The knowledge of the physician. A course of lectures delivered at the Boston university school of medicine, May, 1884.

Contents

LECTURE I.

THE KNOWLEDGE OF LIFE.

Introduction. — Medicine an art, ministered to by its associated sciences. — All sciences made up of phenomena, laws and causes. — The subject of Physiology life. — Life the diffc' rentia of the vegetable and animal creation. — Not motion, even spontaneous motion. — Not growth and waste. — Life consists in assimilation and reproduction. — These essentially one process, and capable of being pei formed by a single substance. — Protoplasm. — Vitality a property thereof. — Identical with " Irritability " of Brown. — History of discovery. — Fletcher, Beale, Drysdale. — The protoplasmic doctrine of life a better basis for philosophy of homoeopathy than that of a "vital force." — Views of Hahnemann and Tessier. — Life no entity, but a music of which organism is instrument. — Living matter seat of disease and drug-action. — Of illimitable sensitiveness, but matter still. — We should be dynamists, without being pneumatists

I. The Knowledge Of Life

Ladies ' and Gentlemen, — It is, believe me, with keen pleasure that I stand here to-day. American homoeopathy has always enlisted my warm sympathies ; but it has been with especial interest that I have watched the rise and progress of the Boston University School of Medicine, now in the second decade of its existence. That such a school should exist, without distinctive name, pledged to the method of Hahnemann only by the convictions of its teachers and the preferences of its pupils, — this makes actual my ideal of what should be. I would it were possible in my own country : I am very glad that it has become so in yours. While, therefore, I feel it an honour and pleasure to be invited to address American students, I am particularly gratified that Boston should be the place in which I am to speak.

* The students of Boston University are of both sexes.

In requesting me to deliver this course of lectures, my friends here have expressed certain wishes as to the topics of which they should treat. Their main subject-matter (it is allowed ) should be that to which I have given the best work of my life, and in the sphere of which I have made my poor contribution to our knowledge, viz. Materia Medica and Therapeutics. But it has been thought well that discussion on this head should be preceded .by some considerations of a more general nature, bearing on Medicine as a whole. In deciding what these should be, I have been determined mainly by the nature of my audience. You are learners as yet, rather than practitioners : what you should knozv concerns you at present more that what you should do. At the same time, it would be a superfluous task to seek to augment your actual knowledge of the topics of medical education. To go again over ground which you have trodden under the leadership of such men as adorn this School would be labour in vain : if you have not learned — or are not learning — from them the physiology, the pathology, the pharmacology they teach, you would not learn it from another. But it has seemed to me that I might to your advantage draw you back a little from your fields of work, and ask you to take with me a survey of the country at large, — to enquire what is the knowledge you are seeking, both in itself, and in relation to the several departments to which it belongs and the action in which it ends. You are to practise the art of healing : you are acquiring the sciences accessory thereto, that you may fulfil your

PHENOMENA. 3

calling aright. What should you know of all of these ? what of each ?

Every science - — that is, branch of knowledge, scientia from scire — consists of three parts, phenomena, laws, and causes. You may perhaps be thinking that phenomena are not peculiar to science, that they are matters of common observation. And so they are ; but common observation just differs from skilled, in that it very imperfectly takes them in. Night after night the host of stars circle around the pole, and the moon and planets wander about among them. All eyes perceive this ; but how few minds take in the details of their order and march ! how few, for instance, when poets like Dante and Tennyson indicate the time of year by the positions then occupied by the constellations, can recognise the description and seize the indication ! He who has studied these and suchlike phenomena has taken the first step towards acquaintance with the science of astronomy. And he has done more. He has mastered a series of facts which henceforth are part of the furniture of his mind, and can be turned to divers uses. Their perception necessarily affords pleasure, which all men can feel for themselves, and some can, by reproduction of its sources, communicate to others. The poet can so describe the starry heavens, the painter so depict them, that quite a new sense of their wonder and beauty is wakened within men. It is thus that fine art lays hold of the knowledge of phenomena. But useful art employs it no less. One of the blessings which the Prometheus of

^schylus claims to have brought to mankind is that he taught them

*' The risin^: and the settins^ of the stars."

From observation of these, of the sun's path among the stars, of the place of the pole and the phases of the moon, our progenitors drew a number of practical applications, to agriculture, to navigation, to the ordering of life and work, which made the lights of heaven — long before any real astronomical science had come into being — of large service to man, availing "for signs and for seasons, for days and years."

I would lay the more stress on the value of knowledge of this kind, as it seems to me to have lost its place of late, alike in education and in appreciation. The world has been so fascinated by the discoveries of the last few centuries that these alone occupy its thoughts ; and to teach science means to impart knowledge of laws and causes, with very little reference to the phenomena which those laws regulate and for which those causes account. It is the same tendency as that which dilates on the philosophy of history, disregarding its facts ; as that which makes books about great authors widely read, while few know the original works themselves. We shall see hereafter how disastrous such procedure has been in the study of medicine : at present we dwell on it only in relation to the subject of physical knowledge in general. Whatever else you learn, inform yourselves thoroughly as to/ac/s,—cis to all that can be

LAWS AND CAUSES. 5

elicited by observation and experiment. Nor take them only from teachers and books. See, hear, feel for yourselves: handle the instruments by which modern observation brings the distant near and the invisible into view, while at the same time you take in the great world of motion and sound, of colour and form, which is open every day to the unaided senses. Daily experience will warrant this counsel by the delight and profit it brings.

But while I make thus much of the knowledge of phenomena — of the exercise upon nature of the perceptive faculties, I would not undervalue that of the intellectual. Man is made to enquire, to ask "how.?" and *'why.?" as well as "what.?" The answer to the two former questions constitutes what is called inductive science — the body of inferences more or less certain, of theories with stronger or feebler warranty, which are the result of thought and imagination when in the presence of natural facts. What a crowd of splendid conceptions rises in the mind when this reference is made ! The heliocentrism of Copernicus, Kepler's laws of the heavenly motions, Newton's gravitation, the nebular hypothesis of Laplace, the undulatory theory of light and the dynamic of heat, morphological type and evolutionary growth in animated nature, — these are but a few of the most striking among them. They are all thoughts rather than observations ; of no necessary or even demonstrable truth ; open at any time to reconsideration on adequate challenge ; — but, while they stand, part of the world's richest wealth, luminous in effect and indispensable to further progress. Because you are thinkers, and not merely perceivers, you must enter into these great thinkings of the giants of scientific discovery : from the vision of things as they appear you must rise to that which strives to see them as they are.

These principles apply to knowledge in general : they characterise no less, of course, that knowledge which is necessary to the physician. He is, as we have said, the practitioner of an art ; and he might carry out his calling by pure empiricism and rule of thumb. At first he had so to do. But, by degrees, the life he has to guard and keep in health, the disease he has to combat, and the drugs he has to employ, have become the subject each of a science special to itself. Of these sciences — of physiology, of pathology, of pharmacology — you have to learn the phenomena, as ascertained by observation and experiment ; and no less to possess yourselves of the noumena, or what are believed to be such — the laws and causes of their workings as brought into view by intellectual vision. [I should say that by this word ''noumena" — from fov?, mind — philosophy designates the reality of things as distinguished from their appearances. This, however, is a metaphysical conception, — one of thought rather than fact ; and I am using the word more in its etymological sense to distinguish that which the vov^ perceives from that which the senses experience — both these being (probably) realities.] Let us pass in review to-day the phenomena and noumena of the first of these

WHAT IS LIFE? *J

sciences, or rather of that which is the subject of physiology — of life.

The fundamental characteristic of that human body for which, as physicians, you will have to care, is that it is a living organism. The meaning of the latter term is obvious. It implies that the body is not simple, as a stone is, but complex in form and structure, its several parts so differentiated as to constitute distinct mechanisms capable of performing various functions, and yet all bound together in unity of existence and (in some measure) of government. This it is to be an organism ; but what is it for such organism to be alive } A musical instrument, a watch, a printing-machine, answers to the definition just given: either is — or may be — of complex structure, having diverse parts subserving diverse purposes, but neither is living. What do we mean by characterising the human organism by this adjective ?

We mean that it belongs to a class of existences, which includes all other animals and the whole vegetable kingdom, but excludes the world of earth and water. In all ages mankind has recognised the distinctness of this class of beings, and has separated them off by ascribing to them the possession of a peculiar quality, which it has called ^wrj, vita, life. Plants and animals have life, they are living things, — this is the language in which mankind expresses a universal perception. The thought has sometimes been confused by the use of terms implying vitality tQ designate inorganic objects. The poet may indeed pardonably speak (like 3helley) of

THE KNOWLEDGE OF LIFE.

The living winds, which flow

Like waves above the living waves below.

or (like Virgil) of ''vivo sedilia saxo." But when philosophers tell us that minerals *' have a life of their own," they are employing language which is needlessly misleading. Minerals exist, having their own laws and history ; but we want to describe that which is peculiar to plants and animals when we say that they live.

Further consideration establishes what it is to live, wherein the differentia of living things resides. It is not that they have a definite form, into which they inevitably grow, and to which they compel all increase of their substance ; for this property they enjoy in common with the lifeless crystal. It is not that they are the seat of motion. There is no rest anywhere in nature : if to move were to live, all things would be alive. The earth and- its sister planets are revolving on their axes, and whirling round the sun ; the sun itself and its brother luminaries are revolving on their axes, and circling some central point in space ; the ether is throbbing with undulations of light and the air with those of sound ; within the earth, the ocean is ebbing and flowing upon the shore, the rivers running to the sea, the winds above as restless as the tides below, the " clouds which far above us float and pause " ever resolving themselves and forming anew, heat is radiating and being absorbed, electricity is producing its attractions and repulsions, its chemic combinations and decompositions, and — if

VITAL GROWTH. 9

we are to believe its latest imaginings — keeping every atom of matter in as restless a whirl as that which urges the suns and their worlds. Motion is not life ; nor does it become so by being spontaneous. We shall see hereafter that vital motions are not initiations, but responses : yet, were they otherwise, that would not make them living, since the total motion of the universe must — so far as science can pierce — be thus conceived of. (I mean, that you must go outside the universe to find its Mover. In itself it appears as self -moved.) Nor does life consist in growth and waste. We open our ears and hear

" The sound of streams that, swift or slow, Draw down Ionian hills, and sow The dust of continents to be."

Every wave upon the cliff, every shower of rain upon the land, is reducing one part of the earth to enrich another. In some places the land has risen, in others it has sunk, within the period of man's existence ; and the whole geologic history before him is one of continual growth and waste.

While, however, growth by accretion is thus a physical process, there is a growth which is purely vital. A granite rock to which chalk has been brought by rivers has no power of changing calcareous into granitic substance. But the plant and the animal, diverse as may be the structures of their several organs and the food supplied to them, can so transform this food within their bodies that it shall become homogeneous with themselves, and go to make their wood, leaf, bone and muscle, and contribute to the texture of such special organs as the brain and the eye. There is nothing like this, save in living beings : it is a purely vital process. And as their growth is not mere accretion, so the correlative waste in them is more than separation. Matter is thrown off from the tissues in lower forms than those in which it exists there : muscular fibre is eliminated as urea, nervous substance in the shape of phosphates.

Growth by assimilation is thus the first process characteristic of life. And the second is like unto it, — it is the reproduction of the kind. This is a power peculiar to plants and animals, and nothing bearing the remotest resemblance thereto exists in any but living beings. It also, therefore, is purely vital, and constitutes an element in life.

Take now the whole life -history of a plant, and we shall find it comprised in these two processes — growth by assimilation and reproduction of its kind, the means for the preservation of the individual and the perpetuation of the species. All else about it is physical, common to the world around : these are peculiar, are vital. Since, then, any property which does not belong to the vegetable creation cannot be essential to life as such, we may consider these two as making up the manifestation of that which we name vitality. Pressing our analysis farther, we find the duality resolving itself into unity ; for in the lowest forms of life generation is no distinctive process, but a simple fission or gemmation — a portion of the liv-

PROTOPLASM. 1 1

ing mass becoming detached, and then growing by assimilation into the parent form. (Microscopically, indeed, reproduction and growth are in all cases identical, consisting essentially in the cleavage and duplication of cells ; but I speak of them as they appear to the common eye.) Now in these primitive regions, among the dim beginnings of things, another fact is pressed upon our notice. It is that the essential functions of life require for their basis none of the developments seen in the higher plants or animals. Tracing these down as they slope towards a fellow, if not a common, root, we come at length to creatures like the amoeba. We have here neither colour nor (permanent) form ; solidity and structure alike are absent ; and yet no one can doubt that the amoeba lives. Retracing then our steps, we find that as we ascend the scale of being, either along the vegetable or the animal side of the slope, we always carry what we may call amoeboid matter with us. Behind all shapely form, within all solid envelopes, is the structureless, transparent, colourless, semi-fluid substance we have seen floating in the waters. We call it protoplasm — not a good word, for it is rather the first to form than the first to be formed. But, however it be named, it must be conceived of as the seat, and the only seat, of vitality — this property being fully manifested when it alone is present.^ Of ourselves we may say, non ovinis vivo: we are not

^ " Wherever there is life, from its lowest to its highest manifestations, there is protoplasm ; wherever there is protoplasm, there also is life " (Professor Allman, Brit. Assoc. Report, 1879).

alive in every part. The fluids of the body do not live, any more than water does. Hair, nails, teeth, bone, are when once formed as lifeless as similar matter existing elsewhere ; and the same is demonstrably, though not so obviously, true of cartilage, fibre, cuticle, and all cell-walls and sheaths.. The soft matter which most of these contain — the contents of the cell, the pulp of teeth, the marrow of bone — this lives and forms its envelope ; but the thing formed, that which has structure, rigidity, colour, has passed from life to death. As dead, it is continually decaying, but as continually being replaced by its indwelling protoplasm, which takes from the food, reaching it as blood, the material for the purpose.

Life is thus a property belonging to matter in that peculiar state which we denote by terming it " living ; " and such living matter, though everywhere present in the organism, constitutes but a small part of the bulk of the frame. The first to promulgate this doctrine was one whom we of the school of Hahnemann may fairly claim for our own ; for though he never practised, and died before homoeopathy became a living thing in his country, he welcomed it and vindicated its claims to attention. I speak of Dr. John Fletcher, of Edinburgh. His Rudiments of Physiology, published between 1835 and 1837, start from the theory first propounded by Brown in 1780, that life is the result of the action of the natural stimuli — light, heat, oxygen and so forth — on the ''irritability" of the tissues. Their capacity of responding thereto is vitality : their actual re-

FLETCPIER AND HIS DISCIPLES. 1 3

sponse is vita — life. This view — espoused by all the great naturalists and physiologists who had followed, by Blumenbach, Cuvier, Bichat, Magendie, Pritchard — is maintained by Fletcher, and opposed to all theories of a "vital principle," in a series of chapters which, as Dr. Drysdale justly says, "for learning, wit, close reasoning, and splendour of diction, have been seldom equalled, and, I venture to say, never surpassed in the literature of physiology." But Fletcher went farther, in perceiving and meeting the difficulty that much of the organism seemed to be irresponsive to stimuli. He did so by arguing that it is indeed not wholly alive ; that its fluids and hard solids have no more vitality than water or wood. The old phrase "materia vitae diffusa" after all expressed the truth ; only it was a "materia" indeed, and nothing semispiritual — a living matter everywhere found where life is manifested, and constituting the substratum of its phenomena. That such a matter there must be, he clearly discerned and irrefragably proved. But he unfortunately went farther still, and thought he had found it in the ganglionic nerve-substance. This error caused his work to be doubtfully received and soon forgotten. There were two of his pupils, however, who held his memory dear, and waited for the time when his discernment would be vindicated. Both have adorned our ranks. One was Dr. Rutherford Russell, a man of no common power and charm, too early lost to us. The other I have already named, and to name him is sufficient : it was Dr. Drysdale. He had not IpPg to )yait. In 1861, Professor Lionel

Beale, of King's College, London, proclaimed as the result of long-continued microscopical study that the substance already recognised in plants and the lower animals, and known as '' sarcode " or ''protoplasma," — that this structureless, transparent, colourless, semi-fluid stuff, is universally diffused throughout the human organism, and everywhere manifests distinctive vital characters, separating it from the "formed material " around. Into this it dies daily, just as the whole organism dies into its post mortem condition, when the mainspring of its common existence has been broken. But, till then, the ''germinal matter," while ever perishing at its circumference, is ever renewing itself at its centre, converting the pabulum it takes up into its own living substance, instinct and quivering with vital motion. All this Beale proved as a fact which none could gainsay ; but the scientific world at large was hardly ripe for the theory of life which followed. Drysdale, on the other hand, prepared by Fletcher, recognised it as that which he had all along been holding, and saw in protoplasm the very materia vitcB whose existence his master had demonstrated, but which he had mistakenly identified. At once, in the British Journal of HomceopatJiy, he commenced a series of papers on the subject, culminating in his separate publications entitled '' Life and the Equivalence of Force" and ''The Protoplasmic Theory of Life." ' Here, While others were hesitating, he boldly grasped and vindicated the doctrine ; and he had the gratification in 1879 of hearing

"^ Published by Bailliere.

PROTOPLASM AND ETHER. 1 5

it proclaimed as generally accepted from the Presidential chair of the British Association. Professor Allman there happily compared the place which protoplasm occupies in the mind of the biologist to that which the ether takes in the conceptions of the physicist. You know that, as sound consists of waves of air, transmitted from a vibrating body to our percipient organs, so light and heat — to go no farther — are best understood when regarded as undulations of some fluid medium. This cannot be the atmosphere, which extends only some forty miles above the earth's surface, while heat reaches us from the sun and light from the most distant of the fixed stars. We have therefore to assume the existence of an "ether," filling all interstellar space, as much finer than air as air is than water, and in like manner filling its " void and bare interstices." Protoplasm, as "co-extensive with the whole of organic nature — every vital act being referable to some mode or property of it — becomes to the biologist what the ether is to the physicist ; only that instead of being a hypothetical conception, accepted as a reality only from its adequacy in the explanation of phenomena, it is a tangible and visible reality, which the chemist may analyse in his laboratory, the biologist scrutinise beneath his microscope and his dissecting-needle."

I am, I confess, desirous of pressing this conception upon you, on account of the part it must necessarily play in your thoughts about the system of Medicine you have adopted. Homoeopathy is not a philosophy, but a method : yet it has a philosophy, l6 THE KNOWLEDGE OF LIFE.

and it is important that this should be clear and sound, and in harmony with the best thought of our time. Hitherto our notions of life have mostly been those enunciated by Hahnemann, In his student days it was always assumed to be a principle, distinct from the organism it animated, — the only question being whether Stahl should be followed in identifying it with, or Hoffmann in distinguishing it from, the immortal soul. When, in later life, he began to think upon the subject for himself, he espoused Hoffmann's doctrine, though with much more philosophic grasp. The vital principle with him was no entity, but a "force," and in conceiving it as such he anticipated (in 1829) the notion of force now everywhere current. '' The organism " he wrote ( in the edition of the Organon that year published ) "is indeed the material machine to the life, but it is not conceivable without the animation imparted to it by the instinctively perceiving and regulating vital force, and tJie vital force is not conceivable withont the orgajiism, consequently the two together constitute a unity, although in thought our mind separates this unity into two distinct ideas, for the sake of facilitating the apprehension of it." The "vital force " is thus, with him, the mode of motion of the living organism.

Through Hahnemann such views of life have generally gained acceptance in the school which he has founded. They have, moreover, been reinforced among us from another and independent centre. In 1849 the distinguished French physician, Tessier, cam.e over to homoeopathy, and brought with him a brilliant

THE ANIMATING PRINCIPLE. 1/

band of disciples. But he was more than a physician : he too was a Master, and taught a complete system of medical thought. His doctrine of life was that of the Thomists, the followers of St. Thomas Aquinas. It is fully set forth in the Elements de PatJiologie of the present coryphaeus of the school, Dr. Jousset — one of the ornaments of our body. We are there told that the cause of life, of that which makes living beings distinct from others, is an ''animating principle," which, existing already in the germ, preserves it from corruption, fashions the organism into which it grows and regulates all the functions of the same, until its final retirement therefrom results in death and dissolution. This animating principle also, like Hahnemann's vital force, is said to be so intimately united with the matter of which it is (in philosophic language) the "form," that the two are inseparable, — their union constituting the living being, one and indivisible. But the Thomist doctrine has the disadvantage of lineal descent from that of Aristotle, and adopts his terminology. The result is that it speaks of the animating principle of a plant as the vegetative soul ( ^A^^x^, anivia ), and as it uses similar language regarding the life of man, it seems to identify his soul with his vital force, and indeed to give him one at all in no other sense but that in which a cabbage has one. Moreover, if ''anima forma corporis " is to be the canon (and our confreres are so fond of this phrase that for many years it has served as a motto for their journal, L Art Medical), — if the soul is the form of the body, and we go to Aristotle to learn what is meant by ''form," we find him ilUistrating it by saying that vision is the form of the eye. The soul, then, so conceived, has not and canr not have any existence independent of the body of which it is the function, — a conclusion tolerable enough as regards animals and plants, but not to be readily entertained by man, who *' thinks he is not made to die." It is a conclusion, I should say, which would be warmly repudiated by the school of which I speak, which is distinctly Christian in its thought ;. but it is one to which logic must remorselessly lead them.'

Is such an ''animating principle" required to account for the facts of the case ? It is argued by Dr. Fredault, another worthy inheritor of Tessier's thoughts, that its existence alone will explain the growth of the germ into the parental form. But crystallisation presents similar morphological phenomena, and no "ame minerale " is even supposed to be working here. It is perhaps easier to conceive of death by calling this its "retirement : " but if it retires, where does it go ? Christian philosophy gives an at least intelligible account of the future of the disembodied spirit ; but what can be thought or said of the separate existence of the bodily life • — of the bodily lives of the million creatures that perish every

^ Mr. St. George Mivart, who represents in England the same CathoHc philosophy, would describe the ^vxv as a " principle of individuation," and would grant its non-existence apart from the body. But he does not grapple with the difificulty in relation to man, save by suggesting that in his peculiar case there may be some interference with the ordinary law ( Brit. Assoc. Report^ 1879. Biological Section).