Medicine - British Medicine in Greater Britain Part 1
( Originally Published 1905 )
TO trace successfully the evolution of any one of the learned professions would require the hand of a master —of one who, like Darwin, combined a capacity for patient observation with philosophic vision. In the case of medicine the difficulties are enormously increased by the extra-ordinary development which has taken place during the nineteenth century. The rate of progress has been too rapid for us to appreciate, and we stand bewildered and, as it were, in a state of intellectual giddiness, when we attempt to obtain a broad, comprehensive view of the subject. In a safer "middle flight" I propose to dwell on certain of the factors which have moulded the profession in English-speaking lands beyond the narrow seas—of British medicine in Greater Britain. Even for this lesser task (though my affiliations are wide and my sympathies deep) I recognize the limitations of my fitness, and am not unaware that in my ignorance I shall overlook much which might have rendered less sketchy a sketch necessarily imperfect.
Evolution advances by such slow and imperceptible degress that to those who are part of it the finger of time scarcely seems to move. Even the great epochs are seldom apparent to the participators. During the last century neither the colonists nor the mother country appreciated the thrilling interest of the long-fought duel for the possession of this continent. The acts and scenes of the drama, to them detached, isolated and independent, now glide like dissolving views into each other, and in the vitascope of history we can see the true sequence of events. That we can meet here today, Britons on British soil, in a French province, is one of the far-off results of that struggle. This was but a prelude to the other great event of the eighteenth century: the revolt of the colonies and the founding of a second great English-speaking nation—in the words of Bishop Berkeley's prophecy, "Time's noblest offspring."
It is surely a unique spectacle that a century later descendants of the actors of these two great dramas should meet in an English city in New France. Here, the American may forget Yorktown in Louisbourg, the Englishman Bunker Hill in Quebec, and the Frenchman both Louisbourg and Quebec in Chateauguay; while we Canadians, English and French, remembering former friendships and forgetting past enmities can welcome you to our country—the land in which and for which you have so often fought.
Once, and only once, before in the history of the world could such a gathering as this have taken place. Divided though the Greeks were, a Hellenic sentiment of extraordinary strength united them in certain assemblies and festivals. No great flight of imagination is required to picture a notable representation of our profession in the fifth century B.C. meeting in such a colonial town as Agrigentum, under the presidency of Empedocles. Delegates from the mother cities, brilliant predecessors of Hippocrates of the stamp of Democedes and Herodicus, delegates from the sister colonies of Syracuse and other Sicilian towns, from neighbouring Italy, from far distant Massilia, and from still more distant Panticapaeum and Istria. And in such an assemblage there would have been men capable of discussing problems of life and mind more brilliantly than in many subsequent periods, in the proportion as the pre-Hippocratic philosophers in things medical had thought more deeply than many of those who came after them.
We English are the modern Greeks, and we alone have colonised as they did, as free peoples. There have been other great colonial empires, Phoenician, Roman, Spanish, Dutch and French, but in civil liberty and intellectual freedom Magna Graecia and Greater Britain stand alone. The parallel so often drawn between them is of particular interest with reference to the similarity between the Greek settlements in Sicily and the English plantations on the Atlantic coast. Indeed, Freeman says: "I can never think of America without something suggesting Sicily, or of Sicily without something suggesting America." I wish to use the parallel only to emphasise two points, one of difference and one of resemblance. The Greek colonist took Greece with him. Hellas had no geographical bounds, "Massilia and Olbia were cities of Hellas in as full sense as Athens or Sparta." While the emigrant Britons changed their sky, not their character, in crossing the great sea, yet the home-stayers had never the same feeling toward the plantations as the Greeks had towards the colonial cities of Magna Graecia. If, as has been shrewdly surmised, Professor Seely was Herodotus reincarnate, how grieved the spirit of the father of history must have been to say of Englishmen, "nor have we even now ceased to think of ourselves as simply a race inhabiting an island off the northern coast of the Continent of Europe." The assumption of gracious superiority which, unless carefully cloaked, smacks just a little of our national arrogance, is apt to jar on sensitive colonial nerves. With the expansion of the Empire, and the supplanting of a national by an imperial spirit this will become impossible. That this sentiment never prevailed in Hellas, as it did later in the Roman Empire, was due largely to the fact that in literature, in science and in art, the colonial cities of Greece early overshadowed the mother cities. It may be because the settlements of greater Britain were of slower growth that it took several generations and several bitter trials to teach a lesson the Greeks never had to learn.
The Greek spirit was the leaven of the old world, the working of which no nationality could resist; thrice it saved western civilisation, for it had the magic power of leading captivity captive and making even captive conquerors the missionaries of her culture. What modern medicine owes to it will appear later. "The love of science, the love of art, the love of freedom—vitally correlated to each other, and brought into organic union," were the essential attributes of the Greek genius (Butcher). While we cannot claim for the Anglo-Saxon race all of these distinctions it has in a high degree that one which in practical life is the most valuable, and which has been the most precious gift of the race to the world—the love of freedom, Of freedom in her regal seat Of England.
It would carry me too far afield to discuss the differences between the native Briton and his children scattered so widely up and down the earth. In Canada, South Africa, Australia, and New Zealand, types of the Anglo-Saxon race are developing which will differ as much from each other, and from the English, as the American does to-day from the original stock; but amid these differences can every-where be seen those race-qualities which have made us what we are—"courage, national integrity, steady good sense, and energy in work." At a future meeting of the Association, perhaps in Australia, a professional Sir Charles Dilke with a firm grasp of the subject may deal with the medical problems of Greater Britain in a manner worthy of the address in medicine. My task, as I mentioned at the outset, is much less ambitious.
Could some one with full knowledge patiently analyse the characteristics of British medicine, he would find certain national traits sufficiently distinct for recognition. Three centuries cannot accomplish very much (and that period has only just passed since the revival of medicine in England), but the local conditions of isolation, which have been singularly favourable to the development of special peculiarities in the national character, have not been without effect in the medical profession. I cannot do more than touch upon a few features, which may be useful as indicating the sources of influence upon Great Britain in the past, and which may perhaps be suggestive as to lines of progress in the future.
Above the fireplace in Sir Henry Acland's library are three panelled portraits of Linacre, Sydenham, and Harvey; the scroll upon them reads Litterae, Praxis, Scientia. To this great triumvirate, as to the fountain heads, we may trace the streams of inspiration which have made British medicine what it is to-day.
Linacre, the type of the literary physician, must ever hold a unique place in the annals of our profession. To him was due in great measure the revival of Greek thought in the sixteenth century in England; and in the last Harveian oration Dr. Payne has pointed out his importance as a fore-runner of Harvey. He made Greek methods available; through him the art of Hippocrates and the science of Galen became once more the subject of careful, first-hand study.
Linacre, as Dr. Payne remarks, "was possessed from his youth till his death by the enthusiasm of learning. He was an idealist devoted to objects which the world thought of little use." Painstaking, accurate, critical, hypercritical perhaps, he remains to-day the chief literary representative of British medicine. Neither in Britain nor in Greater Britain have we maintained the place in the world of letters created for us by Linacre's noble start. It is true that in no generation since has the profession lacked a man who might stand unabashed in the temple at Delos; but, judged by the fruits of learning, scholars of his type have been more common in France and Germany. Nor is it to our credit that so little provision is made for the encouragement of these studies. For years the reputation of Great Britain in this matter was sustained almost alone by the great Dee-side scholar, the surgeon of Banchory, Francis Adams—the interpreter of Hippocrates to English students. In the nineteenth century he and Greenhill well maintained the traditions of Linacre. Their work, and that of a few of our contemporaries, among whom Ogle must be specially mentioned, has kept us in touch with the ancients. But by the neglect of the study of the humanities, which has been far too general, the profession loses a very precious quality.
While in critical scholarship and in accurate historical studies, British medicine must take a second place, the influence of Linacre exerted through the Royal College of Physicians and the old Universities, has given to the humanities an important part in education, so that they have moulded a larger section of the profession than in any other country. A physician may possess the science of Harvey and the art of Sydenham, and yet there may be lacking in him those finer qualities of heart and head which count for so much in life. Pasture is not everything and that indefinable, though well understood, something which we know as breeding, is not always an accompaniment of great professional skill. Medicine is seen at its best in men whose faculties have had the highest and most harmonious culture. The Lathams, the Watsons, the Pagets, the Jenners, and the Gairdners have influenced the profession less by their special work than by exemplifying those graces of life and refinements of heart which make up character. And the men of this stamp in Greater Britain have left the most enduring mark,—Beaumont, Bovell and Hodder in Toronto; Holmes, Campbell and Howard in this city; the Warrens, the Jacksons, the Bigelows, the Bowditches, and the Shat-tucks in Boston; Bard, Hosack, Francis, Clark, and Flint of New York; Morgan, Shippen, Redman, Rush, Coxe, the elder Wood, the elder Pepper, and the elder Mitchell of Philadelphia—Brahmins all, in the language of the greatest Brahmin among them, Oliver Wendell Holmes, these and men like unto them have been the leaven which has raised our profession above the dead level of a business.
The litterae humaniores, represented by Linacre, revived Greek methods; but the Faculty during the sixteenth and at the beginning of the seventeenth centuries was in a slough of ignorance and self-conceit, and not to be aroused even by Moses and the prophets in the form of Hippocrates and the fathers of medicine. In the pictures referred to, Sydenham is placed between Linacre and Harvey; but science preceded practice, and Harvey's great Lumleian lectures were delivered before Sydenham was born. Linacre has been well called, by Payne, Harvey's intellectual grand-father. "The discovery of the circulation of the blood was the climax of that movement which began a century and a half before with the revival of Greek medical classics, and especially of Galen." (Payne.) Harvey returned to Greek methods and became the founder of modern experimental physiology and the great glory of British scientific medicine. The demonstration of the circulation of the blood remains in every detail a model research. I shall not repeat the oft-told tale of Harvey's great and enduring influence, but I must refer to one feature which, until lately, has been also a special characteristic of his direct successors in Great Britain. Harvey was a practitioner and a hospital physician. There are gossiping statements by Aubrey to the effect that "he fell mightily in his practice" after the publication of the De motu cordis, and that his "therapeutic way" was not admired; but to these his practical success is the best answer. It is remarkable that a large proportion of all the physiological work of Great Britain has been done by men who have become successful hospital physicians or surgeons. I was much impressed by a conversation with Professor Ludwig in 1884. Speaking of the state of English physiology, he lamented the lapse of a favourite English pupil from science to practice; but, he added, "while sorry for him, I am glad for the profession in England." He held that the clinical physicians of that country had received a very positive impress from the work of their early years in physiology and the natural sciences. I was surprised at the list of names which he cited; among them I remember Bow-man, Paget, Savory and Lister. Ludwig attributed this feature in part to the independent character of the schools in England, to the absence of the University element so important in medical life in Germany, but, above all, to the practical character of the English mind, the better men preferring an active life in practice to a secluded laboratory career.
Thucydides it was who said of the Greeks that they possessed "the power of thinking before they acted, and of acting, too." The same is true in a high degree of the English race. To know just what has to be done, then to do it, comprises the whole philosophy of practical life. Sydenham—Angliae lumen, as he has been well called—is the model practical physician of modern times. Linacre led Harvey back to Galen, Sydenham to Hippocrates. The one took Greek science, the other not so much Greek medicine as Greek methods, particularly intellectual fearlessness, and a certain knack of looking at things. Sydenham broke with authority and went to nature. It is an extraordinary fact that he could have been so emancipated from dogmas and theories of all sorts. He laid down the fundamental proposition, and acted upon it, that "all diseases should be described as objects of natural history." To do him justice we must remember, as Dr. John Brown says, "in the midst of what a mass of errors and prejudices, of theories actively mischievous, he was placed, at a time when the mania of hypothesis was at its height, and when the practical part of his art was overrun and stultified by vile and silly nostrums." Sydenham led us back to Hippocrates, I would that we could be led oftener to Sydenham! How necessary to bear in mind what he says about the method of the study of medicine. "In writing therefore, such a natural history of diseases, every merely philosophical hypothesis should be set aside, and the manifest and natural phenomena, however minute, should be noted with the utmost exactness. The usefulness of this procedure cannot be easily overrated, as compared with the subtle inquiries and trifling notions of modern writers, for can there be a shorter, or indeed any other way of coming at the morbific causes, or discovering the curative indications than by a certain perception of the peculiar symptoms? By these steps and helps it was that the father of physic, the great Hippocrates, came to excel, his theory being no more than an exact description or view of Nature. He found that Nature alone often terminates diseases, and works a cure with a few simple medicines, and often enough with no medicines at all." Well indeed has a recent writer remarked, "Sydenham is unlike every previous teacher of the principles and practice of medicine in the modern world." He, not Linacre or Harvey, is the model British physician in whom were concentrated all those practical instincts upon which we lay such stress in the Anglo-Saxon character.
The Greek faculty which we possess of thinking and acting has enabled us, in spite of many disadvantages, to take the lion's share in the great practical advances in medicine. Three among the greatest scientific movements of the century have come from Germany and France. Bichat, Laennec and Louis laid the foundation of modern clinical medicine; Virchow and his pupils of scientific pathology; while Pasteur and Koch have revolutionized the study of the causes of disease; and yet, the modern history of the art of medicine could almost be written in its fulness from the records of the Anglo-Saxon race. We can claim every practical advance of the very first rank—vaccination, anaesthesia, preventive medicine and antiseptic surgery, the "captain jewels in the carcanet" of the profession, beside which can be placed no others of equal lustre.
One other lesson of Sydenham's life needs careful conning. The English Hippocrates, as I said, broke with authority. His motto was
Thou Nature art my Goddess; to thy law My services are bound.
Undue reverence for authority as such, a serene satisfaction with the status quo, and a fatuous objection to change have often retarded the progress of medicine. In every generation, in every country, there have been, and ever will be, laudatores temporis acti, in the bad sense of that phrase, not a few of them men in high places, who have lent the weight of a complacent conservatism to bolster up an ineffectual attempt to stay the progress of new ideas. Every innovator from Harvey to Lister has been made to feel its force. The recently issued life of Thomas Wakley is a running commentary of this spirit, against the pricks of which he kicked so hard and so effectually. But there are signs of a great change. The old universities and the colleges, once the chief offenders, have been emancipated, and remain no longer, as Gibbon found them, steeped in port and prejudice. The value of authority per se has lessened enormously, and we of Greater Britain have perhaps suffered as the pendulum has swung to the other extreme. Practice loves authority, as announced in "the general and perpetual voice of men." Science must ever hold with Epicharmus that a judicious distrust and wise scepticism are the sinews of the understanding. And yet the very foundations of belief in almost everything relating to our art rest upon authority. The practitioner cannot always be the judge; the responsibility must often rest with the teachers and investigators, who can only learn in the lessons of history the terrible significance of the word. The fetters of a thousand years in the treatment of fever were shattered by Sydenham, shattered only to be riveted anew. How hard was the battle in this century against the entrenched and stubborn foe! Listen to the eloquent pleadings of Stokes, pleading as did Sydenham, against authority, and against the bleedings, the purgings and sweatings of fifty years ago. "Though his hair be grey and his authority high, he is but a child in knowledge and his reputation an error. On a level with a child, so far as correct appreciation of the great truths of medicine is concerned, he is very different in other respects, his powers of doing mischief are greater; he is far more dangerous. Oh! that men would stoop to learn, or at least cease to destroy." The potency of human authority among the powers that be was never better drawn than by the judicious Hooker in his section on this subject. "And this not only with `the simpler sort, but the learneder and wiser we are, the more such arguments in some cases prevail with us. The reason why the simpler sort are moved with authority is the con-science of their own ignorance; whereby it cometh to pass that having learned men in admiration, they rather fear to dislike them than know wherefore they should allow and follow their judgments. Contrariwise with them that are skilful authority is much more strong and forcible; because they only are able to discern how just cause there is why to some men's authority so much should be attributed. For which cause the name of Hippocrates (no doubt) were more effectual to persuade even such men as Galen himself than to move a silly empiric."
Sydenham was called "a man of many doubts" and therein lay the secret of his great strength.