Sactional

page 17 Proceedings of the Royal Society off~~~Mawine

fte ~ '' Vol. XIL
453

Section of the History of Medicine

President-Sir ARTHUR MACNALTY, K.C.B., M.D.
[January 8, 1947]
Clinical Science in the Light of History
By A. P. CAWADIAS, O.B.E., M.D., F.R.C.P.
MEDICINE is an Art, and as such has existed since the beginnings of humanity.
The Greeks, who created Science in that century tremendous in the development of
humanity, the seventh century B.C., introduced as basis of the art or practice of
medicine the scientific knowledge embodied in two sciences, Physiology in its wider
sense, that is, Physio-pathology, and Clinical Science.
PHYSIO-PATHOLOGY AND CLINICAL SCIENCE
The object of Physiology in its wide sense, or Physio-pathology, is study of the
functions of the human body, of the deviations of these functions, and of the action
of various agents on these functions in their normal and their diseased state. It thus
includes physiology proper, pathology, pharmacology and general therapy. Its
method is a priori thinking, hypothesis, experimentation for the control of hypothesis,
and reasoning on the basis of experimental facts towards the discovery of general
laws concerning health and disease. In his reasoning the Physio-pathologist takes
into consideration the facts of clinical observation, of Clinical Science. Pathology is
thus a branch of physiology, and as this is the section of Physiology in closest contact
with medicine I shall use indifferently the terms Physio-pathology and Pathology.
The object of Clinical Science is study of the morbid phenomena exhibited by human
beings. Its method is clinical observation of these phenomena, their classification
into morbid categories or diseases, and reasoning on the basis of clinical observation
for discovery of methods of diagnosis and treatment of patients showing these par-
ticular morbid categories or diseases. In his reasoning the Clinical Scientist takes
into consideration the data of Physio-pathology.
This science was known by the more general term 17rTptcK translated into
"Medicine". Sydenham introduced the more accurate and expressive term
"Natural History of Diseases". Later the terms "Nosology" and "Clinical
Medicine" were used. I do not know who first used the term Clinical Science, but
I find it in the work of Sir James Paget and later in that of Knud Faber. It is to Sir
Thomas Lewis, however, that we owe the general use of the term Clinical Science.
Unfortunately, this great physician over-emphasized what I shall call later the
''pathogenic chapter " of the natural history of diseases, and stressed certain
clinical experimental procedures to which he seemingly attributed greater scientific
status than to the great and real method of Clinical Science, namely, clinical obser-
vation. Neither can I accept his division into "Theoretical Medicine" and "Curative
Medicine". There are only two divisions in medicine as a science, Physio-pathology
and Clinical Science. We must therefore take the term "Clinical Science" in its
traditional Sydenhamian sense of "Natural History of Diseases".
Although intimately connected-all sciences are connected-Pathology and
Clinical Science are independent and separate sciences. Hippocrates in his Ancient
Medicine had contrasted the i7ptKu with "'Ort 'E,L'e8oYJ-EKX XXot ot0rEpt
aB
cfwva&9 yE7ypac faot" (Empedocles and others have written on Nature). This is
shown not only by the difference in their primary object and in their method, but also
by the history of their creation and development.
JUNE-HIST. OF. MED. 1
454 Proceedings of the Royal Society of Medicine 18
Physio-pathology was created in the sixth century B.C. The first scientists, the
Ionian Greeks, were designated Physiologists, meaning students of Nature in general.
They were the first to reject the supernatural explanation of the universe current
amongst the ancient Eastern peoples, and showed that all phenomena had a "natural
explanation" and that the secrets of the world could be penetrated by the unpre-
judiced observation of things and the power of reason. When Pythagoras brought
the torch of the Ionian Physiology to the Italo-Sicilian Greeks in the late sixth and
early fifth centuries B.C., a group of physiologists passed from consideration of
Nature in general to that of animal and principally human nature, and since then the
term Physiology has been restricted to the study of the functions of the human body.
The originators of this movement, apart from Pythagoras, were Alcmeon of Croton,
Empedocles of Agrigentum, Diogenes of Apollonia, Hippon and Anaxagoras. From
its inception Physiology was Physio-pathology, these first physiologists studying the
functions of the human body in health and disease, as shown in the conception of
disease expressed in the works of Alcmeon, Empedocles and Diogenes. In fact these
first Physio-pathologists were the first physicians. The intimate union between
Physiology and Pathology has persisted ever since. It was developed in the work of
Galen, the greatest of the Greek Physio-pathologists. It was codified later through
the work of John Hunter, Magendie and Claude Bernard, and is embodied in
Magendie's famous dictum, "Medicine (meaning pathology) is the physiology
of the diseased individual".
The method adopted by the first physiologists was a priori reasoning and observa-
tion, including dissections. Experimentation was introduced by the Alexandrians of
the third century B.C. and principally by Galen, but received its greatest impetus from
Harvey, who thus revived Physio-pathology as his contemporary, Sydenham, revived
Clinical Science. Since Harvey the basic method of Physio-pathology has been
experimentation.
Clinical Science was introduced a little later, in fact in the fifth century, by the
Coan physicians represented by Hippocrates, by the Cnidians represented by Euryphon
and also by the physicians of Rhodes. The islands of Cos and Rhodes and the penin-
sula of Cnidos were colonized by that most virile section of the Greek people, the
Dorians, who were, however, influenced by the neighbouring lonia and also by East Asia.
Asclepios, the God of Medicine, was one of the chief Dorian gods, and from the
Dorian peninsula of Peloponnesus with its great sanctuary of Asclepios at Epidauros,
this cult was brought to Cos, Cnidos and Rhodes. The priests of Asclepios, the
Asclepiadae, formed a princely priest-family which attributed its origin to Podalirios,
son of Asclepios. The Asclepiadae did not contifiue in their purely priestly caste
spirit. They were not Egyptians, they were Greeks. Just as the lonians had detached
themselves from the magic and supernatural explanations of the universe and inter-
preted Nature through natural laws, the Coan and Cnidian Asclepiadc abandoned
purely religious healing rites and, with the object of giving more effective help to the
patients who sought relief in the temples of Asclepios, they adopted clinical observa-
tion and healing on the basis of clinical observation.
THE METHOD OF CLINICAL SCIENCE
The method of Hippocrates, the founder of Clinical Science, consists, as described
by Plato, in careful analysis of nature (AteXe&r6at -r4v fvo-wv or clinical observation),
in enumeration of its types (aptO6p,uao-Oat. rad et'Sq or nosographical classification),
and in definition of the appropriate treatment for each (7rpocap07rretv egcaoTroV
/ccACTi.
The Egyptians also observed and recorded observations of their patients, but
clinical observation as introduced by the Coans and Cnidians is an active critical
observation demanding not only keen sense but also a special intellectual structure.
The heights attained by this method among the ancient Greeks can be gathered
19 Section of the History of Medicine 455
from what we know of the Empiricists and particularly from the book of Sextus
Empiricus, which is the Novum Organum of the ancient Greek clinicians. The
Empiricists built their clinical science on their famous tripod io'TropLa (observation
of others), TXp?70-tqs (observation of the physician himself), and ad7ro T 3oVo,uoov
aKcoXov9ia (conclusion from the similarities of both). This special method of clinical
observation has penetrated subconsciously into our own work, and we forget the
painful steps through which it was elaborated, just as we forget that our mode of
thought in general derives from the clear logic constructed by the ancient Greeks,
and for this reason our mode of thought differs from that of certain peoples such as
the Far Eastern peoples, who have not so far come under Hellenic influence.
It is difficult to go through Sextus Empiricus and the passages from Hippocrates
and Galen relating to the method of clinical observation, but nearer to us there is a
remarkable treatise on clinical observation, the On Experience in Medicine of Johann
Georg Zimmermann (1728-1795), a Swiss physician at the Court of Hanover. This
work, inspired by study of the Greek works and often read by the French clinicians
of the nineteenth century, deserves more popularity amongst us. The following
definition is from that work. "Observation is an aptitude for seeing an object in
its true light and distinguishing what there is in it more or less useful. . . . It is
nothing more than the conception of the affinity of things and of the signs which
point out to us their order and combination. The perception of our senses would
be of little use if the mind remained in a state of inactivity. The soul would be rich
in images but overy barren in ideas. We are obliged to have a certain activity of mind
whenever we see-and in this there is an element of comparison."
Thus, what we call clinical observation, as codified by the ancient Greek clinical
scientists, is a complicated process and consists of far more than merely "seeing" and
noting what falls before our senses. It consists in the perception of apparent and
hidden symptoms (thus in perception of biochemical disturbances, for example) and
principally in comparison and synthesis into an all-embracing "intuition " of the
totality of symptoms. It is thus a far more complex and active procedure than
physiological experiment. The term "observations" is up to a certain point a
misnomer. Clinical observation is more than observation.
Connected with clinical observation, and indispensably united with it in the mind
of the clinical scientist, is nosological thinking. The clinician classifies his observa-
tions into special categories, "diseases". He constructs such diseases, or he enters
his observations into "diseases" already described. This nosological thinking was also
introduced by the Coans and the Cnidians, who saw that the morbid phenomena
exhibited by patients are of immense variety and that for their study a method of
classification was necessary. They arrived at that method of classification by
observing that certain symptoms occurred in patients in a certain regularity of com-
bination and development. They abstracted these combinations of morbid pheno-
mena from the individual and constructed special categories, "diseases". The Coan
and Cnidian Asclepiadae thus introduced into science in general the conception of
the E48So or type by abstracting essential features, and this conception of type has
helped enormously the development of all sciences.
A subsidiary process in the development of clinical science consists in a special
utilization of the findings of pathology. Pathology (physio-pathology) and CliniCal
Science have always been intimately connected. As already stated, the early
Egyptians also made clinical observations, and these physicians had little to learn
about specialization and empirical observation but were unable to build a clinical
science. The Coan and Cnidian Asclepiadae achieved this because they had learned
from the Ionian Physiologists how to look for universal laws that could create a
theoretical system capable of upholding a real scientific movement. As Professor
Jaeger puts it (Paedia, p. 20): "Truth can never be dissolved into the infinite variety
of individual cases; or if it could it would have no real meaning for us."
456 Proceedings of the Royal Society of Medicine 20
The Pathologist has to take the findings of Clinical Science into consideration and
the Clinical Scientist is indebted to progress in knowledge of his diseases to the findings
of Pathology. However, the Clinical Scientist must utilize pathological findings in the
light of his method of clinical observation and nosographical classification. He
cannot take pathological findings uncritically and deduce from them clinical scientific
principles. Pathology helps but cannot dominate Clinical Science. Whenever it has
attempted to dominate, the result has been disastrous. This was recognized by Hippo-
crates, who in his Ancient Medicine pointed out the danger of domination of h,rpluci
(what we to-day call clinical science) by the Ionian Physio-pathology. Two examples
from recent history confirm this opinion of Hippocrates.
On the basis of the clinical scientific method of observation (clinico-anatomical),
Laennec had shown the similar nature of tubercles, caseiform processes and cavities.
Virchow and his pupil Niemeyer, on the basis of pure pathology,- separated these
processes and embarked on speculation about chronic catarrhal pneumonia, caseous and
destructive phthisis and so on, until the discoveries of Villemin and Koch proved them
wrong and the despised "ontologist" Laennec right. Bretonneau, also on the basis
of 'clinico-anatomical observation, identified pharyngeal diphtheria and croup. With
Teutonic dogmatism Virchow declared them to be separate and started semi-meta-
physical speculations on diphtheria and croupous inflammation. Of course, Breton-
neau was shown to be right. This does not imply criticism of the general work of
Virchow and his pupils. Virchow did much for Pathology, but he had no under-
standing of Clinical Science and by attempting to suppress it he gave to German in
contrast to British and French medicine an un-Hippocratic theoretical and unclinical
spirit which has persisted until to-day.
THE IMPORTANCE OF CLINICAL SCIENCE
From the beginning certain arguments were directed against the nosographical
method of Clinical Science. -They-were stated and answered by Hippocrates himself.
They were shown to arise from confusion between the science of medicine (clinical
science) and the art of medicine. Diseases are artificial constructions, but necessary
for the classification of knowledge, and thus necessary as far as scientific method is
concerned. In practice, in art we deal not with diseases but with individual patients.
Our object is not to place our patient into a certain morbid category; this is only a
useful preliminary measure. Our object is to study the individual patient and
discover what is wrong with his physiology (and psychology) and what has caused
his individual disturbances. With this aim we study the history of the individual, the
mode of function of his various organs and systems including the psyche, the imme-
diate wetiological conditions which have brought about these disturbances, the special
heredity, environment and constitution. To do all this, however, we must possess
the science of the morbid phenomena as exhibited by human patients. We must
possess Clinical Science, and Clinical Science cannot be taught, cannot develop,
except in terms of morbid categories.
There are no diseases but only individual patients. This platitude has often been
reiterated, and everybody agrees with it. We cannot, however, approach the indi-
vidual patient without previous knowledge of diseases. Clinical Science is based on
artificial constructions. This also is true, but all sciences are artificial. The im-
portant point is whether this artifice works. And history shows that it works. All
physicians who have attempted to practise on the basis of Pathology alone, all those
who have endeavoured to bypass Clinical Science, have failed. Such was the lot of
the Xoytlco (rationalists) who came after Hippocrates, of the pneumatists, the
methodists and other dogmatists of Alexandrian and Roman times, of the scholastics
of the Middle Ages, of the iatrochemists and iatrophysicists of the sixteenth, seven-
teenth and eighteenth centuries, the animists and vitalists and Brownians of the
eighteenth century, of the disciples of Rasori, of Broussais and the early disciples of
21 Section of the History of Medicine 457
Hahnemann in the early nineteenth century, and of the followers of the German
so-called physiological school of the mid-nineteenth century. To enumerate all
these schools, to remember all these names, is to give a list of the medical errors
of the past. The practice of all these schools, based on purely pathological con-
ceptions, resulted in one-sided, often violent and always ineffective treatments.
Nearer todtir own times, what happened to the German school of physiological
or rational medicine is a potent illustration. The Germans came late into medicine.
They had not the advantage of the earlier infiltration of Hippocratic ideas enjoyed by
Italy, Great Britain and France. The attempt of Schonlein to introduce the French
and British Clinical Science failed in great part. The Germans were too prone to
speculation and were too dominated by the principles of "Natural Philosophy" to
understand clear clinical scientific thinking. When, in the middle of the nineteenth
century, they decided to build up a German medicine, they did not adopt the principles
of Clinical Science but were seduced by the empty speculations of the "Physiological
Medicine" of Broussais. They rejected nosographical classifications and tried to
build up their practice on Physio-pathology alone. This was the tendency of Traube,
of Wunderlich, of Virchow. The result was a great physiological and pathological
work, but from the practical point of view a chaos of empty speculations and theories.
This was realized by men like Pfeuffer (himself at the beginning a follower of the
Physiological School), Frerichs, Leyden and Naunyn, who brought German medicine
back into the fold of British and French Nosology.
In knowledge of disease as well as in practice Clinical Science is as important as
Pathology. The mistaken conceptions of tuberculosis and of diphtheria reached by
the Germans on the sole basis of pathology illustrate this point.
Thus history shows that it is not true to say that Pathology is a science and Clinical
Medicine an art. Clinical Medicine is a science, Clinical Science, the natural history
of diseases, a science indispensable in the theory and practice of medicine, a great
science which introduced the first two real scientific methods, observation and
typology.
ISOLATION AND CLASSIFICATION OF DISEASES
From the days of the Hippocratists and the Cnidians to the beginning of the
nineteenth century, morbid categories or " diseases " were isolated on the basis of their
clinical manifestations. Diseases were symptom complexes or, to use the term of
the Empiricists, clinical syndromes. With the advent of the anatomo-clinical schools
of the early nineteenth century many diseases were isolated on the basis of their
clinical manifestations connected with particular anatomical lesions. These diseases
were thus clinico-anatomical syndromes. Later, some diseases were isolated on the
basis of clinical manifestations connected with a particular physio-pathological
disturbance or with a specific causal factor. r

A mode of classification of diseases was necessary for scientific progress. Apart

from a rudimentary attempt at classification found in the Cnidian work and based
on the localization of diseases, the first real attempt at classification was
made by Frangois Boissier de Sauvages of Montpellier in 1731. Sauvages was
influenced by the work of Sydenham, and essayed a classification of diseases on the
principle of classification of natural history. He was not only a physician, but also a
botanist and a friend of Charles Linn&. He based his classification exclusively on
symptomatological pictures and grouped diseases in classes, orders and genera just
as natural scientists at that time were arranging plants and animals. The classification
of Sauvages was cumbersome but it represented a first attempt at putting knowledge
in order. William Cullen gave a better classification in-his Nosology (1769). Whereas
Sauvages often labelled isolated symptoms as "diseases", Cullen grouped symptoms
into symptom complexes. This was more on the lines of the Hippocratists, the Cnidians
and of Sydenham. Nosology was thus simplified, and the number of species of
458 Proceedings of the Royal Society of Medicine 22
diseases or morbid categories was reduced. However, Cullen's nosological divisions,
like those of Sauvages, were based only on symptoms. A further advance was
marked by Philippe Pinel, whose Nosographie Philosophique was published in 1798.
His classification was based on anatomical and physiological considerations.
Since Pinel nosologies, that is, systematic expositions of diseases, have developed
better systems of classification but a perfect classification has not been found and is
in fact impossible. We have -to catalogue and group morbid categories constructed
on various principles. Some diseases are isolated on the basis of their clinico-
anatomical picture, others on the basis of their particular etiology, others on the
basis of their special physio-pathology, others on the basis of the purely clinical
picture. Thus each arrangement has its defects and exhibits only some forced
approximation. We have to consider it as a repertory lacking complete exactitude,
and select that which brings together the greatest number of analogous diseases. We
have also to remember that the classification of diseases is secondary, the most
inportant thing being the isolation of diseases, the accurate description of their specific
combination of symptoms and of their specific course.
The systematic exposition of diseases, thus the systematic exposition of Clinical
Science, would have been designated "Natural History of Diseases" by Sydenham.
Sauvages, Cullen, Pinel and the French clinicians of the first half of the nineteenth
century termed their expositions Nosologies, a term maintained in modern Greek
medical terminology. In contemporary France and in German-speaking countries
the term "special pathology" is current, a term which may cause confusion with
Pathology, which is a branch of Physiology. In English-speaking countries the term
Practice of Medicine is used, meaning "Introduction" in the Oslerian sense to the
practice of medicine. The term Clinical Science would be more appropriate.
THE CLINICAL DESCRIPTIVE CHAPTER IN THE NATURAL HISTORY OF DISEASES
The clinical descriptive chapter is the basic chapter in the natural history of diseases.
It allows isolation of the particular disease and forms the frame for pathogenic,
aetiological, prognostic and therapeutic considerations.
(1) The first clinical scientists described the signs and symptoms in diseases.
Endowed with great powers of observation and the directness of vision characteristic
of the ancient Greeks, they often gave descriptions which have never been surpassed.
The Hippocratists dwelt on general symptoms. The Cnidians endeavoured to
study local symptoms pointing to disease of a particular organ. With the Empiri-
cists study of the symptoms of particular "disease types" reached its zenith. A great
contribution to the symptomatological picture of diseases was made by the Neo-
Hippocratists of the first century of our era, Archigenes of Apamia, Aretaios and
Soranos. Symptomatological and semiological description reached its peak in the
work of Sydenham, whose observational and critical powers and searching vision
appear to me as similar to those of Hippocrates.
Work has proceeded on these lines during the course of the centuries, and the
symptomatological-semiological picture has been progressively completed. The
ancient Greeks dwelt on symptoms, although signs elicited by auscultation, percussion
and palpation were mentioned in the Hippocratic writings. With the advent of the
anatomo-clinical school, signs were much more developed and helped to complete the
clinical pictures of known diseases and to isolate new ones. Recently signs elicited
by special explorations such as the various endoscopies and radiology have been
added.
(2) A further step in the descriptive chapter of the natural history of diseases was
completion of the disease picture through consideration of the anatomical lesions
connected with the symptoms and signs.
The first clinical scientist to connect a symptomatological picture with an anatomical
lesion was Erasistratos, who flourished in the third century B.C. in Antioch as Court
23 Section of the History of Medicine 459
physician to the Selencidk, and in Alexandria. He adopted the principles of the
Cnidian school and looked for the "seats of diseases", Ov ,uovov ro 7racOo9 07rotOV
EOTtVa"X'Xa Kca' 7'ov ra7rXovra o7ror. In the brilliant Alexandria of the first two
Ptolemies dissection of humans was permitted, and Erasistratos availed himself of
these opportunities. He found that in dropsical patients the liver was hard as stone.
He described lesions of the liver and intestine in a form of snakebite, and deduced
from his post-mortem examinations the seat of pleuritis.
During the Renaissance Francis Bacon in his Advancement of Learning pointed
out the two chief ways in which he thought medicine might advance: In the
first place he advocated revival of the Hippocratic method of recording cases in
order that through such observations the description of diseases which had been
undertaken in ancient Greek medicine might be amplified and extended. In the
second place, he held that through anatomical investigation the pathological changes,
"the footsteps of diseases", should be studied, and findings compared with the
symptoms during life. But on the latter point neither the lead of Erasistratos nor
the opinion of Bacon was followed for centuries. It is true that physicians made
post-mortems, and a few of them like the Dane, Thomas Bartholin (1616-1680), and
Theophilus Bonetus (1621-1689) published collections of anatomo-clinical obser-
vations, but they did not endeavour to apply the anatomical findings to complete
the pictures of diseases.
In 1761 Morgagni published his De Sedibus et Causis Morborum per Anatome
Indagati, in which he followed the Hippocratic lines of describing diseases but added
anatomical findings to the Hippocratic symptoms and signs. He thus showed that
disease pictures can gain in completeness and precision by addition to the symptomato-
logical-semiological picture of the corresponding anatomical lesion.
Xavier Bichat in 1801 went a step further. Whereas Morgagni emphasized the
lesions of whole organs Bichat showed that the morbid changes in an organ can be
dissociated in various tissues each of which follows a different course. Later Rudolf
Virchow (1821-1902), availing himself of modern techniques, discovered the import-
ance of cellular lesions. Following the lead of the Morgagni-Bichat-Virchow
triumvirate, clinical scientists completed their disease pictures by linking their
symptomatological-semiological pictures with the macroscopic and microscopic
anatomical pictures. Thus known diseases were more completely described and many
new ones were isolated.- Morbid anatomy gave to Clinical Science and thus to
medicine a greater scientific status.
The first work following the lead of Morgagni was, I think, that of Mathew Baillie,
who in 1793 published the first book describing the anatomical lesions in various
diseases. Unfortunately Baillie, submerged by his enormous practice, lacked the
time to give a powerful impetus to this new method of Clinical Science. This was
reserved for Napoleon's famous physician, Corvisart. In his Essai sur les Maladies
et les Lisions Organiques du Ceur (1806) he maintained that disease could not be
considered as a mere grouping of symptoms, but that the study of anatomical lesions
should complete the picture.
The new method of Clinical Science was followed by great clinicians in France and
England whose names are familiar to all of us. Laennec, Bayle, Charcot, Bright,
Hodgkin, Addison, Graves and many others worked on the Coan-Cnidian lines, and
the British in particular considered pathological anatomy as merely an aid to clinical
medicine and subordinated anatomical findings to the general clinical picture of
disease. Robert Graves (1796-1853) said in his clinical lectures that anatomical
lesions had the rank of symptoms.
The Vienna school also adopted pathological anatomy, but not on Hippocratic
lines. Skoda (1805-1881) and principally Rokitansky (1804-1878) subordinated
pathological anatomy to clinical medicine. They placed anatomical alterations first
in the classification and description of morbid processes and considered that the task
460 Proceedings of the Royal Society of Medicine
of clinical medicine was confined to demonstrating these anatomical changes in
patients. Thus anatomical diagnosis became the sole object of the physician's
efforts. They were far removed from the breadth of view of the natural history of
diseases shown by Hippocrates and Sydenham. The medicine of Skoda and of
Rokitansky was really a mortuary medicine. That the principle was wrong is shown
by the therapeutic nihilism, the negation of medicine, to which the Vienna school Qas
led. "Go to Vienna", people used to say in those days, "There everything is done
for patients. They are diagnosed by Skoda and autopsied by Rokitansky."
A similar spirit pervaded German medicine in the Virchow era. Here also morbid
anatomy and principally morbid histology dominated the clinical symptomatological-
semiological picture of diseases. Virchow went even further and rejected the noso-
graphical- classifications of the British and French as "ontologies". That this
principle too was wrong is shown by the chaos into which German medicine fell until
its rescue by Frerichs, Leyden and others through introduction of the British and
French nosology.
Morbid Anatomy and Histology as a branch of Pathology and thus of Physio-
pathology has its independence. The clinical scientist avails himself of the findings
of this' independent science but useg it to complete his disease pictures. This principle
is being followed to-day.
(3) The introduction of the signs yielded by various laboratory methods marks a
further step towards completion of the description of diseases. Urine, blood, vomit
and feces were examined macroscopically or by some rough methods by physicians
of earlier ages, but it was only in the beginning of the nineteenth century that William
Prout introduced more precise methods for various chemical examinations. In 1843
Gabriel Andral published his Essay on Haematology in which he studied the pro-
perties of the blood in various diseases.
Since then Pathology has given a great number of data on the biochemical, hemato-
logical and bacteriological aspects of disease in general. Clinical scientists avail
themselves of these data to complete the description of each particular disease. The
clinical scientist and the pathologist differ in their points of view. The pathologist
uses biochemical, haematological and bacteriological data to study the general
processes of disease. The clinical scientist uses the same data to complete his disease
pictures. For him all these data are biochemical, hmematological and bacteriological
signs which he inserts in the frame of a particular disease picture, and thus all these
pathological data are judged in the light of the general clinical picture.
The same can be said of the various functional tests. In 1866 Hutchinson investi-
gated the functional capacity of the lungs with his spirometer. William Stokes, the
Dublin clinician, described the " weakness or deficient muscular power of the hearts"
in 1856. Then, inspired by Claude Bernard and his stress on functional disturbances
preceding anatomical lesions, the German school developed the study of functional
tests. Adolf Kussmaul introduced gastric intubation in 1867, and with Leube he
showed later the importance of this clinical method of exploration of gastric function.
Similar functional tests were introduced for circulatory organs, for the liver and the
kidneys. As usual, the technical developments made by the Germans were consider-
able, but the general idea underlying them was essentially wrong. With the exception
of Kussmaul, who worked on British and French nosographical lines, most of them
wanted to bypass nosology and to find tests presenting a physiological understanding
of the individual patient. "We want to cure and not to classify", thundered Ottomar
Rosenbach, the codifier of this line of research. However, the individual patient is
not one or two tests but represents a totality of symptoms which can be understood
only on the basis of previous knowledge of disease types, which represent totalities
of symptoms. Thus these functional tests became useful only when connected with
disease pictures, only when used to complete these pictures, and thus only when
25 Section of the History of Medicine 461
studied in the light of the whole clinical frame. This was effected chiefly by Albert
Robin and by Fernand Widal.
Each disease thus represents a totality of symptoms, which are not only the sub-
jective phenomena but include the so-called clinical signs and the signs given by
special methods of exploration including laboratory exploration. Clinical observa-
tion means not only seeing but also arranging all these symptoms in their proper
order of importance, and particularly in considering the course of this totality of
symptoms. This descriptive chapter is the basis of Clinical Science. The description
of a new disease and the rearrangement of the description of a known disease are of
extremely great importance in practical medicine.
THE OTHER CHAPTERS OF THE NATURAL HISTORY OF DISEASES
The pathogeniic chapter provides the answer to the question as to what kind of
disturbances of body-mind function are the basis of the symptoms shown by a patient
who enters into a particular disease type. The term physio-pathological chapter also
is used, but I prefer the term pathogenic so as to avoid confusion with physio-
pathology.
For construction of this chapter the clinical scientist has to take as main basis the
data of Physio-pathology, but he has to consider these data in- the light of his special
method of clinical observation and, with the object of understanding the particular
disease he is studying, he can resort to animal experimentation and to certain clinical
tests. Thus, although related intimately with Physio-pathology, this chapter is not
Physio-pathology. It is to Sir Thomas Lewis that we owe the codification of the
method of constructing this particular chapter in the natural history of diseases.
This chapter is not, however, as he tended to consider, the whole of Clinical Science
but only a part, and as in Clinical Science in general the preponderant element is
clinical observation, not experimentation.
The a?tiological chapter describes the factors that have determined the disturbances
in physiology manifested by symptoms in a patient showing a particular disease.
The Hippocratists constructed this chapter on the basis of clinical observation,
including a careful history, and described for every disease an interplay of external
abnormal conditions-meteorological, traumatic, dietetic and psychological (the
icaTaGrTao-t or external constitution), acting on a specially predisposed individual,
on the 0f6%-t9 or internal constitution. Sydenham developed this chapter on the
same lines and had the intuition of specific infective wetiology. Physio-pathology
helps clinical observation by its study of the various factors determining disease and
of the mechanism of their action, but the last word remains with clinical observation.
To the Hippocratic external factors physio-pathology has added the infective factors,
and contemporary work as embodied in the teaching of Professor John Ryle, the
social factors.
The therapeutic chapter was also introduced by the Hippocratists and the Cnidians
on the basis of clinical observation. These clinicians applied medicines to patients
entering into a special disease type on the basis of tradition or of certain theoretical
physio-pathological considerations, and observed the effects of their remedies. A
remedy which benefited a patient suffering from a known disease is likely to benefit
another patient suffering from the same disease. This is the famous principle of
a7ro T o/vOt'Ov (LKOXOVOLa, the principle of the clinical empirical method.
Sydenham worked on these lines to discover his specific remedies. Progress in
Physio-pathology enabled clinicians to perfect this chapter. Study of therapeutic
agents, pharmacology in its extended sense, is basically a branch of Physio-pathology,
and further the more perfect conception of the pathogeny of various diseases attained
by advances in general Physio-pathology allowed of more precise indications. How-
ever, the method of clinical observation has the last word. Whatever the physio-
pathological conception, the clinical effect of remedies is over-riding in importance.
462 Proceedings of the Royal Society of Medicine 26
We take our remedies from any source, from old village women or from highly
scientific laboratories. As Trousseau said, "La clinique prend son bien partout oti elle
le trouve". We can neither accept nor reject them on the basis of physiological and
pathological considerations alone, but only on the basis of clinical observation. This
principle should be applied to remedies whose physiological basis is debated, such
as the homceopathic remedies, because their acceptance or rejection on the basis of a
priori physiological thinking does not conform with our scientific method.
This chapter is based also on a special branch of Clinical Science, clinical pharma-
cology, which consists in study of the effects of remedies on healthy and diseased
individuals. It is obvious that this branch is connected with pharmacology, mainly
experimental, which is a branch of Pathology.
GENERAL CONCLUSIONS
There are three things in Medicine, the Art, Physio-pathology, and Clinical Science.
These three are equally necessary but should not be confused, as is being done in
most textbooks of History of Medicine.
The art of medicine consists in the application of scientific knowledge to the care
of the sick. It demands special qualities of intuition and personality, but these
qualities are useless without scientific knowledge. There has been a curious attempt
in Germany-outside the universities-to build up a medicine without science,
a medicine based only on intuition, personality, common sense and popular traditions.
This movement originated with the physician of Bismarck, Ernst Schweninger
(1850-1924), was adopted by the Nazis and was being developed in the Rudolf Hess
Hospital of Dresden. Of course it failed. Medicine cannot be practised with "less
science and more art" but needs "more science and more art".
Physio-pathology and Clinical Science are of equal importance. We cannot
practise only on the basis of Physio-pathology, or even, as the Greek Empiricists and
some early French nosologists of the Pinel type attempted to do, on the exclusive
basis of Clinical Science.
Clinical Science is the natural history of diseases, a natural science comprising four
chapters-the clinical descriptive, the pathogenic or physio-pathological, the etio-
logical and the therapeutic. The term should not be used in the restricted sense of
clinical physio-pathology. It is a great and indispensable science, a branch of Biology.
Research physicians cultivate either Pathology or Clinical Science or both. They
have, however, to keep their pathological and clinical scientific work in separate
compartments.
The following quotation from an address by Sir James Paget in 1869 shows the
real spirit of clinical science.
"I am anxious to urge that all our work should be really clinical; all our chief studies among the
living . . . I think there are even among ourselves signs of a want of faith in the power of clinical
research; signs of too great readiness to reject results and suggestions which are not accordant with
our belief in physiology or anatomical pathology; of too great readiness to accept and act upon
deductions from any other sciences, though they are not approved by our own ... We must believe
and act on the belief that clinical science is as self-sufficient as any other. Self-sufficient indeed no
science can be. All sciences are bound together by common facts and mutual illustrations and the
same cardinal rules of study; yet each having its own subject-matter may claim a special range of
knowledge, and -within this range the highest right of judging what is true. This claim we must
maintain for Clinical Science ... I feel sure that Clinical Science has as good a claim to the rights
and self-subsistence of science as any other department of biology; and that in it are the safest and
best means of increasing the knowledge of diseases and their treatment."