Part 5

I think the more we observe diseases, and the more we examine bodies, the more we shall be convinced of the necessity of considering local diseases, not under the relation of the compound organs, which are rarely ever affected as a whole, but under that of their different textures, which are almost always attacked separately.

When the phenomena of diseases are sympathetic, they follow the same laws as when they arise from a direct affection. Much has been said of the sympathies of the stomach, the intestines, the bladder, the lungs, &c. But it is impossible to form an idea of them, if they are referred to the organ as a whole, separate from its different textures. 1st. When in the stomach, the fleshy fibres contract by the influence of another organ and produce vomiting, they alone receive the influence, which is not extended either to the serous or mucous surfaces; if it were, they would be the seat, the one of exhalation, the other of sympathetic exhalation and secretion. 2d. It is certain that when the action of the liver is sympathetically increased, so that it pours out more bile, the portion of peritoneum that covers it does not throw out more serum, because it is not affected by it. It is the same of the kidney, the pancreas, &c. 3d. For the same reason, the gastric organs upon which the peritoneum is spread, do not partake of the sympathetic influences that it experiences. I shall say as much of the lungs in relation to the pleura, the brain in relation to the tunica arachnoides, the heart to the pericardium, &c. 4th. It is undeniable that in all sympathetic convulsions, the fleshy texture is alone affected, and that the tendinous is not so at all. 5th. What has the fibrous membrane of the testicles in common with the sympathies of its peculiar texture? 6th. No doubt a number of sympathetic pains that we refer to the bones, are seated exclusively in the marrow.

I could cite many other examples to prove, that it is not this or that organ which sympathizes as a whole, but only this or that texture in the organs; besides, this is an immediate consequence of the nature of sympathies. In fact the sympathies are but aberrations of the vital properties; now these properties vary according to each texture; the sympathies of these textures then would do the same.

Observe what takes place in fever, accompanying the different kinds of inflammation. That attending the mucous is slight, that with the serous severe, and that with the cutaneous has the peculiar character of showing itself some days before the eruption, as has been noticed by Pinel. If we attentively observe the fever which attends the inflammations of all the systems, we shall find as many differences, as many peculiar characters, as there are systems. Whence does this arise? From the difference of the relations that unite the heart to each kind of texture; now this difference of relations is the result of the difference of the vital forces peculiar to each.

Observe the itch, herpes, cancer, venereal disease, &c. when they have ceased to be local affections, they spread themselves universally; they alternately attack different textures, according to the relation which they have with the organic sensibility of these textures. But it is almost always separately that they attack them; an organ is never as a whole influenced by them in all its parts. What do I say? If two of these diseases exist at the same time, one seizes upon one texture, the other upon a different one of the same organ. Thus the stomach, the intestines, the lungs, &c. can be attacked by two different diatheses, and each will be independent of the other, because each will be fixed upon a different texture, one upon the mucous, for example, the other upon the serous, &c.

Let us not, however, exaggerate this independence of the textures of the organs in diseases, lest experience should contradict us. We shall see that the cellular system is oftentimes a medium of communication, not only from one texture to another in the same organ, but from one organ to a neighbouring one. Thus in many chronic diseases, all the parts of the same organ are gradually changed, and at the examination of this organ after death, the whole of it appears to have been affected, though one of its textures only was so at first. In the cancer of the breast, you find at first only a small gland that rolls under the finger; finally the glandular, the cellular, and even the cutaneous textures are confounded in one common cancerous mass. Cancer of the stomach, the intestines, the penis, &c. follows the same course. Observe phthisis, exhibiting in the beginning some small tubercles in the pulmonary texture, at length invading oftentimes the pleura, the bronchial membrane, &c. How little soever you may examine bodies with a view to the same chronic disease, and at different periods, you will be convinced of the truth of this assertion, viz. that a texture being at first affected in an organ, communicates its affection gradually to others, and that you will be deceived in judging of the primitive seat of the disease, if you attempt to determine it from the parts found affected at the time of the examination.

In acute diseases, continuity is oftentimes sufficient to explain the different symptoms that appear in textures that are not affected. The peritoneal coat only being inflamed, vomiting is produced. We cough and sometimes expectorate considerably when the pleura alone is diseased. Delirium comes on when the tunica arachnoides is inflamed, though the intellectual functions are not connected with it. Frequently the diseases of the pericardium are sufficient to disturb the motion of the heart, &c. We cannot deny after this, that oftentimes an alteration in one of the textures alone of an organ is sufficient to disturb the functions of all the others; but still it is in one only, that the primitive source of the evil exists.

I now pass to some other considerations relative to the influence of the anatomy of systems in diseases.

Since every organized texture has every where the same arrangement; since, whatever be its situation, it has the same structure and the same properties, it is evident that its diseases must be every where the same. It makes no difference, that the serous texture is connected with the brain by the tunica arachnoides, with the lungs by the pleura, with the heart by the pericardium, with the gastric viscera by the peritoneum, &c. every where it is inflamed in the same manner; every where dropsies take place in the same way; every where it is subject to a species of eruption of little whitish tubercles, like the miliary, of which I believe there has been no description, but which deserves great attention; I have already many times observed this peculiar eruption of the serous texture, which is generally of a chronic character, like most of the cutaneous eruptions; I shall speak of it hereafter. Whatever may be the organ that the mucous texture invests, its affections have in general the same character, excepting the difference only that arises from variety of structure. I will say the same of the fibrous, cartilaginous textures, &c. Mr. Pinel appears to me to have done much for the art, in being the first who arranged inflammations in the order of the systems, and embracing in one general view all those of the same system, whatever may be the organs in which it is found.

There are always two orders of symptoms in inflammations; 1st. those that belong to the nature of the diseased textures; 2d. those which depend upon the affected organ, in which the inflammation exists. For example, the kind of pain, the nature of the accompanying fever, the duration, the termination, &c. are almost always the same, whatever serous surface is affected. But difficulty of breathing, dry cough, &c. prove it to be the pleura; diarrhœa, constipation, vomiting, &c. that it is the peritoneum; injury of the intellectual functions, that it is the tunica arachnoides; irregular pulse, that it is the pericardium, &c. The first belong to the whole class, the second set of symptoms is confined exclusively to this or that particular sort; now the second are, if we may so say, accessory, depending upon the proximity of the affected texture with some other texture. The first are particularly important.

Medicine has yet much to do, in its researches upon the inflammation of the different textures. We are well acquainted with that of the cellular, the cutaneous, the serous, and the mucous; but that of the others is very obscure. It is yet to be ascertained, which is attacked, the fibrous or muscular, in rheumatism. I am inclined to think that it is the first. Almost every thing remains to be known in the cartilaginous, the synovial, the arterial, the venous, &c. as it respects their inflammatory phenomena.

In making these researches, it will be necessary to establish one important distinction; that is, 1st. that certain textures, as the osseous, the muscular of animal life, &c. are precisely the same in all the organs in which they are found, and consequently that their diseases must be the same; 2d. that others, as the cutaneous, the serous, the mucous, &c. experience, according to the organs to which they belong, some variety of structure and vital properties, which necessarily modify the general phenomena of the class of diseases that belong to these textures; 3d. that others, as the glandular, the muscular of organic life, &c. are very different in each organ; and that their general symptoms and class of diseases must consequently differ considerably.

After having shown most of the local diseases, as affecting almost always, not an individual organ, but some texture in an organ, it is necessary to show the differences they present according to the textures they affect. As under each system, this subject will be treated more or less fully, I shall only refer to it here.

We shall see, then, that pain is modified differently in each texture, according to the degree of sensibility that it possesses. No one excites the same sensations as the others when it is inflamed. Compare the burning of erisypelas with the throbbing of phlegmon, the pain of rheumatism with that of inflamed lymphatic glands, &c. We shall see also that the sense of heat, developed in each inflamed texture, has a particular character; here it is sharp and biting, there like the feeling produced by fire, &c. There are two general causes that produce a variation in the symptoms of diseases: 1st. the nature of the affected texture; thus, as I have just said, the inflammation of each produces a different kind of suffering. 2d. The nature of the disease; we know that cancer, whatever texture it may affect, has a pain that is peculiar to it; that syphilis and scurvy have also a peculiar character, that is, however, modified in a slight degree in each texture.

The difference of textures not only modifies the symptoms, but affects the duration of them also. Nothing in medicine is more vague, in this point of view, than the terms acute and chronic, in relation to inflammations of the different textures. Most commonly they run their course rapidly in the dermoid, cellular, serous, mucous textures, &c.; on the other hand, they are slow in the bones, the cartilages, and the fibro-cartilages. If we apply this distinction to the same texture, it is very well; thus there are catarrhs, serous and cutaneous inflammations, &c. that are acute and chronic. But if we generalize it, it cannot be understood. A catarrh would be chronic if it lasted two months; but this is the common term of an acute inflammation of the bones; a chronic one continues for a whole year or more. Cutaneous, mucous wounds, &c. last only five or six days if they heal by the first intention; while it requires thirty or forty for a bone, a cartilage, &c. to be cicatrized by the juxta-position of its different parts. A disease cannot be classed, then, by its duration, as an acute or chronic one, except in relation to the same system; when we describe it then in a general way, this distinction becomes void.

Physicians consider abstractedly almost all diseases. When they speak of inflammation they describe the redness, swelling, throbbing and pain, as general attributes, always uniform. If of suppuration, they take for a general standard that of the cellular texture, in phlegmon, without thinking that it is only one of the modifications of suppuration and its product. The same may be said of gangrene, scirrhus, &c. Nothing is more vague and uncertain than the general ideas that are given concerning a disease; they scarcely agree in one or two of the textures.

It is not only the history of diseases that the anatomy of systems will elucidate; it will change in part the method of treating morbid anatomy. Morgagni, to whom we owe so much in this respect, and many others, to whom the art is indebted, have adopted the general arrangement used in descriptions. They have examined the diseases of the head, the chest, the abdomen, and the extremities. In following this method, they can only form to themselves a general idea of the alterations common to all the textures. The ideas are necessarily too much contracted, when there is presented only an insulated part of a system, which is composed of a great many others. If, besides this, you obtain a general knowledge of the affections of each system, you must bear in mind, with regard to each, the general ideas concerning the affections of the parts they compose.

It appears to me to be infinitely more simple to consider at first all the affections common to each system, and then to observe what every organ has peculiar to itself in the part that it occupies.

I divide, then, morbid anatomy into two great parts. The first contains the history of the alterations common to each system, whatever may be the organ in the structure of which it is concerned, or whatever may be the place it occupies. It is necessary to show at first the different alterations of the cellular, arterial, venous, nervous, osseous, muscular, mucous, serous, synovial, glandular, cutaneous textures, &c. to examine the kind of inflammation, suppuration, gangrene, &c. peculiar to each; to speak of the different enlargements of which they are susceptible, the changes in their nature, which they undergo, &c. Some, as the mucous, the cutaneous, the serous, the glandular, &c. afford in this respect an immense field to morbid anatomy. The others, as the fibrous, the nervous, the muscular, &c. are more rarely changed in their texture. We shall see hereafter that nutrition alone is performed in these, and that the others are particularly the seat of exhalation, absorption, secretion, &c. functions which suppose much energy in the insensible contractility and organic sensibility, which are connected with all the alterations of texture.

After having thus pointed out the alterations peculiar to each system, in whatever organ it is found, an examination should be made of the diseases peculiar to each region; as those of the head, the chest, the abdomen, and the extremities, after the common method. Here they may be divided, 1st. into diseases which can especially affect an organ as a whole, and not one of its textures alone, which is very rare. 2d. Into the characters peculiar to each portion of this or that texture; for example in the head, the peculiar symptoms which are seen in diseases of the serous surface of the tunica arachnoides, those in affections of the mucous surface of the pituitary membrane, &c.

This course is incontestably the most natural, though, as in all divisions in which we wish to copy nature, there are many cases which it almost excludes.

It seems to me that we live at a period, when morbid anatomy should take a higher stand. This science is not only that of organic derangements, that take place slowly, as the principles or consequences of chronic diseases, it consists in the examination of all the alterations our organs can undergo, at any period in which we may observe their diseases. With the exception of certain kinds of fevers and nervous affections, every thing in pathology is within the province of this science. How weak appears the reasoning of many great physicians, when we examine it, not in their works, but on the dead body. Medicine was for a long time excluded from the circle of the exact sciences; it will have a right to be associated with them, at least in the diagnostics of diseases, when we shall every where unite to accurate observation, an examination of the changes our organs undergo. This course is beginning to be that of all rational minds; it will without doubt soon be general. What is observation worth, if we are ignorant of the seat of the disease? You may take notes, for twenty years, from morning to night at the bedside of the sick, upon the diseases of the heart, the lungs, the gastric viscera, &c. and all will be to you only a confusion of symptoms, which, not being united in one point, will necessarily present only a train of incoherent phenomena. Open a few bodies, this obscurity will soon disappear, which observation alone would never have been able to have dissipated.

VIII. _Remarks upon the classification of functions._

The plan that I have followed in this work, is not the most favourable to the study of the functions. Many of them, such as digestion, respiration, &c. would find no place here, because they do not belong especially to the simple systems, but to a combination of them, an union of many systems, and even of many organs. Thus what I have said upon the functions, is introduced only incidentally in this work, the particular object of which is the analysis of the different simple systems that form the compound organs. However, as some would wish to connect the different facts of physiology that it contains, with a physiological classification, I will now explain that which I have adopted in my course of lectures.

We know how different the kinds of classification are. The ancient division, into animal, vital, and natural functions, rests upon so weak a foundation, that a methodical superstructure could not be raised upon it. Vicq d'Azyr has substituted one for it which offers hardly any more advantages, as it separates phenomena that are connected, and changes into functions, properties, such as sensibility, irritability, &c. Since this author, others have made divisions which are not more methodical, and are equally removed from the natural arrangement of the phenomena of life.

I have endeavoured, as far as possible, in classing the functions, to follow the path marked out by nature herself. I have laid, in my work upon Life and Death, the foundations of this classification, which I pursued before I published this work. Aristotle, Buffon, &c. have seen in man two kinds of functions, one which connects him with external bodies, the other, which serves for his nourishment. Grimaud brought forward again this idea, which is as great as it is true, in his course of physiology and in his memoir upon nutrition; but by considering it in too general a manner, he did not analyze it with sufficient exactness, he ranked among the external functions, only sensation and motion, he did not describe the brain as the centre of these functions, nor place the voice among them, which is however one of the great means of communication, with the bodies that surround us. He did not analyze more accurately the internal functions. He did not point out their connexion in the elaboration of nutritive matter, where each works in its turn, if I may so express myself; nor show the distinctive characters, which separate generation from all the other functions relating to the individual alone. Besides, the distinction of internal and external functions was only presented as a general sketch in his Memoir upon Nutrition, and not as a means of classification. He did not avail himself of it, in the division of the functions, in his lectures, of which many manuscripts arranged by himself, are to be met with at the present time; in these he examined, 1st. osteogony, which was treated at much length; 2d. the action of the muscles; 3d. the action of the vessels or the circulation; 4th. generation; 5th. the action of the organs of the senses; 6th. the action of the brain and nerves; 7th. digestion; 8th. secretion; 9th. respiration, &c. From this it may be perceived, that Grimaud, like preceding authors, mixed together all the functions without referring them to certain general heads.

In reflecting upon the division pointed out above, I soon saw that it was not only one of those general views, one of those great outlines, that are oftentimes made by men of genius who cultivate physiology, but that it might become the permanent basis of a methodical classification. To come at this classification I observed that it was necessary at first to refer all the functions to two great classes, one relating to the individual, the other to the species; that these two classes had nothing in common, but the general connexion that unites all the phenomena of living bodies; but a variety of distinctive attributes characterize them, which cannot be separated from them.

These two first classes being rigorously defined, and their limits established by nature, I sought to discover in each, orders equally natural; this was easy in the functions relating to the individual. In fact, this was the place for the general outline of Aristotle and Buffon; but it was not to be presented in too general a manner; the nature and connexion of the functions peculiar to each order, were to be accurately assigned.

I called the order of functions that connects us with external bodies, animal life, thus indicating that this order belongs alone to animals, that it is more with them than with vegetables, and that it is the addition of these functions that particularly distinguishes them from vegetables. I called organic life, the order that serves for the constant composition and decomposition of our bodies, because this life is common to all organized beings, vegetables as well as animals; and because the only condition of enjoying it is organization; so that it forms a boundary between organic and inorganic bodies, as animal life serves to separate the two classes that form the first.

Animal life is composed of the action of the senses which receive impressions, of the brain which perceives them, reflects, and wills, of the voluntary muscles and larynx that execute this volition, and of the nerves which are the agents of transmission. The brain is truly the central organ of this life. Digestion, circulation, respiration, exhalation, absorption, secretion, nutrition, calorification, compose organic life, which has the heart for its principal and central organ.

I place calorification here, because it is evident from what I have said under the article upon the capillary systems, that it is a function analogous to secretion, exhalation and nutrition. It is truly a separation of combined caloric, from the mass of blood. It is, if the expression is preferred, a secretion or exhalation of that fluid in every part of the body. I have not even at present given this place to heat in my physiological classification: but in reflecting upon the method of its production, it will be seen that it ought to have it.

The two orders of the first class being established, it was easy to assign those of the second, which are three in number: 1st. functions belonging to the male; 2d. those belonging to the female; 3d. those arising from an union of the two sexes and the product of this union; these are the three orders.