Part 28

Taken in this broad sense, "medicine" not merely denotes a kind of knowledge, but it comprehends the various applications of that knowledge to the alleviation of the sufferings, the repair of the injuries, and the conservation of the health, of living beings. In fact, the practical aspect of medicine so far dominates over every other, that the "Healing Art" is one of its most widely-received synonyms. It is so difficult to think of medicine otherwise than as something which is necessarily connected with curative treatment, that we are apt to forget that there must be, and is, such a thing as a pure science of medicine--a "pathology" which has no more necessary subservience to practical ends than has zoology or botany.

The logical connection between this purely scientific doctrine of disease, or pathology, and ordinary biology, is easily traced. Living matter is characterised by its innate tendency to exhibit a definite series of the morphological and physiological phenomena which constitute organisation and life. Given a certain range of conditions, and these phenomena remain the same, within narrow limits, for each kind of living thing. They furnish the normal and typical character of the species, and, as such, they are the subject-matter of ordinary biology.

Outside the range of these conditions, the normal course of the cycle of vital phenomena is disturbed; abnormal structure makes its appearance, or the proper character and mutual adjustment of the functions cease to be preserved. The extent and the importance of these deviations from the typical life may vary indefinitely. They may have no noticeable influence on the general well-being of the economy, or they may favour it. On the other hand, they may be of such a nature as to impede the activities of the organism, or even to involve its destruction.

In the first case, these perturbations are ranged under the wide and somewhat vague category of "variations"; in the second, they are called lesions, states of poisoning, or diseases; and, as morbid states, they lie within the province of pathology. No sharp line of demarcation can be drawn between the two classes of phenomena. No one can say where anatomical variations end and tumours begin, nor where modification of function, which may at first promote health, passes into disease. All that can be said is, that whatever change of structure or function is hurtful belongs to pathology. Hence it is obvious that pathology is a branch of biology; it is the morphology, the physiology, the distribution, the aetiology of abnormal life.

However obvious this conclusion may be now, it was nowise apparent in the infancy of medicine. For it is a peculiarity of the physical sciences that they are independent in proportion as they are imperfect; and it is only as they advance that the bonds which really unite them all become apparent. Astronomy had no manifest connection with terrestrial physics before the publication of the "Principia"; that of chemistry with physics is of still more modern revelation; that of physics and chemistry with physiology, has been stoutly denied within the recollection of most of us, and perhaps still may be.

Or, to take a case which affords a closer parallel with that of medicine. Agriculture has been cultivated from the earliest times, and, from a remote antiquity, men have attained considerable practical skill in the cultivation of the useful plants, and have empirically established many scientific truths concerning the conditions under which they flourish. But, it is within the memory of many of us, that chemistry on the one hand, and vegetable physiology on the other, attained a stage of development such that they were able to furnish a sound basis for scientific agriculture. Similarly, medicine took its rise in the practical needs of mankind. At first, studied without reference to any other branch of knowledge, it long maintained, indeed still to some extent maintains, that independence. Historically, its connection with the biological sciences has been slowly established, and the full extent and intimacy of that connection are only now beginning to be apparent. I trust I have not been mistaken in supposing that an attempt to give a brief sketch of the steps by which a philosophical necessity has become an historical reality, may not be devoid of interest, possibly of instruction, to the members of this great Congress, profoundly interested as all are in the scientific development of medicine.

The history of medicine is more complete and fuller than that of any other science, except, perhaps, astronomy; and, if we follow back the long record as far as clear evidence lights us, we find ourselves taken to the early stages of the civilisation of Greece. The oldest hospitals were the temples of Aesculapius; to these Asclepeia, always erected on healthy sites, hard by fresh springs and surrounded by shady groves, the sick and the maimed resorted to seek the aid of the god of health. Votive tablets or inscriptions recorded the symptoms, no less than the gratitude, of those who were healed; and, from these primitive clinical records, the half-priestly, half-philosophic caste of the Asclepiads compiled the data upon which the earliest generalisations of medicine, as an inductive science, were based.

In this state, pathology, like all the inductive sciences at their origin, was merely natural history; it registered the phenomena of disease, classified them, and ventured upon a prognosis, wherever the observation of constant co-existences and sequences suggested a rational expectation of the like recurrence under similar circumstances.

Further than this it hardly went. In fact, in the then state of knowledge, and in the condition of philosophical speculation at that time, neither the causes of the morbid state, nor the rationale of treatment, were likely to be sought for as we seek for them now. The anger of a god was a sufficient reason for the existence of a malady, and a dream ample warranty for therapeutic measures; that a physical phenomenon must needs have a physical cause was not the implied or expressed axiom that it is to us moderns.

The great man whose name is inseparably connected with the foundation of medicine, Hippocrates, certainly knew very little, indeed practically nothing, of anatomy or physiology; and he would, probably, have been perplexed even to imagine the possibility of a connection between the zoological studies of his contemporary Democritus and medicine. Nevertheless, in so far as he, and those who worked before and after him, in the same spirit, ascertained, as matters of experience, that a wound, or a luxation, or a fever, presented such and such symptoms, and that the return of the patient to health was facilitated by such and such measures, they established laws of nature, and began the construction of the science of pathology. All true science begins with empiricism--though all true science is such exactly, in so far as it strives to pass out of the empirical stage into that of the deduction of empirical from more general truths. Thus, it is not wonderful, that the early physicians had little or nothing to do with the development of biological science; and, on the other hand, that the early biologists did not much concern themselves with medicine. There is nothing to show that the Asclepiads took any prominent share in the work of founding anatomy, physiology, zoology, and botany. Rather do these seem to have sprung from the early philosophers, who were essentially natural philosophers, animated by the characteristically Greek thirst for knowledge as such. Pythagoras, Alcmeon, Democritus, Diogenes of Apollonia, are all credited with anatomical and physiological investigations; and, though Aristotle is said to have belonged to an Asclepiad family, and not improbably owed his taste for anatomical and zoological inquiries to the teachings of his father, the physician Nicomachus, the "Historia Animalium," and the treatise "De Partibus Animalium," are as free from any allusion to medicine as if they had issued from a modern biological laboratory.

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." 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. 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." These words of Descartes might be appropriately taken as a motto by the author of any modern treatise on physiology.