PATHOLOGIC PHYSIOLOGY, A NEGLECTED 
 FIELD. 
 
 CHAIRMAN’S ADDRESS BEFORE THE SECTION ON PATH- 
 OLOGY AND PHYSIOLOGY, AT THE FIFTY-SIXTH ANNUAL 
 SESSION OF THE AMERICAN MEDICAL ASSOCIATION 
 PORTLAND, ORE., JULY 11-14, 1905. 
 
 WINFIELD S. HALL, Ph.D., M.D. 
 
 Professor of Physiology, Northwestern University Medical School. 
 CHICAGO. 
 
 Not many generations ago physiology was taught in 
 connection with anatomy only, and was a simple state- 
 ment of the functions, as then understood, of the vari- 
 ous structures described by the anatomist. It was Haller, 
 who in his ^^Elements of Physiology,^^^ outlined the field 
 of physiology and clearly established the boundary line 
 between that subject and anatomy. Since Haller’s time 
 physiology has been recognized as a separate branch of 
 medicine and soon after the publication of Haller’s Ele- 
 ments, provision began to be made by the medical fac- 
 ulties for the teaching of this subject in a separate de- 
 partment. 
 
 Begun as an appendage of normal human anatomy, it 
 continued as normal human physiology, gradually broad- 
 ening into animal and plant physiology. Great as has 
 been the activity in the field of morphology, that in the 
 field of physiology has been scarcely less until the mass 
 of facts and principles of physiology already firmly es- 
 tablished is so great that tiie two years’ course in experi- 
 
 1. Elementa Physlologlse, In six volumes, 1757-1765. 
 
 P 154.JO 
 
2 
 
 mental and didactic instruction in physiology now usu- 
 ally given in medical schools suffices simply to present 
 such fundamental principles and facts of the science 
 as may be applied later in clinical medicine. Further- 
 more, great as this material is, it includes only the dis- 
 cussion of the functions of the normal individual. In 
 other words, the course of physiology as now given is 
 one in normal physiology only. 
 
 If we turn now to the subject of pathology as pre- 
 sented to-day in our medical schools, we find that 
 histopathology — presented usually in the second year — 
 deals almost exclusively with modifications of the struct- 
 ure of the cells and tissues of the body, while the didac- 
 tic course accompanying the microscopic work deals 
 usually with the field of general pathology covering 
 such topics as hydremia, anemia, hemorrhage, transu- 
 dation, thrombosis and embolism; atrophy, degenera- 
 tion, pigmentation and necrosis; hypertrophy, hyper- 
 plasia, metaplasia and regeneration; inflammation; 
 parasites, animal and plant; the relation of micro-or- 
 ganisms to disease, infection and immunity; infectious 
 diseases ; tumors. 
 
 One searches the chapters of general pathology in vain 
 for any sections that deal adequately with the problem 
 of the physiology of disease. 
 
 Taking up the field of special pathology as* usually 
 presented in the third and fourth years of the medical 
 course, one finds that the postmortem furnishes the 
 material for study. The points of fundamental impor- 
 tance at the postmortem as it is conducted by our lead- 
 ing pathologists are: (1) To confirm, or disaffirm, the 
 diagnosis of the condition as made by the attending phy- 
 sician; (2) to gain information that will make the diag- 
 nosis of similar cases more secure in the future; (3) 
 to increase our knowledge of diseased conditions of the 
 
3 
 
 
 body. With these ends in view it is customary to preface 
 the postmortem examination by the reading of the clin- 
 ical history of the case in hand, followed by, first, an 
 examination of the body to determine gross conditions, 
 demonstrating all evident changes of the gross conditions 
 as the examination proceeds ; second, preserving portions 
 of each diseased tissue or organ for later microscopic 
 examination. Such a postmortem examination requires 
 from one to two hours, not including the many hours 
 that may be later devoted to the study of microscopic 
 changes. 
 
 The accumulated material from the numerous post- 
 mortems affords museum material for gross study as 
 well as microscopic material for study in connection with 
 various topics in clinical pathology. 
 
 I believe that the above account, though brief, gives a 
 fair summary of the work now being accomplished in our 
 pathologic laboratories. I think it is not unfair to other 
 departments of the medical school to say that the work 
 of the pathologic department is the most important 
 work in any one department of the medical course, and 
 the work now given in the larger institutions could 
 hardly be improved on in the time that is devoted to it. 
 
 ' It appears to me, however, that a very important phase 
 of pathology and physiology has as yet received scant 
 attention from medical teachers. The postmortem af- 
 fords a golden opportunity for the study of the clinical 
 history, particularly of the symptomatology, of the case 
 in the light of the postmortem findings. The symptoma- 
 tology of disease represents nothing more or less than 
 modified functions as observed in diseased conditions. 
 That there is a definite relation between the symptoms 
 observable in a disease and structural changes that go 
 on in the cells, tissues or organs can not be gainsaid. 
 It may be difficult to establish this relation, but the 
 
4 
 
 pathologists should not be satisfied with their work 
 until eyery disturbance of function has been traced to 
 some disturbance of structure. The disturbance of 
 structure accompanying malnutrition might be so slight 
 as the simple difference in the zymogen granules of the 
 pancreas, or in some obscure physical or physico-chem- 
 ical change in the cells of the thyroid gland, while a 
 derangement of the mind might be associated with a 
 slight change in the Mssl granules in the cortical cells of 
 the brain, or in a slight modification in the space rela- 
 tions (^‘^contiguity”) of cell-processes in the brain cen- 
 ters. 
 
 As stated above, the postmortem affords an opportun- 
 ity for the study of the relation of disturbed function 
 (symptomatology) to the diseased structure. Such an 
 attempt on the part of the pathologist to enter into the 
 discussion of this problem in connection with the post- 
 mortem examination would involve the expenditure of 
 at least twice as much time as is usually now spent on a 
 postmortem examination. In many cases this would 
 entail the necessity of making fewer postmortem exam- 
 inations than is desirable. 
 
 The question might be asked, “Why should not the 
 physiologist cover this field and present to the students 
 normal and pathologic physiology We will say in 
 answer to that question: The physiologist presents nor- 
 mal physiology during the first two years of the medical 
 course. The students have not progressed far enough 
 in the study of pathologic conditions to enter under- 
 standingly into a consideration of the relation between 
 symptomatology and pathology. Thus we find that im- 
 portant as this field is, neither the physiologist nor the 
 pathologist — one for the lack of preparation of his stu- 
 dents, the other for the lack of time — can take up this 
 most important subject. The student therefore enters 
 
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5 
 
 
 on the study of clinical medicine and surgery with a 
 knowledge of normal structure and function, and also 
 a knowledge of diseased structure, but no knowledge of 
 diseased function. The clinician, in his presentation of 
 a clinical case, may or may not discuss the symptomatol- 
 ogy of a case from the standpoint of physiology. If an 
 attempt is made at this at all it is more or less inci- 
 dental to the discussion of diagnosis, of differential di- 
 agnosis and therapeutics. The relation of symptoma- 
 tology to diagnosis on the one hand and to therapeutics 
 on the other, so far overshadows in the mind of the clin- 
 ician its relation to pathology on the one hand and nor- 
 mal physiology on the other, that very little attention 
 is given to these last two phases of symptomatology. 
 
 I believe that the most important step to be taken in 
 scientific medicine is, first, to determine and next to 
 teach every student of medicine the relation between 
 symptomatology and pathology, and this teaching should 
 be a systematic course given to students taking clinical 
 medicine and surgery, and should be divorced from any 
 discussion of diagnosis or therapeutics, so that the un- 
 divided attention of both student and instructor would 
 be directed to the solution' of problems of the relation 
 of modified function (symptomatology), to modified 
 structure (pathology). It might be given by a pathol- 
 ogist, a physiologist or a clinician. In either case the 
 preparation of the instructor could not be deemed ade- 
 quate unless he were well versed not only in physiology 
 and pathology, but also in clinical medicine. 
 
 One naturally asks at this point whether there exists 
 a literature of this subject. Krehl, professor of inter- 
 nal medicine, University of Strassburg, Germany, has 
 prepared a most admirable work of 600 pages entitled 
 ^Tathologic Physiology; A Treatise for Students and 
 
 
6 
 
 Physicians/^^ The third edition of this work was pub- 
 dished' in Leipsic in 1904, The first edition appeared 
 
 about a decade ago. Earlier editions were not trans- 
 lated into English, and it has had a very limited use in 
 Germany and among advanced men in other lands. An 
 English translation of this admirable work is just now 
 completed by Dr. Hewlett of J ohns Hopkins University. 
 Professor Krehl treats this subject from the standpoint 
 of the clinician following the classification of the path- 
 ologist, and harmonizing his treatment at every point 
 with the latest findings in physiology. 
 
 The question of the classification of the subject-mat- 
 ter is one of no small importance, and is a question to 
 which I have given considerable thought. Eor the pur- 
 poses of the physiologist and the pathologist, Krehhs 
 method is advantageous. It is, however, questionable 
 if such a classification would make the work as conven- 
 ient as a manual for the student and practitioner as 
 would a classification on the basis of diseases, following 
 that of works on internal medicine. 
 
 A preliminary chapter or ^^part^^ of such a treatise 
 should deal with general pathologic physiology, setting 
 forth ’the relation between the various disturbances of 
 function and various lesions of disease. Eor example : 
 Variations of pulse, with causes of same; variations of 
 peripheral circulation, with causes for same; variations 
 if distribution of blood, with causes of same; variations 
 of rate or character of respiration, with causes; varia- 
 tions of digestive processes, with causes of same; and 
 so on briefly throughout the list of body functions. 
 
 Following this should be the main body of the treat- 
 ise in which diseases of the circulatory system might oc- 
 cupy the opening chapter. Taking up any particular 
 
 2. Pathologische Physiologie, 3rd Edition, by Dr. Ludolph Krehl. 
 Published by Vogel, Leipzig, 1904. 
 
disease there should be a brief description of a typical 
 case as to etiology, pathology and symptomatology. Un- 
 der the head of pathologic physiology, each S3rmptom 
 should be discussed as to its causes and its relation to 
 the pathologic findings. Diagnosis and treatment need 
 not be mentioned. The discussion of typical cases of 
 each disease would suffice. 
 
 I present a plea for the preparation of such a manual 
 as above outlined and for such a course as above sug- 
 gested, because I believe these are the most urgent needs 
 of medical pedagogy.