Collected Essays III – Science and Education
& BMJ 1881;2;273 – 13th August 1881
The great body of theoretical and practical knowledge which has been accumulated by the labours of some eighty generations, since the dawn of scientific thought in Europe, has no collective English name to which an objection may not be raised; and I use the term "medicine" as that which is least likely to be misunderstood; though, as every one knows, the name is commonly applied, in a narrower sense, to one of the chief divisions of the totality of medical science.
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,1 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 ætiology of abnormal life.2
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.3 At first, studied without reference to any other branch of knowledge, it long maintained, indeed still to some extent maintains, that independence.4 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 Æsculapius; 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-existence 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;5 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 [dislocation], 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.6 Morgagni called his great work, "De sedibus et causis morbonum per anatomen indagatis," and not only showed the way to search out the localities7 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.8
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.9
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 mélée, 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.10
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," [see also] 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," [see also] 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 ignorantiæ" 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 "Harvæus 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 physico-chemical 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.11
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. [See also.]
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 archæus dominating, from its central seat, the parts of the organism, but a compound result of the synthesis of the separate lives of those parts.12
"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.).13
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.14 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 health15 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.16 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.
Those who are conversant with the present state of biology will hardly hesitate to admit that the conception of the life of one of the higher animals as the summation of the lives of a cell aggregate, brought into harmonious action by a co-ordinative machinery formed by some of these cells, constitutes a permanent acquisition of physiological science.17 But the last form of the battle between the animistic and the physical views of life is seen in the contention whether the physical analysis of vital phenomena can be carried beyond this point or not.
There are some to whom living protoplasm is a substance, even such as Harvey conceived the blood to be, "summâ cum providentiâ et intellectu in finem certum agens, quasi ratiocinio quodam;" and who look with as little favour as Bichat did, upon any attempt to apply the principles and the methods of physics and chemistry to the investigation of the vital processes of growth, metabolism, and contractility. They stand upon the ancient ways; only, in accordance with that progress towards democracy, which a great political writer has declared to be the fatal characteristic of modern times, they substitute a republic formed by a few billion of "animulæ" for the monarchy of the all-pervading "anima."
Others, on the contrary, supported by a robust faith in the universal applicability of the principles laid down by Descartes, and seeing that the actions called "vital" are, so far as we have any means of knowing, nothing but changes of place of particles of matter, look to molecular physics to achieve the analysis of the living protoplasm itself into a molecular mechanism. If there is any truth in the received doctrines of physics, that contrast between living and inert matter, on which Bichat lays so much stress, does not exist. In nature, nothing is at rest,18 nothing is amorphous; the simplest particle of that which men in their blindness are pleased to call "brute matter" is a vast aggregate of molecular mechanisms performing complicated movements of immense rapidity, and sensitively adjusting themselves to every change in the surrounding world. Living matter differs from other matter in degree and not in kind; the microcosm repeats the macrocosm;19 and one chain of causation connects the nebulous original of suns and planetary systems with the protoplasmic foundation of life and organisation.
From this point of view, pathology is the analogue of the theory of perturbations in astronomy; and therapeutics resolves itself into the discovery of the means by which a system of forces competent to eliminate any given perturbation may be introduced into the economy.20 And, as pathology bases itself upon normal physiology, so therapeutics rests upon pharmacology; which is, strictly speaking, a part of the great biological topic of the influence of conditions on the living organism, and has no scientific foundation apart from physiology.
It appears to me that there is no more hopeful indication of the progress of medicine towards the ideal of Descartes than is to be derived from a comparison of the state of pharmacology, at the present day, with that which existed forty years ago. If we consider the knowledge positively acquired, in this short time, of the modus operandi of urari, of atropia, of physostigmin, of veratria, of casca, of strychnia, of bromide of potassium, of phosphorus, there can surely be no ground for doubting that, sooner or later, the pharmacologist will supply the physician with the means of affecting, in any desired sense, the functions of any physiological element of the body. It will, in short, become possible to introduce into the economy a molecular mechanism which, like a very cunningly-contrived torpedo, shall find its way to some particular group of living elements, and cause an explosion among them, leaving the rest untouched.
The search for the explanation of diseased states in modified cell-life; the discovery of the important part played by parasitic organisms in the ætiology of disease; the elucidation of the action of medicaments by the methods and the data of experimental physiology; appear to me to be the greatest steps which have ever been made towards the establishment of medicine on a scientific basis. I need hardly say they could not have been made except for the advance of normal biology.21
There can be no question, then, as to the nature or the value of the connection between medicine and the biological sciences. There can be no doubt that the future of pathology and of therapeutics, and, therefore, that of practical medicine, depends upon the extent to which those who occupy themselves with these subjects are trained in the methods and impregnated with the fundamental truths of biology.
And, in conclusion, I venture to suggest that the collective sagacity of this congress could occupy itself with no more important question than with this: How is medical education to be arranged,22 so that, without entangling the student in those details of the systematist which are valueless to him,23 he may be enabled to obtain a firm grasp of the great truths24 respecting animal and vegetable life, without which, notwithstanding all the progress of scientific medicine, he will still find himself an empiric?25
Original References:
[1] Discours de la Méthode, 6e partie, Ed.Cousin, p. 193.
[2] Ibid. pp. 193 and 211.
[3] De la Formation du Fœtus.
[4] Theoria Generationis, 1759.
[5] Anatomie générale, i, p. 1iv.
Some Notes (By Steve Lewis):
1 - Huxley's idea of the organism as an economy is an interesting one which deserves more currency. It is a more 'holistic' view that is commonly encountered today. A more reductionist and sometimes atomistic approach is often encountered. Natural selection would appear to be an undercurrent to his thinking here.
2 - Huxley envisages a much closer association between medicine and biology. Having commented upon the perennial problem of how to distinguish between the 'normal' and the 'abnormal' – and, indeed, the problem of the definition of disease – he proposes that what is “hurtful” to the organism (considered (as above) as a whole) must belong to pathology.
3 - Medicine is, in effect, about helping with survival: survival of individual human beings.
4 - There is still an element of this today. Even a role for the biological sciences has been recognised, a role for biological theory – based as it is on evolutionary theory – remains to be fully integrated into medical ideas.
5 - Those seeking a cure for some ailment would sleep in the temples to which Huxley refers, hoping to be given in their dreams a way to affect a cure.
6 - Huxley makes something of a jump from the Ancients to (what we might justifiably call) the Moderns. Although there will be a little back-tracking later, he omits medieval medical thought completely.
7 - Huxley is, I believe, quite wrong to use the word “localities”. I do not believe that this could have been Morgagni's intention. It it had been, he would have used the Latin word for site (situs) and not the word meaning seat. The seat of a dis-ease is a lesion which affects the whole “economy” of the organism to which Huxley referred earlier.
8 - To clarify – Bichat actually refused to use a microscope even thought they were available to him. He chose instead to rely solely upon the magnifying glass.
9 - Here one might suggest a role for clinical evolutionary medicine. Evolutionary medicine has not given rise to ways of finding new therapies (as some may perhaps have hoped). However, it has certainly offered some knowledge and ways of thinking about clinical problems that can help prevent the clinician from “doing wrong”.
10 - I wonder if this is entirely correct. If, as Huxley suggested earlier, the pathological is that which acts against the organismal economy, then it need not necessarily follow that one has to know the 'normal' workings before recognising the 'abnormal'.
11 - Huxley raises a very important point in relation to thinking about the body as a machine. This is that machines – certainly in his day – tend to have a single, centralised power source. Organisms are not like that. Each cell generates its own energy and has a certain autonomy in this respect while contributing to the “economy” of the whole.
12 - This harks back to the idea that there is no one single energy source. The organism is seen here as “a compound result of the synthesis of … separate lives.”
13 - The sentiment is a good one with which I can agree. However, Huxley uses the word 'disease' to mean the same as 'lesion'. I would wish to separate the two. There are different types of lesion depending upon the tissue involved. The 'dis-ease' is that experienced at the level of the individual (the organism). It too will vary depending not only on the nature of the tissue involved but also upon the way in which that tissue contributes to the organism as a whole.
14 - I find this (and what follows) to be an excellent simile. It is not one that I have ever heard used – nor anything like it.
15 - I would prefer to use the word 'state' here instead of health.
16 - Huxley is making a link based upon the fact that the human body is something studied by the disciplines he has been discussing. He does not make a link between these discipline based upon theoretical or philosophical grounds.
17 - Hurley’s descriptions of the organism may be described as 'constructionist'. Organisms are built of smaller components. While modern anatomy and physiology recognises this, they tend to take a 'de-constructionist' approach by teaching from the macroscopic to the microscopic level. Having done this this form of teaching encounters the 'Humpty Dumpty' problem and cannot put the parts together again.
18 - This recognition by Huxley has stood the test of time. Even at sub-atomic levels “nothing is at rest.” It seems to be a characteristic of existence that the stuff of which things are made must be in flux.
19 - Surely that should be the other way around for living systems. It is the macrocosm (the organism since it is a product of its parts) that repeats the microcosm.
20 - A very interesting idea worthy, I would like to suggest, of much greater consideration.
21 - In the preceding two paragraphs, Huxley is describing a path the modern medicine has followed since the nineteenth century. One wonders how prophet he is being. Or, is he simply elucidating an emerging zeitgeist?
22 - A question raised by Nesse and others is that of medical eduction.
23 - Some aspects of biology are worthless to the clinician. Huxley uses the example of systematics. Those aspects of biology most relevant to the clinician will be those pertaining to the well-being of the individual – not the group.
24 - There is no greater biological 'truth' – in a philosophical sense – than the theory of evolution.
25 - One ends with Theodosius Dobzhansky's 'Nothing in Biology Makes Sense Except in the Light of Evolution' very much in mind.
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