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of malarial poison infested the shores of as we gaze on them in the writings of Greece 20 and Asia Minor 2,500 years ago. Hippocrates, through the dimness of more Nothing is more improbable than that they than two thousand years. In the “Epidemwere always afflicted by the same forms with ics,” we perceive easily, after reading which we are familiar, or that malaria in Littré's masterly analysis of the first and any form was constant in any one locality, third books, that the severest types of or that the malignity of the type was such malarial fever prevailed on the mainland as now fills the army hospitals at Salonica, and the islands which fringed the shores but the evidence is indubitable that in the of Greece and Asia Minor in the days of Greece of Hippocrates, in some of the Hippocrates. We take note of the fact that islands of the Ægean and on the littoral of he confused to some extent, as do modern Asia Minor-perhaps sometimes in one biologists and ethnologists, the effect of place, sometimes in another, varying from “institutions”

on men, and the effects of generation to generation, certainly from the malarial poison working through the season to season-malaria was behind much lassitude of their bodies on their moral of the confused picture of disease we find natures. in the Hippocratic writings.

Many critics have noticed in Hippocrates I see no evidence that such affections have the absence of any indication which they can ever permanently affected the course of plainly recognize of his appreciation of empire, though it is always impossible to the infective nature of fevers arising from say what might have been the course of proximity to the stagnant waters of many events if anyone of the innumerable cosmic of the Greek rivers and swamps. I think this factors which have shaped history in the can hardly be laid at the door of antiquity abyss of time had been absent. We may be with justice since even in Hippocrates we disposed to deprecate the importance of find reference to the influence of locality the factor of malaria, but it is impossible on the type of disease in such connection to ignore the fact that disease has often that it can scarcely be doubted that he was in specific instances halted the march of familiar with pestilential varieties of swamp armies on the road to conquest and raised fever even if he did miss the plasmodium the siege of cities. It is not impossible that malariae and took no note of the anopbeles in the past, as at present, in some of the fasciata. In this book we should not fail districts of central Africa, and in some of to notice in this connection his remark that: the medieval cities, epidemics may have desolated lands and somewhat altered per

Such cities as lie well to the sun and winds, manently the course of human events;

and use good waters, feel these changes less,

but such as use marshy and pooly waters, and but for the most part the evidence in regard

lie well both as regards the winds and the sun, to the permanent influence of disease on

these all feel them more. And if the summer be empires and civilizations is dubious. Yet dry, those diseases soon cease, but if rainy, they Hippocrates was dealing with this very are protracted. problem when he noted the effect which airs, waters and localities had on the nature of

It is interesting in this connection to read man. The factors of this problem are not

what Diogenes Laertius says of the wonders entirely clear in the light modern science wrought by Empedocles. I give it as transhas thrown on them, but they are dark in

lated by Yonge. 21 deed, and but a tangled skein of thread,

21

Diogenes Laertius, “Lives and Opinions of 20 Jones, W. H. S., “Malaria and Greek History.” Eminent Philosophers,” tr. by C. D. Yonge, London: Manchester: University Press, 1909.

Henry G. Bohn, 1853.

XI ... When a pestilence attacked the people of Selinus, by reason of the bad smells arising from the adjacent river, so that the men died and the women bore dead children, Empedocles contrived a plan, and brought into the same channel two other rivers at his own expense; and so, by mixing their waters with that of the other river, he sweetened the stream. And as the pestilence was removed in this way, when the people of Selinus were on one occasion holding a festival on the bank of the river, Empedocles appeared among them; and they rising up, offered him adoration, and prayed to him as to a God: And he, wishing to confirm this idea which they had adopted of him, leaped into the fire. It is very evident that to Alcmaeon and to Empedocles the Hippocratic collection owes much of its physiology and anatomy; perhaps to the former a whole treatise, and it is improbable in the extreme that Hippocrates himself was not familiar with the influence of swamp land on the production of certain types of fever. Reference is made to those that accompany the prevalence of winds from marshy places in the second book on “The Diet” (38), but no classification or comprehension of them based on etiology can be found, conforming to the nosology which has resulted from the discovery of the plasmodium and its carrier, until well within the experience of living men. The comments of Adams and of Littré are scarcely less confusing to the recent graduate than those of Hippocrates. Indeed, in a way, Hippocrates and his immediate predecessors were more alive to all the factors entering into the etiology of malaria than were these gentlemen of the middle decades of the last century. As for us the plasmodium and the anopbeles have all but eliminated from our thoughts the environment which makes their existence possible. For us a chain hangs down out of the sky and we only keep constantly in our visual focus these two links. What is the plasmodium to us but for the anopbeles? What

would become of the anopbeles, but for the swamp and and the heat, and so on ad infinitum. The literature which has grown up around the plasmodium and its carrier serves to alienate the mind, especially the mind uninstructed in the history of the medical art, from an attitude toward the intermittent and continued fevers with which Littré and his contemporaries two generations ago were familiar, and Hippocrates quite as intimately two thousand years ago and more, though the evidence of it is more convincing elsewhere than in this book on the “Airs, Waters and Places."

In addition to the incidental interest to be noted in an account of early attempts to eradicate malaria, and in the reference I have made to early evolutionary doctrine, I have especially striven in the foregoing to show how intimately in the thought of Hippocrates was combined the influence of the same environment on the corporeal and on the spiritual nature of man as well as on his social and political relations. This catholicity of thought is entirely foreign to our modern medical mentality and I cannot urge with too much emphasis that we are thereby the losers. It is that broadening of medical thought which should be the concern of all education, but it is nowhere so lacking in the liberal professions as in the curriculum of the student of medicine. Incoherent as it may appear to the modern reader in the Hippocratic text, which I fear I have not made much more coherent in the foregoing, such defects must be charged to the reader and to the expositor rather than to the author, to whom, obviously, there was no gap in the consecutiveness of the reasoning in his apprehension of the cosmic laws applying to the spiritual and the physical phenomena of human beings. To him, indeed, as to Terence, nothing which was of human interest was foreign.

THE RISE AND EARLY HISTORY OF CLINICAL TEACHING

By DAVID RIESMAN, M.D.

PHILADELPHIA, PA.

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HE history of medicine is in a contact with patients, cannot realize what sense the history of civilization. the teaching of medicine was a few generaAmong a given people, ancient tions ago. In my student days we saw only a

or modern, the state of medicine few medical cases close at hand. Most of them is as much an index of its culture as are its were seen from the benches in the amphitheaart and its literature. The world is, how- tre and I do not think that we ever had an ever, too busy to study medical history in opportunity of making a complete physical order to find out what level a nation has examination of a single patient. Yet we attained at any particular time. This applies were better off than the men who were our not only to the non-medical world but also teachers; and if we go back but a little farto medical men themselves. Only a few have ther, we come to a time when there were no an interest in the history of their calling; and clinical facilities whatever. J. Marion Sims yet nothing is more instructive or inspiring, was graduated in Philadelphia in 1835 and whether viewed from the narrower stand- immediately went to his home in South point of the physician or from the broader Carolina to practise. His sign, which was a one of the student of the race, than is the very big one, had not been out long before development of medicine throughout the he was called on to treat a child of the ages. At the present day the lay public knows leading citizen of the town. He had never a great deal about medicines, but very little until then been in contact with a patient about medicine. If the people knew more and had never made a physical examination. concerning it they would have a greater In consequence, he felt himself helpless, respect for what medicine has accomplished. and when the child died he was profoundly

From the vast and inexhaustible mine of depressed. Then when a second child in the the history of medicine I have extracted a same family died shortly afterward under single chapter, in itself large and fascinating, his ministrations, he quietly took down yet, strange as it may seem, few have written his sign, dropped it into a well, and miupon it. There are tomes upon tomes of grated to Alabama. Fortunately for Amerimedical history, some dealing with the doc- can surgery he did not carry out his intrines and practices in vogue at different tention of giving up the practice of medicine epochs or periods—Hindoo, Greek, Egyp

for good. tian, Arabic, Talmudic medicine, for ex- The first teacher of medicine was necesample. Few, however, concern themselves sity. When primitive man received a wound with the history of medical teaching, with during the chase or in combat, another the ways

in which the accumulated knowl- member of his tribe or of his family applied edge has been transmitted from generation soothing herbs, the virtues of which he to generation. It is a consideration of that knew as the result of some happy accident. phase of medical history that I have made After having obtained success with this my task in this essay.

treatment, he would initiate his son or some The medical students of to-day, who are one else into the secret of the preparation virtually living in the wards of hospitals for and use of the soothing lotion. Thus arose the greater part of their last year in medicine, surgery. In the case of internal diseases, and in that way coming into direct personal and especially those of epidemic character, the causes of which were to him unfathom- and impressed upon his disciples the imable and mysterious, man sought the help portance of bedside observation. In a of his gods and naturally applied to those sense, physical diagnosis originated with who knew the wishes of the gods, the priests. him; for he discovered the succussion splash, These tried to appease the wrathful deity pleural friction and pulmonary râles. He with prayers and incantations-a survival advised that in order to hear these sounds of which we see to-day in public prayers for the ear be laid upon the chest for a conthe sick. The priests were always the ablest siderable length of time. This is the earliest and shrewdest men in the community and mention of auscultation. The Hippocratic by experience through the ages gained con- School also tested the temperature of siderable practical knowledge in the treat- the body with the hand, and by palpation ment of disease. In that way there came determined the boundaries of the liver and to be added to the religious ceremonies spleen. It is scarcely believable, and yet it methods of therapy of more or less value. is a fact, that fifteen hundred

years

later The religious practices and therapeutic these simple but valuable physical methods methods were handed down in the priestly were thought to be of no importance and castes by oral tradition.

were scarcely taught anywhere. Among the Greeks, however, the priest- After Alexander the Great's time, Alexhood never had a very strong influence; and andria became the center of Greek life and the practice of medicine was rather a secret medical teaching. Under Herophilus and in certain families or social groups. The Erasistratus, the Alexandrian School atfirst teacher of medicine among the Greeks tained great fame, so that it was a distincwas the legendary Esculapius, who taught tion to any physician to be able to say that his son Machaon to bind up the wounds of he had studied at Alexandria. the Trojan warriors, and his other son, Among the Egyptians, from whom the Podalirius, to attend to their internal ills. Greeks undoubtedly derived some of their

Eventually the common experience of the knowledge, medicine was in the hands of medical families was written down; and a the priests, who controlled all the learned study of the written works was added to occupations. The foundations of instruction oral tradition. The actual teaching was were the Holy Books in which all Egyptian carried out in the so-called iatria, which knowledge was contained. These books may be compared to our out-patient de- were an encyclopedic work of forty-two partments or dispensaries, and which were parts, of which the last six were devoted usually built in close proximity to an Es- to medicine. The first of these treated of culapian temple. In the iatria, the physician anatomy; the second, of diseases; the third, received and examined the patients, pre- of

surgery; the fourth, of drugs; the fifth, scribed and distributed medicines, per- of diseases of the eye; and the sixth, of formed surgical operations and gave instruc- diseases of women. Only fragments have tion to pupils. The most famous iatria or come down to us. They are contained in the schools, were those of Cnidos and of Cos. "Book of the Dead,” and in the “Ebers The latter was the birth place of Hippo- Papyrus.” There are medical allusions in crates, under whom, at about 400 B.C., the cuneiform inscriptions of the BabylonGreek medicine reached its zenith. As ians and the Assyrians; but in so far as they teachers of medicine Hippocrates and his have been deciphered, they tell us little contemporaries, for the most part unknown about the teaching of medicine, and are to us, were not excelled for a thousand chiefly formulas or, as in the Code of Hamyears; indeed, for nearly two thousand. murabi, tables of fees and penalties.

Hippocrates was a wonderful observer Among the Hindoos, the teaching of

medicine early reached a high plane; and supposed to cure disease. A few curative the Yajur Veda, in the Commentaries of herbs were employed. As stated by Seneca: Charaka and Suśruta, contains explicit in- “Medicina quondam paucarum fuit scientia structions as to the education of the physi- herbarum quibus sisteretur fluens sanguis, cian. Suśruta recommends to the student vulnera coirent” (Medicine was the science of medicine both theoretical and practical of a few herbs by means of which the flowing training. “He who is only theoretically edu- blood was staunched and wounds were cated,” says Suśruta, “and is inexperienced united. Epis. 95). in the details of practical treatment, does not Under Greek influence, a higher type of know what he should do when he receives a medical practice gradually came into vogue; patient, and conducts himself as foolishly as yet medicine was for a long time looked a coward on the battle-field. On the other

upon as a despised trade. The Roman hand, a physician who is educated prac- nobles had it taught to their slaves; or sometically and not theoretically lacks the times, as in the case of M. Portius Cato,. esteem of better men.” This reminds one they acquired it themselves in order that of the dictum of Osler, “to study the phe- they might teach it to their slaves and keep nomena of disease without books is to sail a watch over the health of their own on an uncharted sea, while to study books families. But with the tremendous political without patients is not to go to sea at all.” and social development of imperial Rome, The Hindoo teacher was therefore advised to medicine could not long remain patriarchal. instruct his pupils in the use of salves and Probably the constant foreign wars, reremedies, in the performance of surgical quiring the services of skilled physicians, operations and in general medical practice, helped to bring about the downfall of the “since through hearing lectures no one can patriarchal system. For a long time, howbecome proficient in the medical calling." ever, medicine remained a private matter Suśruta taught that the sweet taste of urine or a free trade that could be followed by was a sign of disease. He advised that a anyone. Under Alexander Severus, special thorough history be taken of every patient, auditoriums were assigned to medical teachsaying that the patient should be asked ers, in return for which they had to instruct where he lives, the season of the year in poor students free of charge. It is probable which his trouble arose, his position, his that the valetudinaria which rich Romans affairs, the nature of his pain, his general established for their slaves were used for strength, appetite, and the duration of his medical instruction. That this instruction illness. Operations were taught on inani- had a decidedly modern aspect is shown in a mate objects. No physician was allowed to sort of novel by Philostratus, in which have more than five or six pupils.

mention is made of two physicians who Hospitals existed in India not alone for visited the sick accompanied by thirty human beings, but even for animals as early pupils. Such visits were made in large conas 300 B.C. (There is one known to have sultation rooms, called taberna medicinæ, existed on the island of Ceylon in the fifth or simply medicinæ. As a further evidence century B.C.) In view of the fact that the that clinical teaching similar to our ward study of anatomy was totally neglected it visits existed, we have the famous lines of is remarkable that Indian medicine was Martial (Epigr. V. 9): able to reach such a high plane. This is one of the riddles of medical history.

Languebam, sed tu comitatus protinus ad me Among the Romans, medicine was on a Venisti centum, Symmache, discipulis, much lower level than among the Greeks. Centum me tetigere manus aquilone gelatæ, Sacrifices, magic formulas and oracles were Nec habui febrem; Symmache, nunc habeo.

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