Pathology as Objective Biology

Thomas SYDENHAM. From Observationes medicae circa morborum acutorum historiam et curationem, London, 1676; tr. by R. G. Latham as Medical observations concerning the history and cure of acute diseases, in The works of Thomas Sydenham, M.D., vol. I, London (for the Sydenham Society), 1848.

. . . how great soever the efforts of others may have been, I, for my own part, have always considered that the breath of life would have been to me a vain gift, unless I, working in the same mine with them, contributed my mite to the treasury of physic. Wherefore, after long meditation, and the diligent and faithful observations of many years, I at length determined—firstly, to state my opinion as to the means by which the science of medicine was to be advanced; secondly, to publish a sample of my endeavours in that department.

I conceive that the advancement of medicine lies in the following conditions:

There must be, in the first place, a history of the disease; in other words, a description that shall be at once graphic and natural.

There must be, in the second place, a Praxis, or Mcthodus, respecting the same, and this must be regular and exact.

To draw a disease in gross is an easy matter. To describe it in its history, so as to escape the censure of the great Bacon, is far more difficult. Against some pretenders in this way, he launches the following censure—"We are well aware that there existeth such a thing as a Natural History; full in bulk, pleasant from its variety, often curious from its diligence. Notwithstanding, whoever would take away from the same the citations of authors, the empty discussions, and, finally, the book-learning and ornaments, which are fitter for

the convivial meetings of learned men than for the establishment of a Philosophy, would find that it dwindled into nothing. Such a natural history is far distant from the one we contemplate."

In like manner it is exceedingly easy to propound some common-place cure for a complaint. It is far harder, however, to translate your words into actions, and to square your results with your promises. This is well known to those who have learned that there occur in practical writers numerous diseases, which neither the authors themselves, nor any persons else besides, have been able to cure.

In respect to the histories of a disease, any one who looks at the case carefully, will see at once that an author must direct his attention to many more points than are usually thought of. A few of these are all that need be noticed at present.

In the first place, it is necessary that all diseases be reduced to definite and certain species, and that, with the same care which we see exhibited by botanists in their phytologies; since it happens, at present, that many diseases, although included in the same genus, mentioned with a common nomenclature, and resembling one another in several symptoms, are, notwithstanding, different in their natures, and require a different medical treatment.

We all know that the term thistle is applied to a variety of plants; nevertheless, he would be a careless botanist, indeed, who contented himself with the general description of a thistle; who only exhibited the marks by which the class was identified; who neglected the proper and peculiar signs of the species, and who overlooked the characters by which they were distinguished from each other. On the same principle, it is not enough for a writer to merely note down the common phenomena of some multiform disease; for, although it may be true that all complaints are not liable to the same amount of variety, there are still many which authors treat alike, under the same heads, and without the shadows of a distinction, whilst they are in their nature as dissimilar as possible. This I hope to prove in the forthcoming pages.

More than this—it generally happens that even where we find a specific distribution, it has been done in subservience to some favorite hypothesis which lies at the bottom of the true phenomena; so that the distinction has been adapted not to the nature of the complaint, but to the views of the author and the character of his philosophy. Many instances prove the extent to which medicine has been injured by a want of accuracy upon this point. We should have known the cures of many diseases before this time if physicians, whilst with all due good-will they communicated their experiments and observations, had not been deceived in their disease, and had not mistaken one species for another. And this, I think, is one reason why the Material Medica has grown so much and produced so little.

In writing the history of a disease, every philosophical hypothesis whatsoever, that has previously occupied the mind of the author, should lie in abeyance. This being done, the clear and natural phenomena of the disease should be noted—these, and these only. They should be noted accurately, and in all their minuteness; in imitation of the exquisite industry of those painters who represent in their portraits the smallest moles and the faintest spots. No man can state the errors that have been occasioned by these physiological hypotheses. Writers, whose minds have taken a false colour under their influence, have saddled diseases with phenomena which existed in their own brains only; but which would have been clear and visible to the whole world had the assumed hypothesis been true. Add to this, that if by chance some symptom really coincide accurately with their hypothesis, and occur in the disease whereof they would describe the character, they magnify it beyond all meas-tire and moderation; they make it all and in all; the molehill becomes a mountain; whilst, if it fail to tally with the said hypothesis, they pass it over either in perfect silence or with only an incidental mention, unless, by means of some philosophical subtlety, they can enlist it in their service, or else, by fair means or foul, accommodate it in some way or other to their doctrines.

Thirdly; it is necessary, in describing any disease, to enumerate the peculiar and constant phenomena apart from the accidental and adventitious ones: these last-named being those that arise from the age or temperament of the patient, and from the different forms of medical treatment. It often happens that the character of the complaint varies with the nature of the remedies, and that symptoms may be referred less to the disease than to the doctor. Hence two patients with the same ailment, but under different treatment, may suffer from different symptoms. Without caution, therefore, our judgment concerning the symptoms of disease is, of necessity, vague and uncertain. Outlying forms of disease, and cases of exceeding rarity, I take no notice of. They do not properly belong to the histories of disease. No botanist takes the bites of a caterpillar as a characteristic of a leaf of sage.

Finally, the particular seasons of the year which favour particular complaints are carefully to be observed. I am ready to grant that many diseases are good for all seasons. On the other hand, there is an equal number that, through some mysterious instinct of Nature, follow the seasons as truly as plants and birds of passage. I have often wondered that this disposition on the part of several diseases, obvious as it is, has been so little observed; the more so, as there is no lack of curious observations upon the planets tinder which plants grow and beasts propagate. But whatever may be the cause of this supineness, I lay it down as a confirmed rule, that the knowledge of the seasons wherein diseases occur is of equal value to the physician in determining their Species and in effecting their extirpation; and that both these results are less satisfactory when this observation is neglected.

These, although not the only, are the main points to be attended to in drawing up the history of a disease. The practical value of such a history is above all calculation. By the side thereof, the subtle discussions, and the minute refinements wherewith the books of our new school are stuffed full, even ad nauseam, are of no account. What short way—what way at all—is there towards either the detection of the morbific cause that we must fight against, or towards the indications of treatment which we must discover, except the sure and distinct perception of peculiar symptoms? Upon each of these points the slightest and most unimportant circumstances have their proper bearings. Something in the way of variety we may refer to the particular temperament of individuals; something also to the difference of treatment. Notwithstanding this, Nature, in the production of disease, is uniform and consistent; so much so, that for the same disease in different persons the symptoms are for the most part the same; and the selfsame phenomena that you would observe in the sickness of a Socrates you would observe in the sickness of a simpleton. Just so the universal characters of a plant are extended to every individual of the species; and whoever (I speak in the way of illustration) should accurately describe the colour, the taste, the smell, the figure, &c., of one single violet, would find that his description held good, there or thereabouts, for all the violets of that particular species upon the face of the earth.

For my own part, I think that we have lived thus long without an accurate history of diseases, for this especial reason; viz. that the generality have considered that disease is but a confused and disordered effort of Nature thrown down from her proper state, and defending herself in vain; so that they have classed the attempts at a just description with the attempts to wash blackamoors white.

To return, however, to our business. As truly as the physician may collect points of diagnosis from the minutest circumstances of the disease, so truly may he also elicit indications in the way of therapeutics. So much does this statement hold good, that I have often thought, that provided with a thorough insight into the history of any disease whatsoever, I could invariably apply an equivalent remedy; a clear path being thus marked out for me by the different phenomena of the complaint. These phenomena, if carefully collated with each other, lead us, as it were, by the hand to those palpable indications of treatment which are drawn, not from the hallucinations of our fancy, but from the innermost penetralia of Nature.

By this ladder, and by this scaffold, did Hippocrates ascend his lofty sphere—the Romulus of medicine, whose heaven was the empyrean of his art. He it is whom we can never duly praise. He it was who then laid the solid and immoveable foundation for the whole superstructure of medicine, when he taught that our natures are the physicians of our diseases. By this he ensured a clear record of the phenomena of each disease, pressing into his service no hypothesis, and doing no violence to his description; as may be seen in his books

’De Morbis,’ ’De Affectionibus,’ &c. Besides this, he has left us certain rules, founded on the observation of the processes of Nature, both in inducing and removing disease. Of this sort are the ’Coacae Praenotiones,’ the ’Aphorisms,’ &c. Herein consisted the theory of that divine old man. It exhibited the legitimate operations of Nature, put forth in the diseases of humanity. The vain efforts of a wild fancy, the dreams of a sick man, it did not exhibit.

Now, as the said theory was neither more nor less than an exquisite picture of Nature, it was natural that the practice should coincide with it. This aimed at one point only—it strove to help Nature in her struggles as it best could. With this view, it limited the province of medical art to the support of Nature when she was enfeebled, and to the coercion of her when she was outrageous; the attempt on either side being determined by the rate and method whereby she herself attempted the removal and the expulsion of disease. The great sagacity of this man had discovered that Nature by herself determines diseases, and is of herself sufficient in all things against all of them. This she is, being aided by the fewest and the simplest forms of medicine. At times she is independent of even these.

The other method whereby, in my opinion, the art of medicine may be advanced, turns chiefly upon what follows, viz. that there must be some fixed, definite, and consummate methodus medendi, of which the commonweal may have the advantage. By fixed, definite, and consummate, I mean a line of practice which has been based and built upon a sufficient number of experiments, and has in that manner been proved competent to the cure of this or that disease. I by no means am satisfied with the record of a few successful operations, either of the doctor or the drug. I require that they be shown to succeed universally, or at least under such and such circumstances. For I contend that we ought to be equally sure of overcoming such and such diseases by satisfying such and such intentions, as we are of satisfying those same intentions by the application of such and such sorts of remedies; a matter in which we generally (although not, perhaps, always) can succeed. To speak in the way of illustration, we attain our ends when we produce stools by senna, or sleep by opium.

I am far from denying that a physician ought to attend diligently to particular cases in respect to the results both of the method and of the remedies which he employs in the cure of disease. I grant, too, that he may lay up his experiences for use, both in the way of easing his memory and of seizing suggestions. By so doing he may gradually increase in medical skill, so that eventually, by a long continuance and a frequent repetition of his experiments, he may lay down and prescribe for himself a methodus medendi, from which, in the cure of this or that disease, he need not deviate a single straw’s breadth. ...

An objection against me will be made by the vulgar and unthinking only, viz., that of having renounced the proper pomp of physic, and of having recommended medicines so plain and simple as not to be reducible to the Materia Medica. Wise men know this—whatever is useful is good. They know also that Hippocrates recommended bellows for the colic, and nothing at all for the cancer. They know, too, that similar treatment is to be discovered in every page of his writings; and withal that his merits in medicine are as great as if he had loaded his pages with the most pompous formulae.