No. 3067.

JUNE 10, 1882.

Arris and Gale LecturesON THE

RELATION OF EXPERIMENTAL PHYSIOLOGYTO PRACTICAL MEDICINE.

Delivered at the Royal College of Surgeons, June, 1882,BY G. F. YEO, F.R.C.S.,

PROFESSOR OF PHYSIOLOGY IN KING’S COLLEGE.

LECTURE 1. -PART I.THE SYSTEMS OF MEDICINE NOT DEPENDENT ON

PHYSIOLOGY.

MR. VICE. PRESIDENT AND GENTLEMEN,-From a naturaldistaste to medical matters, which seems fixed in the mindof all healthy individuals, and the many technicalitieswhich are inseparable from the healing art, the details ofmedical science are ignored by the great majority of thelaity. One is often surprised to find intelligent and well-educated people with but a vague idea of what physiologyreally is, and without the least conception of the meaningof the term experimental research. But it is still more

surprising, and to physiologists more disappointing, to

find that some medical men do not appreciate what theyowe to experimental physiology. I have met with manywho regard physiological teachers and workers as veryuseful persons in so far as they instruct young men in theelements of their profession, and prepare them to pass theexaminations imposed by the licensing bodies. Some even

go so far as to admit that a little knowledge of physiologyis advisable or even necessary for the practice of medicine;but when they hear of any form of exact modern research,such as the graphic method, or some new mode of investiga-tion, they are ready to exclaim that physiology of this kinddoes not bear any very close relation to the practice of theirprofession, either as surgeons or physicians; they believetint the physiology they learned as students sufficed to imake them very successful practitioners. This is in mostcases quite true, and would have been equally so hadHippocrates, Boerhaave, or Cullen said it in their time. Buteven a modern practitioner, following a routine practicewould not like to be deprived of his knowledge of thecirculation when feeling a pulse, or of the uses andmechanism of breathing when examining a patient’s chest.Yet the times were when the views we now hold on thesevery subjects were thought to be worse than new-fangledand useless, and were said to be wrong and hurtful to thesound practice of physic.We are now, no less than at all other times, at a point

of medical history when complaisant reflections concerningthe adequacy of our knowledge must be challenged. Oneof those remarkable periods has arrived when the natureand the necessity of a certain branch of medical studyare called into question by the public. I believe theultimate progress of medicine is seriously threatened,partly by a want of understanding as to -what are itstrue aims, foundations, and modes of growth, and partlyon account of a wave of intense sentiment which is

influencing the judgment of a certain powerful class whichnow-a-dds seems to be thrown with great readiness intoturbulent undulations. When we glance over the historyof the healing art, we recognise that there were periods inwhich medical science was not only threatened, but abso-lutely checked and sent backwards, by the force of bigotryon the part of the public. It seems difficult for usnow to conceive how it came to pass that for some twothousand years (twenty centuries) biologists and philoso-phers remained ignorant of the construction of the humanbody. But we know such to be the fact, and that it wassimply because a certain prejudice forbade the section of thedead.To-day it is the sister study of physiology, by which

we learu the mode of working of the living tissues, that isthreatened with annihilation from a somewhat similarprejudice. So important do I think the present crisis so1ar as the progress of medic-d knowledge is concerned, at

least in this country, that 1 have chosen to devote the threelectures I have the honour to give under the foundation ofthe Arris and Gale bequest to an attempt to make clear thedependence of the ordinary details of the rational practice ofmedicine upon a groundwork of physiological knowledge.And further, I shall show that physiology depends on ex-perimental methods of investigation. Experiment, it is true,is only the scaffolding by means of which the edifice is builtup, and of which one hears but little when the house iscompleted and the inhabitants enjoy its comforts. Physio-logy itself is the main structure of the building, while theeveryday application of medicine in practice corresponds tothe internal furniture which makes the whole habitable anduseful. A man resting in his easy chair may disclaim theutility of scaffolding and bricks and mortar, &c. Hemight say, "this chair is good enough for me, I want no yscaffolding," with quite as much reason as a medical manengaged in practice could declare himself independent of theknowledge of physiology. In order to form a right judg-ment on these matters I must ask you first to accompanyme back to the earlier stages of medical knowledge, beforephysiology was known, and to reflect on the modern systems,which depend on vague or unscientific physiology. We shallthen recognise the fact that for a long time the best humanintellects struggled to understand the working of the humanorganism, without making any material steps in advance,and that medical science had to wait many centuries beforepermanent improvement occurred; and, further, that thisdid not take place until after the birth of physiology as adefinite branch of experimental science.Under the heading of to-day’s lecture I propose to include,

first, Mystic Methods; secondly, the routine application ofrigid rules commonly known as the Methodical System ;thirdly, Vulgar Empiricism.The first attempt at the healing art of which we have

any record was intimately related to the mystic and reli-gious ideas which naturally suggest themselves to the un-occupied mind of primitive man. All completely uncul-tivated human beings, finding themselves surrounded bythe imposing phenomena of nature, begin to regard themwith a peculiar mystic dread, and, recognising in themirresistible powers, proceed to give fantastic personifica-tion to all-the phenomena which they cannot understand.They thus be-people the entire natural world with super-natural beings, whom they think capable of doing them abenefit or an injury. The exigencies of existence promptthem to formulate the convenient doctrine that good andbad deities or demons exist ; and by certain dogmatic rulesthey hope to propitiate the one and protect themselvesagainst the other. By this kind of primitive religion they pro-cure for themselves the most immediate and beneficial resultsin the least troublesome and most efficacious way. Themost awful among the more striking occurrences which arepresented to their minds are sickness and death. These aswell as all other misfortunes are attributed to the worstsort of demons, so a means had to be found either to pro-pitiate these supernatural enemies, or, with the aid of otherdemons, to check their power. This controlling of unknownpowers has always been found to be a matter of somedifficulty, and the task had therefore to be confided tospecialists (the priests), who by their learning and superiorintellect were better able to cope with the higher beings.The priests supplied blessed curative charms, and ex-

pensive emblems for the cure as well as the preventionof disease. Incantations, prayers, ceremonies, and manyother methods, which strike us as ridiculous, and opposedto all reason and common sense, are employed for curingdisease even to this day by all barbarous and somecultivated peoples. In the undated ages of early Indianhistory the gods were the only protectors of health andcurers of disease. Then came priestcraft ; at firt holy,then magical, and fimlly purely mercenary. The priestsof the great Zjroastrian religion, the magi, were theonly medical practitioners of their time in the empire ofPersia. In Egypt, the priests, prophets, or magicians,attained great repute as therapeutists ; and though theymingled some alchemy with their charms, their chief treat-ment depended on the occult powers they were supposed topossess. Among the Israslties the priests had charge of thehealth of the people; and know how in the wilder-ness sickness was cured and plague checkei by religiousmethods. When the Levites became too corrupt in thelater days of the empire, the prophets alone could be trustedto cure disease, and then only by powers given them directly

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from Jeh’.vah Even in the home of antique culture, wherehUniá’nHb.tt’dJ03sP’ly, atlfained its holiest’summit, 4A findApollo/’fh% of pjetry and nrssic, also presiding overmedicine. -p,Mml-t.R6 - Temple of Pelos come some of -theearlIest’rec,wds 6I’Gtecum medicine; and later the Templesof Cos and Kuido-s,"-’a’nd others, became justly celebrated.To these holy and hygienicatly situated health resorts, nonedared approach without due and who;lesome.preparations byprayer; ahl1;LtioÍ:Íà, oerings/and fastings. The. patients werereceived byhe priests (the direct descendants of aesculapius)with M’ysteriousc6donies, music, amdfgtes. Aided by thesalubrity of the Situation of the temple, and by’tbe hygieniccare ’t6"*hich fhe patients were subjected, the simplecases usually progressed -favourably, and’ the priests weresoon able to apply a 11 cure," -saxd to be revealed to them ina dream. In Rome, where Civilisation had aayanced in somany respects, the healing art remained in the hands of thegods.---Pruyers to Hygeia, Isis, Minerva, Mercury, or Her-cules were deemed more useful thanany human means in case’of illness When- a plague broke out, there were but tworecognised methods of causing it to abate..One consisted ingiving a grand feast to the ,gods, when ’the most delicatecomestibles were offered to their idols by’being exposed inthe streets: When this Leciistern, as’ it was called, did notprovesiicessfu6,= there remained but the solemn ceremonyof drivibed nail into the. right wall of the Temple of Jupiter.Time after time the enraged gods sent terrible plagues toRome, and again and again a lavish feast was offered to theidols, or’the mystic nail was driven into the temple wall.Then’’’came the Christian era. When the church

spread its influence over the great easiberrf empire, the

old-temple medicine naturally had to give way and poly-theistic therapeutics gradually began to die ’but. ‘ Therulers of the day having adopted Christianity, they ’madeuse of all its name and influence to put down’the oldpower of heathen magic. Just as the early Christians wereat -first pelsecuted as sorcerers, and their chiefs regardedas Jewish cabalists, so, when the tables were turned thenewly acquired strength of -Christianity was devoted withequal barbanty and cruelty to. the extinction -of themedical witchcraft and other dangerous magic influences.The heathen deities were looked upon as representing fallenangels, and those who practised medicine were thought to-be in direct communication with the devil. The-idols of thegods were :dashed to atoms, and those who professed to cureby what was called the black art were massacred or burned.It became not only the right but -the duty- of all goodChristians to lend a hand to the doing away with medicalconjurors, witches, and the like/ till Europe blazed withburning stakes to which were tied the workers of thesemagic cures. But this burning -of magic doctors did littlegood for the healing art. The monks assumed, and for manycenturies held almost a monopoly, of medical practice. Learnedthough they were, they remained throughout the period of theirsway far behind the old temple medicine of centuries before.The love of mystic methods was too deeply rooted in thehuman breast to be banished by the destruction of the pro-fessors of mystic medicine. We find that the practice of theholy monk-physicians differed chiefly in name from those ofthe sorcerers whom they persecuted with such zeal. Theygave !,,to their patients blessed amulets,,on which were mystic signs i

to cure and ward off disease, as well as to act as a protectionfrom witchcraft. The therapeutic value of fragments from ’,the’graves of holy martyrs, themeacy of a drop of water

’’

from a holy well were highly esteemed. Religious ceremoniesand prayers were still the only sure means of cure ; and wehear of special saints who exerted specific influence uponvarious forms of disease-as St. Judas’for cough, St. Valen-tine for epilepsy, St. Clara for ophthalmia. The laying-onof hands by some f’aintJy father, and other mystic add theisticrites, WHe the best of the then known therapeutic methods.Under the influence of this dogmatic religious system allmedical learning remained in abeyance. The sound princi-ples of Hippocrates were forgotten, the crude physiology ofGalen was no longer made use of. How far the all-absorbinginfluence of Christianity, guided by the rigid dogmas ofRome, is responsiole for this long period of darkness and igno-rancewe cannot say ; but the astounding and instructive factremains that for more than 1200 years not one great step inadvance was made in the healing art.With the revival of letters a marked change comes over

the scene. The Reformation broke the power of the priests.The art- of printing aided in a way heretofore impossiblein the diffusion of knowledge. Universities were founded.

The sciences began to move onward. The mode of workingof, the human body was again taken into consideration bysome professors of medicine and anatomy.But the mystic element still pervaded the minds of even

some of the most learned men. Paracelsus was one of these.Equally notorious for his power as a reformer, and his per-sonal vanity, he may be regarded as the greatest mysticphysician of the Renaissance-or, indeed, of any age.Thoroughly imbued with the alchemistic and astrologicalmagic of his time, yet versed in the old Grecian philosophy,he spent his life in searching for a universal specific,and in uprooting the faith in the ancients; he despisedthe physiological essays of Galen, and burned his works.Paracelsus was the very type of a thorough charlatan,the prince of anphysiological medicine. He denied theutility or necessity of knowing the cause or mode oforigin of disease. The physician, he said, need onlybe able to cure it. According to him there were fourpillars to medicine: philosophy, astronomy, alchemy, andthe qualities of a physician. Excellence in these alone wasneeded to ensure the cures of all diseases. He regardeddisease as a real personified enemy, with which the spiritualpower of the organism had to fight. He says: "The bodyof man is made of visible parts, the flesh and the blood, andof invisible parts which reside in this body, and see, feel,and understand: this is the internal alchemist." He declaredthat one must study the cheiromancy of plants, " Since thelines of the leaves show their powers and properties." Thus,heart-shaped leaves were employed byhimin cardiac diseases,yellow saffron was used to cure jaundice, and many absurdand disgusting remedies were administered by him on similargrounds. Much and deservedly as Paracelsus has beenabused, we must admit that we owe something to him. Hehelped to make way for the advancement of medicine, notby adding one jot of knowledge, but by breaking down thegreat barrier ’of authority which the slothful ignorance ofages had allowed to stand in its path. It was not by hisgenius or learning he did this. It was chiefly by his egotismand vanity, which prompted him to set himself up above allhis,predecessors and contemporaries. His name gives a fairidea of his character, in full it runs thus, Aurelius PhilippusTheophrastus Paracelsus Bombastes von Hohenheim !

If the anti-vivisectionist axiom be true, that all we knownow could have been made out by’clinical observation andthought, why is it, I ask, that such an able man asParacelsus went backward instead of onward when headopted these means of study and despised and neglected allexperimental investigation ? .,

His views soon became ridiculous. But long afterParacelsus was dead, mystic medicine showed itself indifferent forms. These all had in common a perfect dis-regard for the working of the healthy human frame andthe mode of prigin of pathological processes. Of each ofthese we have examples still extant. The first is thepurely religious. Believing that all forms of disease aresent by the Almighty as punishment for our sins, this sectthinks that all human efforts for their prevention or cureare, and must ever be, fruitless. Prayer alone is efficaciousin making amend for sins, and therefore it is the only reliablemode of treating the diseases induced -,by them. This formof belief is now not very widespread; but it still exists inEngland. Not unfrequently we hear of a person belongingto the class known as " peculiar people " being summonedby the public prosecutor for allowing a patient to diewithout the advice of a duly registered practitioner.It appears to me to be a strange anomaly that the lawof the land makes it manslaughter to adopt an ancientform of non-physiological treatment, and at the same timea felony to carry out the investigations on which rationalmedicine has been built up. -

, The second sect of persons are those who believe onlyin speeiiics, disregarding the cause, mode of progress, oreven the region in which the disease lies. There are to-day, as 350 years ago, people who have an implicitbelief in remedies that can cure the majority of incurablediseases. The enormous sale of the many quack specificsnow in vogue, the great fortunes amassed by the pro-prietors of absurd patent medicines, the number of other-wise reasonable people who habitually dose themselves withsome useless mess, clearly show that in these matters thepublic is not influenced by wisdom or knowledge, or eventhe crudest common sense.The third form of mystical practice is homceopathy. On

the Continent, where it was born and for some time ran rife,

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penetrating even into the schools of medicine, it is nowalmost dead. It is only in England and America thathomoeopathic hospitals exist. The Germans say they cannotunderstand how it is, when Englishmen are " sonst so sehrpractisch," that England is the birthplace of bigotry, thenursery of fanaticism, the garden in which all forms ofhumbug seem indigenous.The similia sÙnilibus of Hahnemann can obviously be

traced to the dicta of the arch-quack Paracelsus. The same

power that induces a disease can cure it, said he. With thecause, the mode of action, or pathological change producedby the ailment the physician has nothing to do. Diseasebeing a peculiar condition of an immaterial vital principle,the medicines should be suited to its properties, and mustbe used in such doses, and in such states, as make thempowerful against such a force. Thus the extremely minutedoses and their dilution became an important item in thismode of treatment. The persons who practise homceopathyat this moment are the active opponents of physiologicalstudy, and are often held up to the public as examples ofmedical men opposed to vivisection, and their opinions arefreely quoted to rebut those held by the leaders of ourprofession who are best versed in physiological knowledgeand its worth. Of course, homoeopathic practitioners dis-approve of physiological work. It is antagonistic to theirtrade. They cultivate the ignorant longing for mysticismwhich is inherited by every human being from his remoteancestors.

Clinical LectureON THE

ASSOCIATION OF TABES DORSALIS WITHSYPHILIS.

BY THOMAS BUZZARD, M.D., F.R.C.P.,PHYSICIAN TO THE NATIONAL HOSPITAL FOR THE

PARALYSED AND EPILEPTIC.

TABES DORSALIS is the most frequent of all the chronicaffections of the cerebro-spinal axis, and the prognosis inthis disease is practically hopeless. There is increasingevidence, no doubt, to show that cases may go on for avery long time without the symptoms becoming materiallyintensified, and even with encouraging periods of improve-ment. Bat as matters stand, we are unable to count uponmore than this in any case of a confirmed character. Atfirst sight, therefore, it would seem to be a point of morethan ordinary importance to discover whether the disease isso far connected with a syphilitic origin as to encourage usto hope for success by treating the patient energetically withspecific remedies.

In many morbid conditions such a discovery, by leadingto appropriate treatment, produces the most triumphantresults. But, as a matter of fact, in the case of tabesdorsalis expectations that may have been formed of a similarsuccess have not been realised. Now and then, it is true,wd meet with cases which improve remarkably for a timewhilst iodide of potassium is being administered, but in myexperience I have never known a cure to result from specificmeasures. From mercurial treatment, indeed, which I havehad very carefully applied by inunction in a number of caseswhere the history of syphilis was distinct, I have seen nogood whatever, but, on the contrary, as it seemed to me, atendency to harm.In 1871, writing upon the subject of syphilitic affections

of the nervous system,l I included progressive locomotorataxy amongst the nervous affections belonging to the ter-tiary stage of syphilis. At that time the frequency withwhich a syphilitic history was to be noted in these caseshad long impressed me, and I was in the habit of treatingmy ataxic patients with iodide. But the remarkable absenceof successful results appeared to throw so much doubt uponthe matter that I carefully excluded the disease from con-sideration in my work on syphilitic nervous affections. 2

The connexion between nervous disorders and syphilis was

1 THE LANCET, March 11th, 1871.2 Clinical Aspects of Syphilitic Nervous Affections, 1873-74.

then not generally recognised, and I was anxious to avoidweakening the force of that which was to be said on avery important subject by the introduction of debateablematerial. -

The question of the relation of tabes to syphilis, althoughit had not escaped the attention of Lancereaux, Dlichenne,and other writers, had not been very prominently broughtforward before 1875, when M. Fournier, of Paris, expresseda strong opinion on the subject. Out of thirty ataxieshe found a history of syphilis in twenty-four. He be-lieved that the tabes in these cases was an outcome ofsyphilis, although according to his view it does not inthese circumstances present any special symptomatology orlesions.Now, it had been urged by Charcot in 1873 that certain

lesions of the spinal cord, primarily developed outside theposterior columns, might at a given moment invade these ata variable height, and produce accidentally, as it were,some symptoms of locomotor ataxy ; but this, he went on tosay, was not truly progressive locomotor ataxy.More recently Dr. Gowers, in an able paper read before

the British Medical Association in 1878,3 pointed out that itwas common for an acute change, as e.g., primary myelitis,which had extended widely through the section of the cord,to clear off from all except the posterior columns, and to per-sist in these. In such cases a weakness of the legs of suddenonset would give place to incoordination of movement, andthis would increase so as to present the typical features oflocomotor ataxy. Eliminating such cases as these, ofsecondary origin, he thought that nearly one-half of ataxieshad a history of antecedent syphilis.

I do not know that I am disposed to draw a very hard-and-fast line between tabes supposed to be of primaryorigin and that which is secondary to acute changes. It iscertain that in inquiring into the history of many caseswhich, when they come before us, present all the charac-teristics of typical tabes dorsalis, we frequently hear adescription of symptoms, often long past, which can only bereferred to the occurrence of spinal meningitis, usually of aslight and strictly localised character. The fact that someslight thickening of the soft membranes and adhesion to theposterior surface of the cord is commonly met with in post-mortem examination of tabetic cases is well recognised.Vulpian, who was at first disposed to think that this menin-gitis might be primary, has rejected the idea, because thechange is not proportionate to the amount of lesion in theposterior columns, and he now attributes it to a propagationinto the membrane of the irritative action going on in theneuroglia. But it is not disproved that initiatory inflam-mation of the pia mater might spread itself by continuitytothe neuroglia. There may possibly be anatomical reasonsconnected with the disposition of bloodvessels which wouldexplain the confinement of the inflammation which had thusbeen started to a certain locality of the cord. I am inclinedto think also, from certain observations, that a limited spinalmeningitis may clear off without leaving traces perceptibleto the naked eye in the portion of membrane which hasbeen affected.In the early part of his history Fredk. J- had very

severe pain in the mid-dorsal region. He could not bend hisback without severe pain-a symptom strongly suggestive of £meningitis. There was a clear account of a chancre six yearsbefore the commencement of his symptoms.In 1870 I saw a gentleman, aged fifty-eight, who was

typically ataxic. He bad what he described as " a tremen-, dous sensation of a cord around his waist." There had been

constant pain in the back and right side of the spineabout the level of the lower dorsal vertebrae for two years,

, and he frequently suffered from what he called ",,4pasms " inthe right hypochondrium. There was a distinct history of

: syphilis.I examined, in 1880, a gentleman, aged thirty-three, who

had suffered for fifteen months from "a a grinding, aching. feeling from the left side of the spine to the p;t of the stomach."i He could walk and had not lost much power in his legs. It. was for this strictly localised pain that he sought advice, but; examination showed that he was suffering from tabes, and a, year later he came to me with paralysis of the left oculo-. motor nerve. There was history of syphilis of eleven years’! standing.; Such examples could be readily multiplied to almost any

extent. They can hardly be explained, I think, except by

3 Syphilitic Neuroses, Brit. Med. Journ., March 1st, 1879.