THE HISTORY OF PATHOLOGY.1

By CHARLES WORKMAN, M.D.

Medicine in the very earliest times of which we can get any record seems to have commenced along two lines. One of these, which we might name primitive surgery, was the treat- ment of injuries caused by accident or in battle with men or animals; in this case the cause of the lesions was readily seen and understood. But on the other hand, we find that our forefathers had to deal with many conditions of which the causes were to them absolutely unknown, or, at least, very obscure indeed; such conditions were the fever and delirium produced by wounds, the effects of some poisons, and zymotic diseases ! These conditions were immediately ascribed by them to the malevolent action of the spirits of animals or men, the interference of the gods, or the power of witchcraft brought upon the invalid by his living enemies. And as these two lines of primitive surgery and primitive medicine were soon seen to have close relations, we find in very early times that a guild of medical practitioners arose specially trained to undertake the treatment of both these forms of disease; and as many of the diseases which they had to treat were supposed to be due to the anger of God, which must be appeased by sacrifice, this medicine-craft became often amal- gamated with priestcraft. This was by no means always the case, as the medicine men in many countries remained quite distinct from the priests of religion. Medicine having reached this stage made very little progress 1 Address delivered at the opening of Session 1897-98, St. Mungo's ?College, Glasgow. 340 Dr. Workman?The History of Pathology.

for a long time, and we find that among savage races the healing art is confined to a special guild of medicine men and sorcerers, or is in the hands of the priests to this day. The delay in progress would seem to have been due largely to the superstition or reverence for the dead, which hindered anyone from making any anatomical investigation of the bodies of those who had died from disease or injury; and although a knowledge of the anatomy of animals was acquired at a comparatively early date, no one supposed that the information thus obtained could throw any light on the diseases and injuries of man. A great advance would appear to have been made in very early times (three to four thousand years B.C.) in both China and Egypt, though this advance was almost wholly empirical, as very little was known in either country of human anatomy or physiology, and it was due apparently to the increase of practical knowledge of the effects of different drugs on the body. In Egypt, also, considerable dexterity was acquired in the treatment and diagnosis of disease of the eye and of the skin. But in spite of the knowledge which we might expect the people of that country to have obtained from the operation of embalming, no progress seems to have been made by them either in normal or pathological anatomy of the internal organs. The first advance on the lines of anatomy seems to have been made by the early Greek physicians, though most of them only made dissections on the bodies of the lower animals. The advance made by Hippocrates seems to have been brought about chiefly by his wonderfully careful clinical observations. Some three hundred years before Christ the medical school at Alexandria had broken through the barrier of reverence or superstition, and Herophilus and Erasistratus not only used the bodies of the dead for dissection, but it would even seem that they used condemned criminals for the purpose of vivi- section. The latter (Erasistratus) also appears to have made post-mortem examinations on the bodies of persons who had died from disease, and to have observed and noted certain changes in the organs due to the disease, as he describes changes in the liver, &c. For some four hundred years after this time medicine appears to have made little or no progress?that is, till the time of Galen; and, indeed, the knowledge of anatomy and pathology seems rather to have lost ground than to have advanced, though practical surgery and medicine advanced in an empiric fashion. Galen, however, was much in advance of Dr. Workman?The Histoi-y of Pathology. 341

his time, and though not a man of the type of Hippocrates .nor of his ability, yet he made very considerable progress in anatomy by his dissections of the lower animals. He does not seem to have often dissected human bodies, for he mentions with surprise that those physicians who attended the Emperor Marcus Aurelius in his campaign against the Germans had the opportunity of dissecting the bodies of the barbarians slain in battle. His own description of the human hand is evidently taken from that of an ape with undeveloped opponens pollicis. Galen allowed his philosophical notions to outweigh the observation of nature, and he endeavoured to systematise his knowledge when he had far too slight data on which to found his systems, and thus in his writings we find much that is valuable and of interest among a mass of false and confused ideas of anatomy and physiology. His ability and personal power were so great, and his writings so vol- uminous and so much in advance of his time, that they became and remained the text-books of medicine and surgery for a thousand years after, and all medical writers were taken up simply with discussing and commenting on his works. This condition of things lasted till the time of Vesalius and Harvey?that is, till the beginning of the seventeenth century ?and it would seem to have been the study of anatomy and physiology which brought about the change. Harvey himself realised the value of careful pathological observation, for he states that he considered the dissection of one body dead of phthisis or of any lingering disease of more value than the dissection of ten hanged people. An immense impetus was given to these studies by the improvement made about this time in the microscope as an instrument of precision, by the means of which such men as Hooke, Loewenhoek, and Malpighi added enormously to the knowledge of histology; and Loewenhoek may be considered the discoverer of those most wonderful creatures, the bacteria and infusoria. In pathology the improvement shows itself first by the careful noting of post-mortem appearances and their relation to clinical symptoms found in the works of Bonetus, Valsalva, and above all of Morgagni of Forli, who may well be called the father of pathology, for his careful descriptions of clinical symptoms and of the related post-mortem appearances are of the greatest interest and value even to this day. His book on The Seats and Causes of Disease is a model of careful investigation well worth your study. Giovanni Battista Morgagni was born in 1682. Following, 342 Dr. Workman?The History of Pathology,

and perhaps inspired by, the works of Morgagni, William and John Hunter set about making the most careful observations, the first chiefly in anatomy, the latter more in pathology, and, at the same time, they saw the importance not only of publishing their observations but of forming collections illustrating the experiments they made, and the facts which they had discovered. These collections remain as a grand memorial of their labours in the Hunterian Museums of Glasgow and London. The Senate of the University of Glasgow has shown but little appreciation of the treasure left to its care by William Hunter, as it is only now beginning to put the collection in order, and make it available to our students; and the collection is even yet in a very unsatisfactory position in a badly heated and inefficiently lighted loft. It is also only by special grace that students can gain admission to the collection. The museum of a public institution such as the University should be thrown open not only to the students and teachers but to the public without fee or charge, as in this way their value would become more generally known, and those who have the opportunity would the more readily add to them and subscribe money for their better preservation and exhibition. Since the time of the Hunters, who were born in the early part of the eighteenth century, John in 1728, very steady progress has been made in the etiology, pathology, and treat- ment of disease. It is curious to note that this revival of scientific investigation was first started in Italy by Morgagni, from which country the impulse passed to England and France, while Italy, for long after Morgagni, made no advance ; then the impulse seems to have passed to Germany, and the great names in practical and experimental pathology with which we conjure now are German. A few of these are of such importance that they may be specially mentioned. Cohnheim, of Leipzig, who has made his name known by his book on General Pathology, and by the work he has done in the experimental investigation of the subject; Robert Koch, the bacteriologist who has gained world-wide fame by his discovery of the bacillus tuberculosis and of the spirillum of cholera; and, above all, Rudolph Virchow, of Berlin, who has done such splendid work as is evidenced in his books on Cellular Pathology and Die Krankhaften Geschwiilste, as well as in editing for many years the magazine which is known by his name, Virchoiv's Archives. He is by far the greatest living pathologist, and, in addition to all his labours in this line and as professor in the University of Dr. Workman?The History of Pathology. 343

Berlin, he is a politician and orator on the side of free thought and liberalism in the German Reichstag. Another name is one much less known in this country, Bernard von Gudden, who was a martyr to his profession in that, when attending on the late King Ludwig of Bavaria he was drowned by him in the Stranberg Lake. His name is known, perhaps, mostly by his microtome for making brain sections, but he did enormous pioneer work in the study of the nervous system and its diseases, and was the first to use the method of following up the degeneration or want of develop- ment which follows the removal of a limb or organ, and thus mapping out the nervous centres which are connected with the functions of the part removed. He was, at the same time, most earnest and philanthropic in endeavours for the good of the insane under his care in the asylum at Munich. The name and follies of the king who drowned him will probably " be remembered long after his name has faded into the infinite azure of the past." I wish to call upon you, my fellow-students of St. Mungo's College (for though a teacher I am still, I hope, your fellow- student), to take up the gauntlet for Scotland, not to rest idly on the laurels of your predecessors, but to determine that the next generation in Glasgow shall be more scientific, more hopeful, more brilliant than the past. To turn now to the work done in the investigation of medical questions during the present century. One of the most important changes is as regards our view of the causation of some forms of disease, and from this to a certain degree there has been a considerable change in the method of treat- ment. Up till a comparatively few years ago heredity was thought to play a very important part in the causation of such diseases as consumption (phthisis pulmonalis) and leprosy, as well as in cancer and sarcoma, which are still considered by many, if not most, pathologists to be greatly the result of hereditary tendency. In the earlier half of this century it was believed that this heredity was not merely the transmission of a tend- or but that the actual ency to the diseases phthisis leprosy, exciting cause was transmitted, just as at the present time it is believed that a father may transmit syphilis to his child without the mother being infected. Johnathan Hutchinson has stated quite lately that this is a frequent way for syphilis to be transmitted from parent to child. This idea, in the case of phthisis, was combated by Cohnheim and others before the Koch and germ of the disease had been demonstrated by 341 Dr. Workman?The History of Pathology,

Baumgarten, and he came to this conclusion largely from his experiments on animals. He was so convinced of the purely infectious nature of the disease that he was able to prophesy that a germ would be found to be the cause some time before the bacillus tuberculosis was discovered. Other pathologists came to much the same conclusion as regards the fallacy of the view that heredity was the cause of that disease from very different data. My teacher, Professor Redfern, argued, from his experience, that the disease was produced by unhealthy surroundings, for if you breed rabbits in damp unhealthy hutches great numbers are sure to die from this disease, while if they are bred in dry hutches the mortality is greatly reduced, and he believed from this and from his observations of patients that where the disease appeared to be transmitted from husband to wife, or vice versa, this was due to the damp caused by sweating, as profuse perspiration is well known to be a common feature in this disease. We now know that in such a case the direct transmission of the germ is far more probably the cause, but the argument against heredity remains the same. Again, the father of Sir William MacCormac, an old and highly educated Belfast physician, held the view that the cause of this disease was rebreathed air, practically that it was due to excess of carbonic acid, and he recommended everyone to sleep with the windows of their rooms open both above and below, in order that fresh oxygen might be admitted. And I remember well his telling me, when I called his attention to the discovery of the bacilli in the sputum, that these must be only accidental, as he had examined the sputum in a great number of cases and had never seen such a thing. He did not seem to realise that the power he had used was too low, nor did he understand the importance of proper staining, but he had come, from a wide experience, to see that the cause was from without, and that the disease was not a hereditary one. And now, to crown all, we have the clear experimental evidence that this disease can be produced by the inoculation of a pure cultivation of the bacillus, so that it is almost universally believed that heredity can only act in this disease by producing a weakness of the individual, and that a suitable soil is thus produced in his lungs for the growth and development of the germ. In the same way, up to the present time, heredity was believed to be a prime factor in the causation of leprosy, but it is almost certain that this disease is produced by a very similar organism to that of tubercle, and that the reason why Dr. Workman?The History of Pathology. 345 its infective nature was so long obscured was simply the very prolonged incubation stage. This incubation stage has been found to last several years. In one case a soldier who had been in India, and was there, probably, exposed to infection, a year or two after returning to Ireland was attacked by the disease, and ultimately died from it. Afterwards, a friend with whom he had been living, but who had never been out of Ireland, developed leprosy. A number of similar cases have lately been published, notably that of Father Damien, which all go to prove the infectious character of the disease and its non-hereditary nature. In the case of the malignant tumours the question is a much more difficult one, yet even here the importance of heredity, even as a predisposing cause, is coming to be doubted, for Snow argues that, if you inquire as to the family history of healthy persons you have as great evidence of cancer as you will find in the family histories of those who are cancerous. Practically, the fact is that everyone has some history of malignant disease if the family records be thoroughly investi- gated. On the whole, I am strongly inclined to the view that we cannot blame our forefathers with our infirmities and diseases, but must put them down to some breaking of the laws of health, either in ourselves or in our neighbours, so that we become infected with disease of some kind. In our knowledge of epidemic diseases great advance has been made within the last half century, both as regards their causation and the best means of putting a stop to their spread. In olden time any systematic regulation of the treatment of the plague-stricken or of the bodies of those who had died from the disease was rendered impossible by the insane terror which took possession of the inhabitants of any affected town, as may be well seen from the description of the Attic plague given by the Greek historian, Thucydides, who was himself a sufferer; and even a few years ago, when cholera attacked Naples, the people fought with the sanitary authorities when they attempted to remove the sick to hospital for better treatment; and a similar difficulty was experienced in Bombay this year, the people endeavouring to hide the occurrence of cases of bubonic plague for fear of the sanitary regulations. Now, in civilised countries the people generally have come to realise that the spread of a plague is only encouraged by such demoralisation, and that their individual danger is enormously increased by it, so that it would be impossible for such a condition of things to occur among us, and this advantage was 346 Dr. Workman?The History of Pathology. well seen a year or two ago when the cholera invaded Hamburg and caused terrible mortality?it was not looked upon as some dreadful incomprehensible scourge coming from the planet Mars or from elsewhere, and from which there could be no escape but in flight. The plague was calmly investigated, and proper means taken to stamp it out. Very soon this was accomplished, and the epidemic which seemed about to spread over all Europe was confined to the narrow limits of Hamburg and Altona. In the early part of the century but little was known of the fevers typhus, enteric, and relapsing, and they were very completely confused with one another; this may be seen from our old pathological reports, where I find a case in 1852 put down as typhus which, on reading the account of the post- mortem appearances found in the intestine along with the report of the symptoms during life, was evidently a case of most pronounced enteric. In those days typhus appears to have been very common in Glasgow and all cities of like size, while now, that better sanitary arrangements have been obtained, both that disease and relapsing fever are very rare indeed; so much is this the case that you may probably pass through your course as students and obtain your diploma without ever having seen a case of either disease, and yet even in my student days in Belfast, which are not very long past, I saw many cases of typhus. I am sorry that we cannot speak of a similar improvement with regard to enteric fever, which is still fearfully prevalent in spite of all our sanitary regulations and precautions, especi- ally when they are not carried out, as has been the case just now at Maidstone. And here I should like to call your attention to a rather remarkable fact which may or may not have some causal relation to this difference in the results obtained. In enteric fever a definite germ has been found?the bacillus of Eberth?which has been almost certainly proved to be the exciting cause of that disease, while in the other exanthe- matous fevers?typhus, small-pox, scarlatina, and measles? no germ has been found which with any show of reason can be considered to be the cause of the disease. Along with this fact, it seems to me remarkable that enteric fever does not give such a pronounced immunity from a second attack as we find in these other diseases, and it does not seem to give rise to direct infection, but the disease appears almost always to be spread by means of food or drink. Before passing from the subject of the fevers, I should Dr. Workman?The History of Pathology. 347 point out a change in opinion among pathologists as to direct infection. Morgagni, in his book, states that he always avoided making post-mortem examinations in such cases for fear of infection, and this fear seems to have hindered many other earnest students as well as him from such investigations. Now, on the other hand, such an experienced physician as Dr. Wilks, of London, who was formerly pathologist to Guy's Hospital, stated that he had never known an infectious disease to be transmitted from a dead body by post-mortem examina- tion, and for myself I certainly should not fear to make an inspection on any disease that I ever heard of or saw. Enormous advance has been made of late years in our knowledge of nervous diseases, as I have already indicated in speaking of my old teacher, Professor von Gudden. This has specially been in the way of localising the seat of various brain diseases, and thus enabling surgical interference to be of use. As I have indicated, Gudden was a pioneer in this direction, but his work was followed up and improved upon by Munk in Germany and by Ferrier in this country, until now brain surgery has become so common and, by means of aseptics and anaesthetics, so safe as almost to be considered a minor operation. Just lately a new line of research has been opened in nervous disease by the studies of Charcot and others into the nature of hypnotism, somnambulism, and allied states, and this may lead to an advance in our knowledge of pschy- cology and mental disease, which has been almost hopelessly obscure. I remember Huxley, in an address at Belfast, speaking of metaphysics as a useless study, for one might as well try to lift himself by the band of his trousers as hope to get any light by that study. If one uses a pulley it is possible to raise oneself by the bellyband, and it is just possible that in hypnotism and its allied states we may find a suitable pulley to raise us from our ignorance. It is remarkable that there are remnants of ancient patho- logical philosophies and ideas still prevalent not only among the uneducated, but even among well-educated physicians and surgeons. We often still hear ideas propounded that take us back to Galen and his four humours. We hear even doctors speaking of medicines that open or close the pores, thus to let out evil humours or to hinder the loss of good ones. And how very often do we hear both doctors and laymen talk of the liver as if it were some evil demon placed within us to destroy our happiness, and medicines are given to purge the liver or to 348 Dr. Workman?The History of Pathology. soothe the liver, and men talk as if the whole function of this organ was to produce bile, while physiologists tell us that the production of this secretion is only a very slight and insignificant part of its duties, and as to the nature and method of its real work we are still sadly in the dark. When men speak of their liver being out of order, all that is meant is that they are suffering from one of the many forms of stomach or intestinal indigestion. The plan of blaming the liver may be a very nice way of soothing our patients and comforting them, but we should never let it blind us to the fact that it is merely a cloak for our ignorance, and though we may calm our patients by this means, we should endeavour to find out what is really wrong and, if possible, relieve it. Another form in which ancient medicine remains with us is in the idea that patients are either sthenic or asthenic, taken from the medical philosophy of Brown, whose view was that disease is caused either by the fact that the vital force is in excess of or below the mean of health?in the first case to be treated by blood-letting and purging; in the other case to be treated by food and stimulants. This view has probably a certain amount of truth in it, at least in certain cases of disease. But it probably led to great injury when frequent bleeding was indulged in, as it used to be even a quarter of a century ago. The medical philosophy of the Jin de siecle appears to be the microbic origin of almost all diseases and their treatment by various kinds of antitoxic serum. Do not, however, be in too great a hurry to conclude that when you have found a special organism in the blood or tissues of a patient suffering from a peculiar disease, and that you can cultivate it pure in gelatine or agar, and further, that by inoculation of the pure cultivation you can produce similar symptoms to those of the patient in men or animals inoculated, that you have found out all that can be known of the disease and its causes; future years may show us that when we have found the germ we have only reached the bottom rung of a very long ladder. The prospect, also, which seems at present to stretch before us, that we must have our children vaccinated and then injected with antidiphtheritic, antirabic, antisyphilitic, anti- mallic, and no one knows what other antitoxic serums, is to my mind anything but reassuring, and comes to look very much as if we were trending back to the old Galenical ideas of good and bad humours. Gentlemen, although we sometimes, as in this serum craze, .are apt to go faster than our knowledge or our experiments Dr. Findlay?Presidential Address. 340 would warrant, yet, on the whole, in the course of the ages I am convinced that gradual progress is being made, and that we enjoy a much greater freedom from illness and from anxiety than did our forefathers of two hundred years ago, in spite of the fact that our progress in civilisation has added many new dangers, as well as making us realise more clearly the dangers which surrounded them and still surround us in the struggle for existence. A few words now of welcome and of warning to those of you who are just commencing your studies in the medical profession. You are entering on a serious life work, which is almost certain to cause you great happiness or sore suffering, for I cannot think that any of you would take up such a profession simply for the purpose of pecuniary gain. If you are well equipped by your studies in the school and in the wards, you will have joy in the help you can give to your suffering fellow-creatures; while if you have idled away your student years, you will have the great sorrow of seeing those you should have aided suffering through your ignorance. " Geh ! gehorche meinen Winken, Nutze deine jungen Tage, Lerne zeitig kliiger sein ; Auf des Gliickes grosser Wage Steht die zunge selten ein; Du rausst steigen oder sinken, Du musst herrschen und gewinnen, Oder dienen und Yerlieren, Leiden oder triumphieren, Ambos oder Hammer sein."?Goethe.