The Thruston speech on the progress of medicine 1880
ON THE PROGRESS OF MEDICINE SINCE THE TIME OF DR. CAIUS
DELIVERED AT CAMBRIDGE ON MAY 11, 1880,
AT THE REQUEST OF THE MASTER AND FELLOWS OF GONVILLE AND CAIUS COLLEGE
DONALD W. CHARLES HOOD,
M.D. CANTAB., M.R.C.P. LOND.
ASSISTANT PHYSICIAN TO THE WEST LONDON HOSPITAL.
J. & A. CHURCHILL, NEW BURLINGTON STREET.
THE THRUSTON SPEECH.
So great has been the progress—or I would rather say the development, of the theory and practice of medicine during the past three or four hundred years—that we physicians of the nineteenth century, while fully admitting our own want of true knowledge, can with but difficulty, appreciate the gross ignorance and superstition, which prevailed even among the most educated classes, at the time of the birth of our founder, which I may remind you took place on the sixth day of October, 1510.
We may, indeed, obtain some slight insight into the general state of ignorance which existed at this time, by glancing at an Act of Parliament, which became law some two or three years after the birth of Caius.
Thus we find an Act evidently framed as protective, against the dangers which rightly might be apprehended, from the ignorant practices of those aspirants to medical fame, whose knowledge could scarcely be said to equal their assurance. In the preamble of this Act we may read as follows:—
"Foreasmuch as the science and cunning of physic and surgery, to the perfect knowledge whereof be requisite both great learning and ripe experience, is daily within this realm exercised by a great multitude of ignorant persons; of whom the greater part have no manner of insight in the same, or in any other kind of learning; some also can know no letters on a book, so far forth that common artificers as smiths, weavers, and women boldly take upon themselves great cures and things of great difficulty, in the which they partly use sorcery and witchcraft, and partly apply such medicine unto the disease as be very noxious, and nothing meet thereof, to the high displeasure of God, great infamy of the faculty, and the grievous hurt, damage, and destruction of many of the King's liege people, more especially of those who cannot distinguish uncunning from cunning."
Therefore, we find, with due regard to the protection of the public, it was enacted that in future an examining board be formed, or rather called together, by the Bishop of London, or the Dean of St. Paul's, and that no person be allowed to practise as either surgeon or physician unless he should have first satisfied this examining body.
We find, moreover, that this Act only legislated for the City of London and its environs to the extent of seven miles. It is, I say, difficult for us in the present day to realize the depth of ignorance and superstition which must have existed, to have rendered necessary such a procedure on the part of Parliament, and we can feel no wonder that a man gifted as Caius must have been, with more than an ordinary amount of intelligence, should have hesitated before applying himself to the study of medicine in England, but rather sought further help at the hand of a foreign school; we find him therefore studying in Italy; and from Vesalius, the world-renowned teacher of anatomy, he gained those first principles of exact medical knowledge which, quickly bearing fruit, enabled him, on his return to England in 1547, to assume the head of the English School of Medicine. To a scholar, to an ardent student of Nature, as Caius undoubtedly was, the very exactness of his new studies must have been a refreshing contrast to those gross absurdities and superstitions under which he had seen the art of medicine practised in his mother country; and so Caius, acting under the conviction of the greatness of the future of medical research, when carried on with true scientific principles, contributed largely towards its subsequent attainment, by founding this our College, which is proud to bear his name, and, still more, is proud to enrol among her graduates, some of the most distinguished professors of an art which yields to none other in its anxiety to contribute, as the result of labours, good to the world at large.
In attempting to sketch some few of those points which appear to us to mark the progress of medicine during the past three or four hundred years, an ample margin must be allowed, solely on the grounds of the magnitude of such advance, which, to say the least, has rescued an art based upon the truest scientific principles from the hands of the most ignorant empirics, and placed it on a pedestal which demands for its perfect and complete construction, a large acquaintance with those sister studies so necessary to a thorough appreciation of the science of medicine.
We are at the very onset of our inquiry met with this difficulty, that in medicine we are perforce called to look upon progress as being almost synonymous with extinction, or perhaps better with prevention; thus, in studying the history of medicine, we are at once struck by the fact, that some of the happiest results which can be brought forward as instances of evolution towards a more truthful understanding of some of the problems with which disease brings us face to face, can only be thoroughly understood after full consideration of this important fact.
The study of medicine, as carried on in the present day, is characterized by the attempt to base the art upon a more exact scientific foundation than that upon which we find it resting in former years—may be, we strain the attempt too far. In the present state of our knowledge we can hardly expect to find a solution to each problem which medicine presents us with; but still the method of examination is right and will very assuredly produce some good fruit.
For a moment think of the way in which disease is studied in the present day. Studied often not so much with regard to the individual, but with the hope of ascertaining those principles under which lie the disturbing causes productive of disease. Compare for a moment our methods of investigation as witnessed in the daily treatment of disease, with those which were adopted in former times. The use of our instruments of precision, our knowledge, of pathology, all tend to narrow that bridge which must extend as a connecting link between empirical treatment, and treatment depending for its success upon a comprehensive knowledge of the natural history of disease.
Again let us dwell for a short time upon the all-important point of diagnosis, and let us give the word a far more liberal meaning than that usually applied to it.
And I think in doing so we shall gain an insight into the most important advance which medicine as a study has made. And we shall find that our knowledge of disease extends far beyond the mere citation of observed facts, for as to descriptions of disease we shall find it difficult to frame more truthful ones than those left for our consideration by Sydenham. A brilliant portrait it may be lifelike, of disease, is doubtless of great value in assisting us to recognize varieties from the normal standard, but for the good of the public we require that the physician should not only recognise the actual existence of disease, but it should be his earnest endeavour to detect those changes, be they only functional, which mark a pre-pathologic stage; a stage antecedent to organic change. And the highest aim of the physician is to gain such knowledge as will assist him in stamping out those evils of the human race which are the necessary concomitants of disease. And it needs no mere believer in an Utopian existence to follow me in this statement. The practical daily work of the physician, and, indeed, still more the study of medical history, cannot but convince the would-be sceptic that a very large proportion of those diseases which we are called upon to treat, are by their very nature to be prevented; and such knowledge should spur on the student with renewed energy to prosecute those inquiries which in many cases will result in the complete banishment of some of our most pernicious diseases.
In every age in which we may study the history of medicine, we cannot fail to be impressed by the one dominant idea which appears to have possessed the minds of those who have made medicine their peculiar study; I allude to the search for specific remedies against disease. There are undoubtedly those who profess to believe that we have but to search with sufficient acuteness, to find a remedy specific in its action against any disease which we may be called upon to treat; such a belief may be considered almost akin to the search for the philosopher's stone of old. It has had certainly an evil effect upon the growth of the practice of medicine, for we may constantly find those who, while deploring their own want of exact knowledge in the absence of those remedies which are known to have a specific influence, deny their patients the means of relief, which doubtless originating in empiricism, prove themselves to be of advantage in the daily treatment of disease.
A large amount of progress has taken place in treatment when considered with regard to the mere administration of drugs; the nauseous complicated formula of even our more immediate forefathers, have given place to a much simpler method of prescribing. But those who have made a study of the amazing influence of the nervous system in its full relation to the life of the creature—an influence the knowledge of which I think I am right in saying is only on the very threshold of our field of discovery—must acknowledge that there may be grounds which are sufficient to justify us in making use of remedies, the exact scientific action of which we are at present unable to give. And I do but re-echo the sentiments of one of our most distinguished physicians when I urge the far greater importance of studying disease with regard to its extinction, rather than endeavouring to find those antidotes, the very existence of which is shrouded in the greatest uncertainty. And we shall gain fresh courage in our researches when we recall to mind the immense benefits which we can already count as ours—benefits which are due directly to the investigation of disease in relation to its causation. Consider the advance which has taken place in our knowledge relating to those affections which owe their birth to a want of appreciation of those hygienic principles so necessary to the perfect health of a community; and I cannot but think that we owe a debt of gratitude to this University for recognizing among the first, the importance of such studies.
Instructive, indeed, are the lessons to be gained from a study of the History of Medicine, but perhaps none more so than those which point out to us the advantage of studying disease with special regard to its ultimate consequences, rather than with respect alone to its more prominent symptoms. If we pass in review those diseases which come before us, we can with advantage consider them, as indeed we must, when they come before us in practice, first with regard to their single primary effect, and then, secondly, with regard to those complications or sequelæ which are apt, as a result of subsequent development, to follow in their train. Such a division helps us to appreciate what an enormous number of so-called diseases originate in a previous attack of more or less acute character; and further it should act as an incentive to the physician to pay all the greater attention to that period which immediately follows any of those acute attacks, which so frequently, as their result, leave some slight spot of organic change, the rapid growth of which leads to irreparable degeneration of tissue, ending sooner or later in the death of the sufferer. We have this point brought most prominently before us by comparing the opinions as held in the present day on such a subject as general dropsy, with those which we may gather to have been held, I may say, almost within our own memory. We find dropsy spoken of as a disease, a disease to be treated on definite principles, but it is indeed but very lately that we find the true connection thoroughly recognized, as that which exists when we place such a state of the system in its true position, and realize the importance of following to the very fountain-head that train of events which has led to those conditions of tissue change which demand the exudation of serous fluid as a necessary complement. Such an inquiry takes us back it may be to the damaged valve of a heart, which again dates its origin to an act of rheumatism; such a sequence may take years for its fulfilment, and each stage, as it were, marks an epoch in the history of medicine. First we find the connection between rheumatism and diseases of the heart becoming recognized; and then, again, the relation which exists between exudation of fluid and certain diseases of the circulatory apparatus. Step by step it brings vividly before us that sequence of events which it is now the ambition of every physician to prevent, by paying the greater attention to the primary evil, during which period he now knows so well he has to apprehend the danger of subsequent complications.
We can only now take this one example as an indication of the importance of closely studying the natural history of disease as is to be gathered from an examination of its consequences. Undoubtedly one of the most important steps which medicine has made in its development, is the recognition of the difference between disease itself and those symptoms which may be caused as the result of such disease. We shall find that in most, if not in all, of the older writers on medicine, the treatment of the physician was directed towards the alleviation of those prominent symptoms, which, then not so much looked upon as symptoms, were only recognized as the main cause of the attack. Such a method of treatment had the manifold disadvantage of, in many cases, masking the true nature of the complaint by the very action of the physician himself, who, in his endeavours to but relieve the distress of his patient, gave but little or no thought to the primary cause of the attack.
In glancing at the various theories which we find at one time or another to have been held in high repute even among those most to be noted for their absurdity, we cannot help being struck by some points deserving the attention of the student of medical history. Thus, if we examine closely into the system of medicine as laid down by Stahl, who about the beginning of the eighteenth century appears to have led the more advanced school of medicine, we shall gain our first insight into the expectant method of treating disease, a method based upon the belief that Nature itself is gifted with those forces which alone are sufficient to restore health when interfered with by disease. We shall find that in the case of Stahl the most extreme views were held. He promulgated the opinion that in the treatment of disease more reliance should be placed on the unaided powers of Nature. A wondrous step in the right direction when considered with regard to the treatment of disease in his day, but the theory upon which Stahl based his practice was ridiculous in the extreme. He taught that the soul was gifted with that most extraordinary power of self-intelligence which enabled it to detect the presence of any noxious influence, and not only thus recognizing their presence without any physical connection taking place, was capable of exciting those changes in the body which were antagonistic to the pernicious influences which otherwise would result as the effect.
In studying such a system, we can without difficulty understand the good which would be likely to ensue in a large proportion of those cases treated by Stahl; but he, like many others who base their practice on a theory of their own raising, carried his principles to that extreme which denied the possible efficacy of any drug, and the use of those remedies as bark, opium, and the like, were on no account permitted to his followers.
In Stahl's idea of the almost omnipotent power of the soul, we may, I think, trace an attempt to explain those subtle changes of nutrition and repair which we now understand as connected in a great measure with the nervous system. These phenomena were as certainly present at the time that Stahl lived as they are now, and we can scarcely feel any surprise that a careful observer should have longed for some explanation. The knowledge of the nervous system was in its darkest state, little or nothing being really known of the function of the nerves, absolutely nothing of that system, the sympathetic, of which it is only in the present day that we are but beginning to appreciate the enormous importance. Such being the case, we cannot feel any surprise at such a theory as that laid down by Stahl.
We might, indeed, with great advantage to ourselves, take one by one those theories which checker the growth of medicine, and in most we should find some truth valuable to the student, though, may be, in its discovery we find it hidden under the mass of superstition and ignorance which interfered with its practical good.
We see, then medicine, both considered as an art and as a true scientific study, has slowly evolved from the darkest shades of superstition and credulity.
We see the theories which at one time or other have possessed the minds of those who have been engaged in the practice of medicine overthrown, when viewed by that pure light which the investigation of disease alone can give.
And more than all we shall see medicine now studied with the view rather of anticipating disease or its results, and bringing to the help of its investigations that aid from science, which directly and indirectly contributes so largely to the ultimate success of such an undertaking.
Sciences which the student of medicine in the present day has innumerable opportunities of makmg himself acquainted with in this University, I might also add in this College, which to-day celebrates the memory of that founder, who of his substance contributed so munificently to our resources.
- Sir William Gull's Harveian Oration.