactions of a vast number of bodies.

In like manner we may learn the reaction of foreign bodies introduced into the circulation upon the inherent forces of the cell-wall. Reasoning upon the general physical law that “like effects are produced by similar causes,” we conclude that, if, in any case, having introduced into the circulation of the healthy subject a foreign body, we observe the phenomena of congestion and exudation with stagnation of the current of the blood, identical with those known to us as the phenomena of inflammation, then the peculiar inherent powers of the cell-wall must have been affected by this foreign body in precisely the same way (whatever it be) as that in which any accidental exciting cause of inflammation affects these forces. We thus discover reagents which act directly upon the inherent power of the cell-wall, and we thus, by experiments upon the healthy, determine precisely the limits and direction of their action. This knowledge is rendered possible and exact by the science of Pathology, which enables us to trace out and analyze the remits of intentionally induced abnormal cell-action, just as it does those of accidental disease.

This is not a matter of mere speculation. It is well known. to every physician that almost every drug every substance in fact which is not a simple aliment, has besides any chemical affinities it may possess for some of the secretions of the living organs, a certain peculiar power of modifying the functions of some of the organs of the body, a power which is inexplicable and is recognized only by its results. Examples of this power of drugs are found in that of Tartar emetic to produce changes which result in congestion and exudation, of Opium to produce changes which result in narcotism, etc. These, which are known as the specific properties of drugs, are evidently the properties by which they modify the forces of the cell-wall, and from which all observed Pathological (or Pathogenetic) and Pathologico-anatomical phenomena result.

And it is manifest that the specific modifying power of each drug can be surely ascertained, as an absolute property, by testing it upon the healthy living organism. And it follows as clearly, from all that has been said, that the application of specific drugs which have a direct action upon the cell-wall whose inherent forces are acting abnormally under the influence of disease, is the only direct and radical method of curing disease.

The task of finding out by what formula the specific action of drugs upon the cell-forces of different tissues should be 'brought to bear upon the perverted cell-forces in any given case of disease, comes under the science of Therapeutics and lies beyond our present province. It is the problem of the Therapeutic Law.

From all that has been said, the Relations of Pathology and Therapeutics may be deduced in a few words.

Physiology and Pathology themselves teach us that the science of Pathology can in no sense serve as a basis or foundation of the science of Therapeutics. They show us that whereas Pathology is the science of disease based on a theory of observed morbid processes, Therapeutics, when truly regarded, is a science of cure, based on a theory of cure and resting on a foundation of experiment. Although not the basis of Therapeutics, Pathology must yet be a most important instrument in the practical application of the science of Therapeutics.

The problem in the art of medicine, being to apply to the abnormally acting cell-wall that remedial agent which is capable of acting directly upon it, and in such way as to restore its normal action, it is clearly indispensable that the physician be able to trace the morbific agent through all its complex resultant phenomena up to the original perversion of cell-force, from which the whole disorder springs; that he be able to analyze secondary and tertiary series of phenomena into their simple elements. And in this work Pathology is the instrument of which he avails himself.

I cannot refrain, in conclusion, from rendering homage to that wonderful prevision of genius by which, in an age when Pathology, as we understand it, was unknown, Samuel Hahnemann anticipated all that we have said, and all that the most advanced writers of our day have taught, respecting the scope and influence of Pathology in relation to Therapeutics.

The symptoms of the urinary organs in connection with the discharge of morbid urine would at one time have been regarded as the proper subject of treatment. But Pathology has now taught us to trace these symptoms back to the kidney, and beyond the kidney to the blood, and beyond the blood to the nutrition and the destruction of all the nitrogenized tissues. As Dr. Carpenter remarks, “when, for example, the urine presents a particular sediment, our inquiries are directed not so much to the kidney itself, as to the constitutional state which causes an undue amount of the substance in question to be carried off by the urinary excretion, or which prevents it from being (as usual) dissolved in the fluid.” To confine the attention, therefore, in prescribing for a given case, to the immediate organ the perversion of whose functions is most obviously pointed out by the prominent symptoms, is to disregard the clearest indications of Pathology. “We must analyze these obvious symptoms and must include their remotest elements in our indications. Nay, these remotest elements, the constitutional disturbances, for instance, of which Carpenter speaks, are even more important indications for treatment than the more obvious and objective symptoms. But how can we analyze these more obvious symptoms, and ascertain those “constitutional disturbances” in which they have their origin. In no other way than by a study of the functions of the entire organism — in what way and to what extent they are performed in an abnormal manner. But this brings us at once to that rule on which Hahnemann so strongly insisted, that the entire organism of the patient should be examined in every possible way, and that the “totality of the symptoms” should be made the basis of the prescription; nay, that the constitutional, general symptoms are often more conclusive as to the proper treatment than the more obvious local symptom. The grand old master reached at a single bound the same conclusions to which the labors of a half century of able Pathologists have at length, with infinite research, brought the medical profession.

And those of our school who insist upon pathology as a basis of Therapeutics, who look only upon the single objective symptom and its nearest organic origin as the subject for treatment, and who deride the notion of prescribing upon the totality of the symptoms and claim to be more than mere symptom-coverers, in that they discover and aim to remove the cause of the disease — these colleagues are as false in their Pathology according to the highest old school authority, as they are faithless as to the doctrines, and impotent as to the successes of the founder of the homoeopathic school.