Some Prolegmena to a Philosophy of Medicine

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CHAPTER II. Nbxd and Conditions of Philosophy in Medioinb

§ 1. — Three- fold view of success. § 2.— Illastration. § 3. — Success dependent on philosophical habit of mind. § 4. — Relationship of medical knowledge to other knowledge. § 5. — Wideness of a philosophy of medicine. § 6. — Scientific and philosophical methods compared. § 7. — The physician's mission. § 8. — Individual observation and practice. § 9.— Philosophy of medicine a constructive process. § 10. — Positive science and common sense. § 11.—** States of health." § 12.— Life and not-life. § 13. — Unity of life (conscUmsness and knowledge). § 14. — Test of theory. § 16. — Self-evident conclusions. § 16. — ** What is life ? *' § 17.— Herbert Spencer's theoiy. § 18. — Protoplasmic theory. § 19.— Final test question.

CHAPTER in.

A Bio-Dynamic Law . . . . . . . . . . 24

§ 1. — Requirements of a bio-dynamic law. § 2. — Rest and activity of conscious thought. § 3;—** Rest. " § 4.— Definition of the theory of life. § 6.— Explanation of terms used. § 6. — A re-statement of the theory. §7. — Illustrations: Movement of Protoplasm, §8. — Physiology of the cell. § 9,— Embryology, § 10,— Qeneral physiology, § 11,— Psychology,

CHAPTER IV. Infebences fbom the Bio-dynamic Law . . . . . . 45

§ 1.— Health defined. § 2. — The law of life and disease. § 3. — External and internal conditions. § 4. — Clinical history — morbid anatomy— pathology, § 6. — Diagnosis of disease. § 6. — Natural classification of disease. § 7.— Recovery from disease. § 8,— Prognosis of disease. § 9,— Treatment of disease. § 10. — Explanatory value of the law of life. § 11.— Bacteriology and the law of life. § 12. — Pharmacology (pharmacodynamics and drug pathogenesy). § 13.— Therapeutics and disease. Inductions of Hahnemann. Other inferences.

SOME PROLEGOMENA TO A PHILOSOPHY

OF MEDICINE.

CHAPTEE I.

Introduction .

The question often crosses the mind of the convinced homoeopathist, why the majority of the profession refuse medical reform in the direction of an avowed and general adoption of the homoeopathic rule or method. The medical mind is open to advances in knowledge in all other branches, which are the foundations of practice — medical or surgical. Even pharmacology, although with little generalised system, has found a place among the sciences of medicine. But, when the schools arrive at therapeutics, there is a steady, point-blank refusal even to inquire into a method, which is really simple when once conceived, practically universal as far as the uses of drugs are concerned, and verified by the experience of a large body of medical men throughout the world.

What is the fundamental reason of this attitude — apart, I mean, from wilful ignorance or misrepresentation? I cannot believe that men who have open minds to the new facts of other sciences, can simply be blindly led by bigotry or partisanship when they come to consider a branch of knowledge most nearly concerning their success as practitioners, and their reputation as honest, open-minded observers and seekers after truth.

*J SOME PBOLEGOMENA TO A PHILOSOPHY OF MEDICINE.

The reason lies, as it seems to me, in the fact that as far as the current knowledge of physiology and pathology goes (and therapeutics are rationally based on these sciences), the homoeopathic method or rule is ultra-rational, or ultrascientific. What are the facts on both sides ? Take those first of physiology and pathology. The object of physiology is stated by Landois and Sterling^ to be the establishment of the phenomena of organisms, to determine their regularity and causes, and to refer them to the general fundamental laws of Natural Science, viz., the laws of physics and of chemistry.

And again, the whole series of phenomena of physiology considered as a sign of life, and termed metabolism, consist in the introduction, assimilation, integration, and excretion of matter.

With regard to pathology, Sir James Paget says, in Quain's *' Dictionary of Medicine": "It is the name generally given to the science of disease, but the subjects which it may include cannot be exactly defined. For ease and disease, well and ill, and all their synonyms, are relative terms of which none can be defined unconditionally,** and in a later paragraph, '* Pathology finds in physiology its basis, the varying standards of healthy structure and functions with which its subject matters are in contrast, and the models and methods of its study ; but its range is wider than that of physiology, inasmuch as the conditions giving rise to disease are much more numerous and more various than those of health.** With regard to rational therapeutics, Dr. Lauder Brunton, in the same work, says, "that depending on experimental physiology and pharmacology, the practitioner may hope to recognise, from the symptoms of the patient, the organ affected by disease, the nature of the disturbance in its function, and to apply, with some degree of success, a remedy which will counteract such disturbance.'* Now it will be readily agreed that neither in physiology nor pathology, have we anything approaching simplicity of aim, or method, or result. In therapeutics, matters are still more confused.

> " Text-book of Physiology," vol. i., Introduction.

The conditions on which the single result desired, the cure of disease, depends, are known to be so complicated, that though based on facts from all the natural sciences, uncoordinated and unarranged, it is deemed rational to apply the bare notion of physical force, to bring about that result. Reason, we may well exclaim, but it requires an adjective to qualify it, the reason of blind force, it is true, but not of science either exact or even natural.

But turn to a similar line of facts relating to homoeopathy. The ground-work of homoeopathy is unquestionably the science of pharmacology or drug pathogeiiesy, as our classical work on the subject has it.^ The methods of this science are those of experimental physiology, carried, in theory at least, to the finest degree in the human subject, with side-lights from experiments on animals.

In the application of the method of homoeopathy, the facts of disease, in their simultaneity and succession and interdependence, are the only reliable phenomena which have to be dealt with as disease, and the rule of application between these phenomena and . those of drug pathogenesy is the authority of a similar relationship. The authority of a similar relationship ! What is that authority ? Here we have the crux of the question. Two recent writers opposed to each other agree that the method does not " explain itself , and never can.** Still, the grounds for the adoption of homoeopathy are good, and by a long way higher than the roughly rational quasi-scientific methods of the predominant school. For the past hundred years, in the hands of observers equally competent to any in any field of science, in the phenomena of drug pathogenesy, and in the results of the treatment of disease by homoeopathy, we have had, in process of collection, the concrete phenomena for the formation of a science of therapeutics, but the law which connects them has not as yet been defined.

Many analogies in the history of disease and its natural recovery, suggest that there is such a law, some among them having been brought forward by Dr. Madden in his presidential address at the recent Homoeopathic Congress at

* *' Oyolopaedia of Drug Pathogenesy.*' Edited by R. Hughes and J. P. Dake.

4 BOMB FBOLEQOMENA TO A PHILOSOPHY OF MEDICINE.

Leeds.^ A number of explanations have been offered, as yoii know, which are suggestive, but by no means conclusive, but we have no law to explain the operation of the simillimum, in the sense that gravitation is law, or in the sense of Ohm's law of electricity, or Bell's law of the sensory and motor functions of the roots of spinal nerves. The advocates of homoeopathy, however, by the parallelism they draw between drug effects and disease, and by the universality of the application of one to the other they endeavour to establish, assert in effect, that the rule of similars must be based on a law of equal universality, if only such a law could be perceived, defined, and established in the mind.

Now this philosophical position of homoeopathy places it higher in the scale of thought than the current philosophical bases of physiology, pathology, and therapeutics. As far as average science is concerned, homoeopathy is therefore ultra-rational — it is beyond science. In the minds of those who are convinced of the practical value of the rule of simi-r lars in the treatment of disease, its scienti6c truth remains as a conviction, a belief, a faith, and there remains yet the necessity of formulating the basis of this conviction in philosophical relationship with other departments of medical knowledge.

What relationship, then, do the supporters of homoeopathy bear to the dominant school ? In view of the responsibility which attaches to the medical community in the treatment of disease, the relationship between the two spheres of thought is plainly ethical. Not the common ethical basis of professional etiquette. Far higher than that. On the one side, physiologists and pathologists, who are, at the same time, practitioners of medicine, ought not to close their eye& to the facts of experience, or the claims of a method which results in those facts, even though no explanation is forthcoming, and the facts run counter to received opinion 6t reason so far developed. And, on the other hand, men who have become convinced of the practical utility of the homceor pathic rule ought to set forth their experience clearly and scientifically, in accordance with received and known con^

* Homaopathie Beview, October, 1895.

SOME PBOLEaOMENA TO A PHILOSOPHY OF MEDICINE. O

elusions in physiology and pathology, and to spare no pains to discover, if possible, the law or laws on which the issue of those facts depends. This philosophical aspect of homceopathy is the main consideration, why I have chosen to address you on the subject of the philosophy of medicine this evening, and to give you the views which form the chief part of the following address. But before I do give you those views I should like to make a personal explanation respecting them.

These views did not arise in my mind, while endeavouring to find a scientific or rational explanation for the rule of •similars, but while giving close consideration to another branch of philosophy. I make this explanation so that without " special pleading '* I may emphasise the fact that I believe homoeopathy may fall naturally into its place in a general philosophy of life and mind.

In the preparation of this address I have to gratefully acknowledge my indebtedness to a number of authors and works. For the scientific part, I have reUed mainly on Quain's ** Anatomy,'' the latest edition, edited by Professors Schafer and G. D. Thane ; Landois and Sterling's " Text-book of Physiology"; Quain's ''Dictionary of Medicine"; and a little ** Manual of Bacteriology," by Professor Klein. I must add to these the works of Hahnemann as translated by Dudgeon, and the writings of Hughes, Carroll Dunham, Drysdale, Hayward, H. E. Madden, and others. In philosophy, including psychology, I have taken much from the works of Bain and Spencer and William James. " The Protoplasmic Theory of Life," by the late Dr. Drysdale, has been a great help to me, as also, in philosophical purpose and method, a presidential address by Mr. Shadworth Hodgson, entitled, ** Philosophy and Experience";^ and various articles which, from time to time, have appeared in Mind,

Williams and Norgate, 1885.

CHAPTEE II.

Need and Conditions of Philosophy in Medicine.^

§ 1. The attainment of success is uppermost in the mind of every medical man. Success is what every man hopes for, and it is the only goal he can be satisfied with as a result of his study, his knowledge, and his practice. But the word must not have given to it a narrow or restricted meaning. Success does not include merely personal success. Such is the place medical men occupy in the social organism, that it is the welfare of the community they are bound to consider before their own. Although personal success does not fall out of consideration, it occupies distinctly a second place. It is wrapped up in the welfare or success of suffering humanity ; or, we might say, it is on the relief of suffering humanity that medical success depends.

There is another aspect of success which must not be overlooked. As personal success depends on the welfare of the community, whom it is the duty of the medical man to serve, so does it also depend on the combined success of the whole profession. What is success for one man to-day, will be, by imitation, success for all to-morrow. What is success for the whole profession to-day, may be success for the single man to-morrow.

§ 2. This three-fold view of success may be illustrated by a reference to the possible experience of surgeons in the development of a major operation ; taking ovariotomy for an example. In ord^r to make the operation of ovariotomy a success the whole mind and interest of the surgeon are, for the time, intent upon the preparations, the instruments, and

^ About half the paragraphs in this and the next section were omitted ia

delivery.

SOME PROLEGOMENA TO A PHILOSOPHY OF MBDIOINB. 7

the manipulations required for its performance. On these, all combined, the condition of the patient being considered suitable, the successful result of the operation depends. The operation is performed ; and is successful if the patient survives its actual performance. This is a personal success for the surgeon so far ; and such success is not detracted from by the fact of the death of the patient after the operation, from any cause not directly ensuing from the fact of its performance. But if all patients died after the performance of that operation, even though every attention had been paid to ensure its successful performance, and the patients had survived the performance, the surgeon would not consider he had attained success in that operation, and he would seek for an explanation of the reason why. But supposing the experience of the particular surgeon w&s but the experience of all surgeons (which was, in fact, the case with ovariotomy before the introduction of antiseptics), the success of the one man would not be such a serious consideration to him personally, except in so far that in his own success was implied the success of the whole profession ; and that the success of the whole profession would become one condition of the success of the single man.

§ 3. The illustration here used serves to point out the place of philosophy in medicine, and to suggest that the success of every man depends on his exercising a philosophical habit of mind. It was impossible that an operation like ovariotomy, which had aroused the keenest interest among surgeons, and which had in it all the elements of successful performance, could be allowed to drop. What was the process which raised it to its present position as not only a justifiable operation, but as a triumphant success to the community, to the profession, and to the individual surgeon ?

This success depended in the first instance on the explanations of failure. The philosophy of the subject was brought into view by a re-examination of the facts and principles on which the operation had been based ; these were found to be good in all save one most important particular. But this particular, the septic condition of wounds,

8 SOME PROIiBOOMBNA TO A PHILOSOPHY OF MEDICINE.

was being investigated in collateral fields ; the method of antiseptics was introduced ; it was tried in this operation with partial success, the inference of asepsis was drawn fi:om partial failure under antisepsis, and now under asepsis and antisepsis the operation has become a success of which the whole profession, as well as the individual surgeon, might well be proud.

§ 4. It is an extension of the method of explanation in view of failure to attain success in every disease which makes possible a philosophy of medicine. If, in the face of failure and in the absolute necessity of success, and in the interest which a view of both failure and success excites in the mind, we have impelled a philosophical habit of mind which invites investigation of particular points, and by means of explanation', and the application of principles and inferences from different departments of knowledge, there ensues great practical advance in the direction of success — that is to say, that inferences of the mind are as real in themselves as the processes concerning which the inferences are made — it is a legitimate deduction that a proportionately great practical advantage would ensue if the process of explanation were so extended that a final explanation of all the explanations becomes possible. It also may be safely inferred that such an explanation may be as real as any of the explanations it seeks to explain (and they have been proved real by serving practical purposes) ; therefore, if the final explanation is real, it also will be conducive to success, relatively that through it all facts, causes, processes, and results included in both failure and success can be understood as they become objects of thought and relation by the mind.

If, on undertaking the consideration and treatment of a case of disease the practitioner of medicine or surgery knows precisely and definitely the relationship of causes, symptoms, and morbid anatomy so that a prognosis can with certainty be made, whether the case were left alone, or what would ensue if all available measures of treatment were adopted, he would look upon the consideration and treatment of such a case with perfect confidence or rest

SOME PBOIiEGOMBNA TO A PHILOSOPHY OF MEDICINE. 9

of mind, provided always that recovery were the issue he knew would follow. The practitioner would be confident of success. It is confidence, or rest of mind, that is the goal of philosophy and that all understanding aims at, not rest in the sense of inactivity, but rest as preliminary to, and a basis of, increased personal activity. If a practitioner understands a case, he is in a position to treat it. His position is satisfactory philosophically. His knowledge furnishes his understanding with objective thought. Objective thought leads to the subjective act. The subjective act leads to further objective thought ; the relation between the two sides of the shield is one of rest ; and, as a final point, the rest of the practitioner of medicine is in philosophical relationship to his life and mind as a man among other men.

Thus we have set out the scope and purpose of philosophy in medicine. It begins with explanations of failure in single instances, and it ends by arriving at an explanation of the relationship of all medical knowledge to other knowledge, and also in what all knowledge consists, and on what it depends.

§ 5. An immediate practical inference may be drawn from a recognition of the wideness of a philosophy of medicine. The vastness of knowledge and the success which results from it, do not depend upon the knowledge and practice of one man but upon all. ** Every man in his place,*' to the exercise of the highest and all his capacity, is as much a motto for the medical profession as for the ancient Hebrew army man. And every man who does what he can, cannot be done without. Whatever in the opinion of Mr. Herbert Spencer^ may have been the ancestry of " physicians and surgeons,'' and by what process of evolution their descent down the ages has been accomplished, the point in evolution which interests them most is that they are here, they have arrived, and, nolens volens, they find themselves dependent on each other for the work they have to do.

10 SOME PBOIiEGOMENA TO A PHILOSOPHY OF MBDICINE.

§ 6. In philosophy as applied to medicine as to any other department of knowledge, a distinction has to be drawn between philosophical method and scientific method. For a complete account of this distinction the reader is referred to Mr. Shadworth Hodgson's Aristotelian address entitled " Philosophy and Experience." ^

Experience is the field both of philosophy and science, but in philosophy the question is asked. What is ? as distinct from the question of science, How comes? and the question. What is? asked after the question, How comes? has exhausted the possibility of an answer. Science makes her answers first and then hands them on to philosophy for farther investigation, and she puts again the question to each of them. What is ? There are, however, two aspects of scientific investigation, and philosophy in reality deals with only one of them, and her results are applicable as explanations through one to the other. Philosophy explains through psychology to positive science and common-sense. Take as an illustration the ordinary common-sense idea of the cure of disease. Science asks. How comes it? Philosophy takes up the answers given and asks of each of them. What is it ? Her answer can only be given in terms of science plus the personal experience of science. Even then the question may be re-asked of the answers given, What is it ? And the answer given is the most final one that can be given. However often the question. What is? may be put, the nearest answer that can be given is a psychological or subjectively scientific one ; therefore, if positive science and common-sense are treated philosophically they must be so through psychology or subjective reality.

§ 7. Hahnemann has said that ** the physician's high and only mission is to restore the sick to health, to cure, as it is termed."^ Some of the sick, however, cannot be cured, and it is a matter of common experience that they cannot. Where the structure of organs has been destroyed by disease — and such a contingency may arise in a moment of time — neither knowledge nor practice are of any. avail to

^ Williams and Norgate, 1885. '!';*^. *iCJrganon of Medicine," § 1, translated by Dudgeon, 1893.

SOME PEOLEGOMBNA TO A PHILOSOPHr OP MEDICINE. 11

restore the sick to health, or to cure as it is termed. Thus, as well as asking what is the cure of disease, the mind cannot help asking. What is incurable disease? And so opens up at once one of the widest questions of the medical philosopher, , What is disease at all ? An attempted single answer to this question is not a primary one, however, and would not give much aid to a true solution of it.

But the common experience of disease and of incurable disease, also the discovered power to prevent some of the causes of disease, has led to further inquiry into the cause of all disease, and the aim to prevent it all. Hence is arrived at a further conception of the mission of the physician. He is the curer of disease ; but he is also the preventer of disease. It is not, however, by an attempted answer to the question. What is the cause of all disease? that disease can be prevented : ' but in the scientific way of all true philosophy, the question is asked in a given instance, What is the cause of this ? Having ascertained the cause of one, it can be correlated with others, and with the power to prevent them. So by a widening and deepening of knowledge of proximate causes with the ability to prevent some of them, the modern science of preventive medicine is being built up. It would not be very hazardous to prophesy that, as knowledge of disease and its causation advances, and as higher conceptions of responsibility in general human life emerge, the major consideration in medical practice will become the prevention of disease rather than its cure. The differentiation of medical knowledge into curative medicine and preventive medicine had not been made in Hahnemann's time, although he was fully alive to the importance of it when he says : " He (the physician) is likewise a preserver of health if he knows the things that derange health and cause disease, and how to remove them from persons in health.'*

§ 8. But we must enlarge the mission of the physician even yet. As we saw that the success of the single man depepded so largely on the success of the whole profession, so the continued inevitable progress of the knowledge of the whole profession, and the modification of practice in accordance therewith, depends for its advance upon the observation

12 SOME PBOLEaOMENA TO A PHILOSOPHY OF MEDICINE.

and practice of the single man. I need not enlarge on the detail of what such a conception of the mission of the single medical man involves. Broadly, it may be said, the education of the profession depends upon him. Although, in accordance with custom and best method, certain men are told oflf as teachers, and these find their places in colleges and universities, the facts of knowledge have to be gleaned first from the single case and group of cases ; and the profession depends on every man to furnish some fact or facts to the common fund. How much this is the case may be noticed by a reference to the conditions under which medical education is conducted. The position occupied by hospitals, their relation to the medical schools, and the attitude of the State to both of them, are such that the responsibility for the record of facts is placed almost entirely upon the single man, or, at the most, on the voluntary association of men together, for the purpose.

§ 9. These three common conceptions; the cure of disease, the prevention of disease, and the education of the profession, thus indicate the experience which marks off the medical man from other individuals in the social community. We are, therefore, in a position to indicate the scope and limitations of a complete philosophy of medicine.

A philosophy of medicine will include a personal analysis, with results giving in psychological fact and arrangement all objects and branches of knowledge which can be included within the conceptions of the prevention of disease, the cure of disease, and of what is special in the acquisition or the imparting of knowledge included in these conceptions. Having made his analysis, the philosopher will be then in a position to bring his results to a psychological arrangement with each other, in the ordered system of his entire mental experience. He may become constructive. It will thus be perceived that philosophy is regarded as a process, a living and growing process, which can go on in the experience of every man, if he gives his attention to it ; and, as we have gathered, the medical man is compelled, by the very nature of that experience, to engage somewhat in the philosophical process. A system of philosophy is the final result if the philosophical process is pushed to the utmost limits the mind is capable of, which involves a final analysis and construction of itself, as the philosophising instrument.

It may, however, be added that inasmuch as knowledge is for ever growing, any system of philosophy, to be of value, must give an account of and allow for this growing process, or it will have little explanatory value except for the immediate present. It will soon be relegated to the limbo of forgotten thought.

And it must also be added, that what one man may do by way of a personal analysis and synthesis of his own knowledge, has a supreme value for himself alone, until he can set forth the process of his thought in language that may be used and understood by other minds, and by the association of this language in their own minds they are able to perceive and co-ordinate their own experience by his.

§ 10. In a series of prolegomena to a philosophy of medicine it must first be noticed, what are the special features in medical knowledge which distinguish it as knowledge from the ordinary every-day knowledge of people at large ? And what are the special conditions of its acquisition ?

Broadly stated, this distinction consists in the difference carried as far as possible between positive science and common-sense. In the education of students of medicine^ it is necessary to attract attention away from the ordinary objects of experience and common-sense, and to fix it on an accurate and orderly presentation of the facts which are to form the content of his medical knowledge. But the difference does not lie here alone. In ordinary common-sense knowledge and experience, the conceptions of objects and relations between them and generalisations, from them, of which this knowledge is built up, has a certain indefiniteness about it ; the sensory impressions received from without have not had their utmost afferent discharge; they have been inhibited, partly by their multiplication and confusion together, partly by want of voluntary attention to one element or group of elements at a time, and partly by some other process in

14 SOME FBOLEaOMENA TO A PHILOSOPHY OF MEDICINE.

consciousness, or a feeling of self. Common-sense knowledge, however, serves the ordinary every-day requirements of man that he has in common with the average of his fellows. But such common-sense knowledge is by no means sufficient when from one branch of thought an accurate co-ordinate practice has to ensue. A step in advance of common-sense has then to be made. Such is the ca^se par excellence with medical knowledge. Were it not so, every element of that knowledge would have to be accompanied with a further explanation and life would be all philosophy and no science and no practice. In medicine, as, indeed, in all positive science, the inhibitory process, which is everywhere prone to operate on sense impressions, is itself further inhibited by a higher requirement of interest or duty on the part of the mind. Every sense impression which this interest or duty points to as important is allowed to have its full afferent discharge. Attention, which from one point of view may be described as the inhibition of inhibition, has the exercise of its full voluntary activity, discrimination of relations is exercised to the utmost, and generalisations formed are definite, and rounded off only by the impressions and relations which have been received from without and conceived to exist. If to a generalisation is added any contributory element of the mind other than that supplied from without, either past or present through association, the generalisation partakes of the character of unverifiable theory, and can have no place as real and positive medical knowledge.