Chapter 22

It may be added, that it is not easy to see in what way it could have benefited a physician of Alexander's time to know all that Aristotle knew on these subjects. His human anatomy was too rough to avail much in diagnosis; his physiology was too erroneous to supply data for pathological reasoning. But when the Alexandrian school, with Erasistratus and Herophilus at their head, turned to account the opportunities of studying human structure, afforded to them by the Ptolemies, the value of the large amount of accurate knowledge thus obtained to the surgeon for his operations, and to the physician for his diagnosis of internal disorders, became obvious, and a connection was established between anatomy and medicine, which has ever become closer and closer. Since the revival of learning, surgery, medical diagnosis, and anatomy have gone hand in hand. Morgagni called his great work, "De sedibus et causis morborum per anatomen indagatis," and not only showed the way to search out the localities and the causes of disease by anatomy, but himself travelled wonderfully far upon the road. Bichat, discriminating the grosser constituents of the organs and parts of the body, one from another, pointed out the direction which modern research must take; until, at length, histology, a science of yesterday, as it seems to many of us, has carried the work of Morgagni as far as the microscope can take us, and has extended the realm of pathological anatomy to the limits of the invisible world.

Thanks to the intimate alliance of morphology with medicine, the natural history of disease has, at the present day, attained a high degree of perfection. Accurate regional anatomy has rendered practicable the exploration of the most hidden parts of the organism, and the determination, during life, of morbid changes in them; anatomical and histological post-mortem investigations have supplied physicians with a clear basis upon which to rest the classification, of diseases, and with unerring tests of the accuracy or inaccuracy of their diagnoses.

If men could be satisfied with pure knowledge, the extreme precision with which, in these days, a sufferer may be told what is happening, and what is likely to happen, even in the most recondite parts of his bodily frame, should be as satisfactory to the patient as it is to the scientific pathologist who gives him the information. But I am afraid it is not; and even the practising physician, while nowise under-estimating the regulative value of accurate diagnosis, must often lament that so much of his knowledge rather prevents him from doing wrong than helps him to do right.

A scorner of physic once said that nature and disease may be compared to two men fighting, the doctor to a blind man with a club, who strikes into the _mêlée_, sometimes hitting the disease, and sometimes hitting nature. The matter is not mended if you suppose the blind man's hearing to be so acute that he can register every stage of the struggle, and pretty clearly predict how it will end. He had better not meddle at all, until his eyes are opened, until he can see the exact position of the antagonists, and make sure of the effect of his blows. But that which it behoves the physician to see, not, indeed, with his bodily eye, but with clear, intellectual vision, is a process, and the chain of causation involved in that process. Disease, as we have seen, is a perturbation of the normal activities of a living body, and it is, and must remain, unintelligible, so long as we are ignorant of the nature of these normal activities. In other words, there could be no real science of pathology until the science of physiology had reached a degree of perfection unattained, and indeed unattainable, until quite recent times.

So far as medicine is concerned, I am not sure that physiology, such as it was down to the time of Harvey, might as well not have existed. Nay, it is perhaps no exaggeration to say that, within the memory of living men, justly renowned practitioners of medicine and surgery knew less physiology than is now to be learned from the most elementary text-book; and, beyond a few broad facts, regarded what they did know as of extremely little practical importance. Nor am I disposed to blame them for this conclusion; physiology must be useless, or worse than useless, to pathology, so long as its fundamental conceptions are erroneous.

Harvey is often said to be the founder of modern physiology; and there can be no question that the elucidations of the function of the heart, of the nature of the pulse, and of the course of the blood, put forth in the ever-memorable little essay, "De motu cordis," directly worked a revolution in men's views of the nature and of the concatenation of some of the most important physiological processes among the higher animals; while, indirectly, their influence was perhaps even more remarkable.

But, though Harvey made this signal and perennially important contribution to the physiology of the moderns, his general conception of vital processes was essentially identical with that of the ancients; and, in the "Exercitationes de generatione," and notably in the singular chapter "De calido innato," he shows himself a true son of Galen and of Aristotle.

For Harvey, the blood possesses powers superior to those of the elements; it is the seat of a soul which is not only vegetative, but also sensitive and motor. The blood maintains and fashions all parts of the body, "idque summâ cum providentiâ et intellectu in finem certum agens, quasi ratiocinio quodam uteretur."

Here is the doctrine of the "pneuma," the product of the philosophical mould into which the animism of primitive men ran in Greece, in full force. Nor did its strength abate for long after Harvey's time. The same ingrained tendency of the human mind to suppose that a process is explained when it is ascribed to a power of which nothing is known except that it is the hypothetical agent of the process, gave rise, in the next century, to the animism of Stahl; and, later, to the doctrine of a vital principle, that "asylum ignorantiae" of physiologists, which has so easily accounted for everything and explained nothing, down to our own times.

Now the essence of modern, as contrasted with ancient, physiological science appears to me to lie in its antagonism to animistic hypotheses and animistic phraseology. It offers physical explanations of vital phenomena, or frankly confesses that it has none to offer. And, so far as I know, the first person who gave expression to this modern view of physiology, who was bold enough to enunciate the proposition that vital phenomena, like all the other phenomena of the physical world, are, in ultimate analysis, resolvable into matter and motion, was René Descartes.

The fifty-four years of life of this most original and powerful thinker are widely overlapped, on both sides, by the eighty of Harvey, who survived his younger contemporary by seven years, and takes pleasure in acknowledging the French philosopher's appreciation of his great discovery.

In fact, Descartes accepted the doctrine of the circulation as propounded by "Harvaeus médecin d'Angleterre," and gave a full account of it in his first work, the famous "Discours de la Méthode," which was published in 1637, only nine years after the exercitation "De motu cordis"; and, though differing from Harvey on some important points (in which it may be noted, in passing, Descartes was wrong and Harvey right), he always speaks of him with great respect. And so important does the subject seem to Descartes, that he returns to it in the "Traité des Passions," and in the "Traité de l'Homme."

It is easy to see that Harvey's work must have had a peculiar significance for the subtle thinker, to whom we owe both the spiritualistic and the materialistic philosophies of modern times. It was in the very year of its publication, 1628, that Descartes withdrew into that life of solitary investigation and meditation of which his philosophy was the fruit. And, as the course of his speculations led him to establish an absolute distinction of nature between the material and the mental worlds, he was logically compelled to seek for the explanation of the phenomena of the material world within itself; and having allotted the realm of thought to the soul, to see nothing but extension and motion in the rest of nature. Descartes uses "thought" as the equivalent of our modern term "consciousness." Thought is the function of the soul, and its only function. Our natural heat and all the movements of the body, says he, do not depend on the soul. Death does not take place from any fault of the soul, but only because some of the principal parts of the body become corrupted. The body of a living man differs from that of a dead man in the same way as a watch or other automaton (that is to say, a machine which moves of itself) when it is wound up and has, in itself, the physical principle of the movements which the mechanism is adapted to perform, differs from the same watch, or other machine, when it is broken, and the physical principle of its movement no longer exists. All the actions which are common to us and the lower animals depend only on the conformation of our organs, and the course which the animal spirits take in the brain, the nerves, and the muscles; in the same way as the movement of a watch is produced by nothing but the force of its spring and the figure of its wheels and other parts.

Descartes' "Treatise on Man" is a sketch of human physiology, in which a bold attempt is made to explain all the phenomena of life, except those of consciousness, by physical reasonings. To a mind turned in this direction, Harvey's exposition of the heart and vessels as a hydraulic mechanism must have been supremely welcome.

Descartes was not a mere philosophical theorist, but a hardworking dissector and experimenter, and he held the strongest opinion respecting the practical value of the new conception which he was introducing. He speaks of the importance of preserving health, and of the dependence of the mind on the body being so close that, perhaps, the only way of making men wiser and better than they are, is to be sought in medical science. "It is true," says he, "that as medicine is now practised it contains little that is very useful; but without any desire to depreciate, I am sure that there is no one, even among professional men, who will not declare that all we know is very little as compared with that which remains to be known; and that we might escape an infinity of diseases of the mind, no less than of the body, and even perhaps from the weakness of old age, if we had sufficient knowledge of their causes, and of all the remedies with which nature has provided us." [1] So strongly impressed was Descartes with this, that he resolved to spend the rest of his life in trying to acquire such a knowledge of nature as would lead to the construction of a better medical doctrine. [2] The anti-Cartesians found material for cheap ridicule in these aspirations of the philosopher; and it is almost needless to say that, in the thirteen years which elapsed between the publication of the "Discours" and the death of Descartes, he did not contribute much to their realisation. But, for the next century, all progress in physiology took place along the lines which Descartes laid down.

The greatest physiological and pathological work of the seventeenth century, Borelli's treatise "De Motu Animalium," is, to all intents and purposes, a development of Descartes' fundamental conception; and the same may be said of the physiology and pathology of Boerhaave, whose authority dominated in the medical world of the first half of the eighteenth century.

With the origin of modern chemistry, and of electrical science, in the latter half of the eighteenth century, aids in the analysis of the phenomena of life, of which Descartes could not have dreamed, were offered to the physiologist. And the greater part of the gigantic progress which has been made in the present century is a justification of the prevision of Descartes. For it consists, essentially, in a more and more complete resolution of the grosser organs of the living body into physicochemical mechanisms.

"I shall try to explain our whole bodily machinery in such a way, that it will be no more necessary for us to suppose that the soul produces such movements as are not voluntary, than it is to think that there is in a clock a soul which causes it to show the hours." [3] These words of Descartes might be appropriately taken as a motto by the author of any modern treatise on physiology.

But though, as I think, there is no doubt that Descartes was the first to propound the fundamental conception of the living body as a physical mechanism, which is the distinctive feature of modern, as contrasted with ancient physiology, he was misled by the natural temptation to carry out, in all its details, a parallel between the machines with which he was familiar, such as clocks and pieces of hydraulic apparatus, and the living machine. In all such machines there is a central source of power, and the parts of the machine are merely passive distributors of that power. The Cartesian school conceived of the living body as a machine of this kind; and herein they might have learned from Galen, who, whatever ill use he may have made of the doctrine of "natural faculties," nevertheless had the great merit of perceiving that local forces play a great part in physiology.

The same truth was recognised by Glisson, but it was first prominently brought forward in the Hallerian doctrine of the "vis insita" of muscles. If muscle can contract without nerve, there is an end of the Cartesian mechanical explanation of its contraction by the influx of animal spirits.

The discoveries of Trembley tended in the same direction. In the freshwater _Hydra_, no trace was to be found of that complicated machinery upon which the performance of the functions in the higher animals was supposed to depend. And yet the hydra moved, fed, grew, multiplied, and its fragments exhibited all the powers of the whole. And, finally, the work of Caspar F. Wolff, [4] by demonstrating the fact that the growth and development of both plants and animals take place antecedently to the existence of their grosser organs, and are, in fact, the causes and not the consequences of organisation (as then understood), sapped the foundations of the Cartesian physiology as a complete expression of vital phenomena.

For Wolff, the physical basis of life is a fluid, possessed of a "vis essentialis" and a "solidescibilitas," in virtue of which it gives rise to organisation; and, as he points out, this conclusion strikes at the root of the whole iatro-mechanical system.

In this country, the great authority of John Hunter exerted a similar influence; though it must be admitted that the too sibylline utterances which are the outcome of Hunter's struggles to define his conceptions are often susceptible of more than one interpretation. Nevertheless, on some points Hunter is clear enough. For example, he is of opinion that "Spirit is only a property of matter" ("Introduction to Natural History," p. 6), he is prepared to renounce animism, (_l.c._ p. 8), and his conception of life is so completely physical that he thinks of it as something which can exist in a state of combination in the food. "The aliment we take in has in it, in a fixed state, the real life; and this does not become active until it has got into the lungs; for there it is freed from its prison" ("Observations on Physiology," p. 113). He also thinks that "It is more in accord with the general principles of the animal machine to suppose that none of its effects are produced from any mechanical principle whatever; and that every effect is produced from an action in the part; which action is produced by a stimulus upon the part which acts, or upon some other part with which this part sympathises so as to take up the whole action" (_l.c._ p. 152).

And Hunter is as clear as Wolff, with whose work he was probably unacquainted, that "whatever life is, it most certainly does not depend upon structure or organisation" (_l.c._ p. 114).

Of course it is impossible that Hunter could have intended to deny the existence of purely mechanical operations in the animal body. But while, with Borelli and Boerhaave, he looked upon absorption, nutrition, and secretion as operations effected by means of the small vessels, he differed from the mechanical physiologists, who regarded these operations as the result of the mechanical properties of the small vessels, such as the size, form, and disposition of their canals and apertures. Hunter, on the contrary, considers them to be the effect of properties of these vessels which are not mechanical but vital. "The vessels," says he, "have more of the polypus in them than any other part of the body," and he talks of the "living and sensitive principles of the arteries," and even of the "dispositions or feelings of the arteries." "When the blood is good and genuine the sensations of the arteries, or the dispositions for sensation, are agreeable.... It is then they dispose of the blood to the best advantage, increasing the growth of the whole, supplying any losses, keeping up a due succession, etc." (_l.c._ p. 133).

If we follow Hunter's conceptions to their logical issue, the life of one of the higher animals is essentially the sum of the lives of all the vessels, each of which is a sort of physiological unit, answering to a polype; and, as health is the result of the normal "action of the vessels," so is disease an effect of their abnormal action. Hunter thus stands in thought, as in time, midway between Borelli on the one hand, and Bichat on the other.

The acute founder of general anatomy, in fact, outdoes Hunter in his desire to exclude physical reasonings from the realm of life. Except in the interpretation of the action of the sense organs, he will not allow physics to have anything to do with physiology.

"To apply the physical sciences to physiology is to explain the phenomena of living bodies by the laws of inert bodies. Now this is a false principle, hence all its consequences are marked with the same stamp. Let us leave to chemistry its affinity; to physics, its elasticity and its gravity. Let us invoke for physiology only sensibility and contractility." [5]

Of all the unfortunate dicta of men of eminent ability this seems one of the most unhappy, when we think of what the application of the methods and the data of physics and chemistry has done towards bringing physiology into its present state. It is not too much to say that one-half of a modern text-book of physiology consists of applied physics and chemistry; and that it is exactly in the exploration of the phenomena of sensibility and contractility that physics and chemistry have exerted the most potent influence.

Nevertheless, Bichat rendered a solid service to physiological progress by insisting upon the fact that what we call life, in one of the higher animals, is not an indivisible unitary archaeus dominating, from its central seat, the parts of the organism, but a compound result of the synthesis of the separate lives of those parts.

"All animals," says he, "are assemblages of different organs, each of which performs its function and concurs, after its fashion, in the preservation of the whole. They are so many special machines in the general machine which constitutes the individual. But each of these special machines is itself compounded of many tissues of very different natures, which in truth constitute the elements of those organs" (_l.c._ lxxix.). "The conception of a proper vitality is applicable only to these simple tissues, and not to the organs themselves" (_l.c._ lxxxiv.).

And Bichat proceeds to make the obvious application of this doctrine of synthetic life, if I may so call it, to pathology. Since diseases are only alterations of vital properties, and the properties of each tissue are distinct from those of the rest, it is evident that the diseases of each tissue must be different from those of the rest. Therefore, in any organ composed of different tissues, one may be diseased and the other remain healthy; and this is what happens in most cases (_l.c._ lxxxv.).

In a spirit of true prophecy, Bichat says, "We have arrived at an epoch in which pathological anatomy should start afresh." For, as the analysis of the organs had led him to the tissues as the physiological units of the organism; so, in a succeeding generation, the analysis of the tissues led to the cell as the physiological element of the tissues. The contemporaneous study of development brought out the same result; and the zoologists and botanists, exploring the simplest and the lowest forms of animated beings, confirmed the great induction of the cell theory. Thus the apparently opposed views, which have been battling with one another ever since the middle of the last century, have proved to be each half the truth.

The proposition of Descartes that the body of a living man is a machine, the actions of which are explicable by the known laws of matter and motion, is unquestionably largely true. But it is also true, that the living body is a synthesis of innumerable physiological elements, each of which may nearly be described, in Wolff's words, as a fluid possessed of a "vis essentialis" and a "solidescibilitas"; or, in modern phrase, as protoplasm susceptible of structural metamorphosis and functional metabolism: and that the only machinery, in the precise sense in which the Cartesian school understood mechanism, is, that which co-ordinates and regulates these physiological units into an organic whole.

In fact, the body is a machine of the nature of an army, not of that of a watch or of a hydraulic apparatus. Of this army each cell is a soldier, an organ a brigade, the central nervous system headquarters and field telegraph, the alimentary and circulatory system the commissariat. Losses are made good by recruits born in camp, and the life of the individual is a campaign, conducted successfully for a number of years, but with certain defeat in the long run.

The efficacy of an army, at any given moment, depends on the health of the individual soldier, and on the perfection of the machinery by which he is led and brought into action at the proper time; and, therefore, if the analogy holds good, there can be only two kinds of diseases, the one dependent on abnormal states of the physiological units, the other on perturbations of their co-ordinating and alimentative machinery.

Hence, the establishment of the cell theory, in normal biology, was swiftly followed by a "cellular pathology," as its logical counterpart. I need not remind you how great an instrument of investigation this doctrine has proved in the hands of the man of genius to whom its development is due, and who would probably be the last to forget that abnormal conditions of the co-ordinative and distributive machinery of the body are no less important factors of disease.

Henceforward, as it appears to me, the connection of medicine with the biological sciences is clearly indicated. Pure pathology is that branch of biology which defines the particular perturbation of cell-life, or of the co-ordinating machinery, or of both, on which the phenomena of disease depend.