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him from all parts of the world. This man enabling Sydenham to go to Montpellier was Boerhaave, called “Medicorum Univer- and Harvey to Padua. I am one of those sæ Europæ Præceptor," under whom the who regret to see the Latin language medical school of Leyden attained an disappearing from the college curriculum. extraordinary fame. As a teacher his influ- A fair amount of Latin and a little Greek ence has probably never been equaled. The are of inestimable value to the medical son of a clergyman, he was himself prepared student and the physician. for theology but preferred medicine. His The Edinburgh school is of special interest teaching consisted in lectures and beside to Americans, as it was there, under Cullen demonstrations in which he followed the and others, that John Morgan, the founder cases through their course. His, to us, absurd of the medical school of the University of theories of fluida and solida and of tem- Pennsylvania, the first medical school in this peraments, are characteristic of his time,
country, was educated as well as William but could not endure when morbid anatomy Shippen, Jr., Benjamin Rush, Samuel Bard in the epoch-making work of Morgagni and many other pioneers. (1682–1771) showed that disease had a One of Boerhaave's greatest pupils, Van local habitation. Boerhaave had a good deal Swieten, was called to Vienna by Maria of common sense and attributed many Theresa and there laid the foundation for diseases either to poverty or to luxurious Vienna's subsequent position as a center living, “nibil citius debilitat quam luxus." of clinical teaching. Being overwhelmed It does not appear that he made any autop- with practice, Van Swieten in 1754, called sies, being in this respect far behind his Anton de Haen, also a pupil of Boerhaave, predecessor in the Leyden chair, the famous from the Hague to take charge of clinical De La Boë, or Sylvius (1614–1672). Consider- teaching in Vienna. De Haen received the ing that the seat of diseases was in the blood enormous salary of five thousand florins in or the bile, he naturally could not appreciate order that he might devote himself excluthe importance of local pathologic processes. sively to teaching. He was thus the first The methods of the Leyden Clinic, which of full-time clinical teachers; but as the had only twelve beds, were carried to all position yielded the munificent income just parts of Continental Europe and by Pringle mentioned, his problem was not quite as and others to England. In Edinburgh a difficult as that of professors in American number of men, directly or indirectly pupils schools confronted with the question of deof Boerhaave, established clinical teaching ciding between full- or part-time teaching. early in the eighteenth century. It appears There are other reasons why De Haen that one Daniel Duncan inaugurated such should be remembered. He reintroduced the teaching in 1720, but the first regular courses Hippocratic practice of allowing fever pawere given by Rutherford and afterwards tients to have fresh air. On the basis of the by Cullen, Gregory and Drummond. The doctrine of crises it had become the custom last two were the first to teach in the to swathe and cover fever patients and keep English language, Latin having been used every breath of air from them, a practice prior to that time. In the days of which I that has not altogether died out among our am speaking, every physician had to know foreign population, especially among the Latin virtually as well as his mother tongue, Italians. and the better educated also knew Greek. De Haen espoused the study of bowel It was the possession of the Latin language excretions as a means of diagnosis and that made it possible for men to study and prognosis. This study, though not pursued to teach in any university in Europe, in quite as unscientific a manner as was that of water casting, was very popular was compelled to make the statement that among medical men, which fact led the in France no physician had studied his art satirical Gideon Harvey, physician of at the bedside of a patient. In not a single Charles II, to speak of doctors as “medici one of the thirty-two medical faculties of stercorarii qui morbos per anum expellunt.” France was there any clinical teaching One of De Haen's assistants, a Jesuit priest worthy of the name prior to the Revolution. by the name of Stoll, deserves to be men- Desault, in 1787, and Corvisart, in 1788, tioned in a history of clinical teaching. Aside must be looked upon as the founders of clinfrom having the questionable honor of being ical teaching in Paris. During the French the father of the bilious diathesis, which has Revolution all the old institutions and cordragged itself through the ages to this porations were overturned. The medical day, he has the greater distinction of being faculty and the academy of surgery were one of the first to insist upon thorough abolished; the masters of medicine had no physical examinations. He did not, how- place to exercise their teaching, and the stuever, resort to percussion, though he writes dents had no schools, no instruction. Two that in pleurisy the percussion note is like courageous men, Forcray and Thorat, prothat of the thigh.
tested publicly against the prevailing politiThe impetus given to clinical teaching by cal spirit which “seeks to destroy everythese men endowed the Vienna school with thing and to build up nothing”; an uttera wonderful reputation, which later great ance that reminds us of the charge so freclinical teachers maintained until the out- quently made to-day against Bolshevism. break of the world war.
On an earlier page I spoke of Morgagni The French school of clinical teaching and the influence of his work in morbid began a little later and passed through anatomy upon the teaching of medicine. numerous vicissitudes. Although clinical Morgagni, as the founder of the anatomic teaching was proposed as early as 1562 by school, placed the habitat of disease in one Pierre de la Ramée, practically nothing the organs instead of in the humors. But was done until the close of the eighteenth
neither he nor his immediate successors dicentury. It is doubtful whether anything vined any relation between the diseases of could have been done in Ramée's time, for various organs. Another great generalizaone physician then had charge of about a tion was necessary, and that we owe to thousand beds in the Paris hospitals. La- François Xavier Bichat (1771-1802), who menting the utter inadequacy of the teach- by showing that there was a similarity in ing of medical students, Ramée exclaimed: the tissues composing the different organs "de nouveau médecin, cimetière boussu." of the body, became the founder of general About two hundred years later (1778) Duch- anatomy. From his day onward disease was annoy and Jumelin proposed the reintroduc- placed not in the organs as a whole but in tion of clinical teaching. Arguing in favor the tissues composing them, and the fact beof such teaching they expressed themselves came established that the same tissues in as follows: “Young medical students may different organs might be subject to the reasonably be regarded after their studies same disease processes. It remained for the as a body of young soldiers who, abandoned great Rudolph Virchow to carry the anato themselves and without leaders, ravage tomic idea one step farther by his formulathe provinces of a country which they tion of the cellular doctrine, under the ægis should protect and succor.” Their sugges- of which morbid anatomy has made enortion and protests were of no avail, and as mous strides and maintains itself until late as 1787 the Royal Society of Medicine
Toward the end of the eighteenth century a powerful impetus was given to clinical teaching by John Peter Frank (1745–1821). Of a restless, roving disposition, Frank taught at Padua, Vienna, Göttingen, in Russia, and, for a brief period, in Edinburgh. The Edinburgh method of long discourses on certain diseases, without special reference to any particular case, in other words, the didactic lecture, did not appeal to him. In his courses he divided his students into two groups, the auscultants, who did not take part in practical demonstrations, and the practicants, who participated in the practical exercises. Believing that the functions of the teacher were to teach the healing art, he totally ignored incurable cases as being of no moment. He established a mortuary so that one could preserve a patient and be sure that he was dead before beginning the autopsy. His instructions to students are of interest: the history must be full of details, must be carefully taken and kept up from week to week. If the patient died the student had to read the history at the autopsy. The student who had assisted in the morning had to come back in the evening at a definite time to visit his patient. If any patient was seriously ill, the professor himself came. John Peter Frank, as well as his son Joseph, was an ardent supporter of the fantastic doctrines of John Brown, who was responsible for the promiscuous and intensive bleeding in vogue at the end of the eighteenth and at the beginning of the nineteenth century. Brownianism, though originating in Edinburgh, found its most zealous advocates in Germany and in America, particularly in Philadelphia.
One of the greatest advances in clinical teaching, indeed in the whole practice of medicine, came about through a discovery made in the latter half of the eighteenth century, but not fully utilized until fifty years or more afterwards. In 1761, Leopold
Auenbrugger, a modest physician connected with the so-called Spanish hospital of Vienna, published a small booklet of ninetyfive pages which he called, "Inventum Novum ex Percussione Thoracis Humani ut Signo Abstrusos Interni Pectoris Morbos Detegendi,” in which he showed that valuable information might be obtained from striking the chest with the finger or, as he termed it, by percussion. The work remained unnoticed. Even his great fellowcitizen, Van Swieten, in a book on pulmonary phthisis and empyema published in 1765, does not mention percussion. A Frenchman, Rogières de la Chassagne, of Montpellier, translated the work into French and incorporated it as an appendix to a manual on pulmonary diseases, but so little did he think of percussion that he especially said that it would never occur to him to use such an absurd method.?
It was Napoleon's physician, Corvisart, who by translating the little work of Auenbrugger into French gave the method its second birth. Immediately percussion became widely popular,
dely popular, with the result that the Paris school under Louis, Laennec and Piorry was for a time the Mecca of those seeking clinical instruction. Through the application of Auenbrugger's methods, and through the discovery of the stethoscope, physical diagnosis was advanced by leaps and bounds, almost to the stage in which we now have it. Notwithstanding the brilliance of the Paris medical faculty
7 Another author had the hardihood to write as follows: “La clinique, ou la leçon médicale au lit du malade (tel est le sens du mot clinique), se reduit maintenant a l'exploration sous toutes les formes: percussion, auscultation, mensuration et autres procédés qu'on qualifie ridiculement de scientifiques, et qu'on met volontiers en relief et en grande vénération auprès de la sotte majorité, en les affublant de noms étranges, bizarres, hybrides, le plus souvent absurdes, surtout quand ils sont empruntés de la langue grecque, en dépit de la logique et de l'étymologie.” (Guardia: “La Médecine à travers les Siècles,” p. 724.)
at this period, it had a great and worthy nent, integral parts of universities, but rival in the Dublin school, in which perhaps were in intimate relation with the metrothe best clinical instruction of the world politan hospitals where some of the phywas given in the middle of the last century. sicians took pay pupils with them on their Graves and Stokes took their students with
rounds. them into the wards of Meath Hospital The preëminence of the French school and inaugurated the type of clinical bedside did not last long. Dominated by the spirit teaching in vogue at the present day. I of Laennec, its great fault was a disrehave elsewhere published the history of gard of physiology. In overemphasizing these great Irish clinicians, as well as that anatomy, gross and microscopic, it ignored of Corrigan and Cheyne, all men who in the fundamental fact of biology—that form power of observation, in keenness of analy- is an expression of function. The Vienna sis, and in the exercise of common sense, school soon became preëminent as the center have not been surpassed in any land. In of clinical teaching, and, as I have said England medical teaching early took on a above, remained so until the outbreak of practical character. The reasons for this the War. change are to be found partly in the prac- I shall not carry the subject beyond this tical type of mind of the English and their point. The next great step in the progress of innate aversion to philosophical hypotheses, clinical teaching came through the conand partly in the fact that in England junction of the work of the laboratory with medical schools were not as on the Conti- the work at the bedside. That step, which
constitutes the greatest advance contributed 8The Jobns Hopkins Hosp. Bull., Balt. vol. to the teaching of medicine by our own time, xxiv, no. 270, August, 1913.
lies beyond the scope of this essay.
THE FACIES HIPPOCRATICA
In acute diseases, the physician will note the following: he will consider first of all the patient's expression of countenance to see if it is like that of healthy people, but above all to see if it is like the patient's own natural appearance. This would be the most favorable facial expression, and the more it is departed from the greater the danger. It will have attained the last degree of alteration when the nose is sharpened to a point, the eyes sunken, the temples depressed, in relief, the ears cold and contracted, the lobes of the ears detached, the skin of the
forehead dry, tense and arid, the skin of the whole face yellow or black, livid or leaden. If the patient have this appearance at the beginning of the disease, and if the condition is not explicable from the other symptoms, inquire if the patient has lost sleep or been purging or has suffered from hunger; if any of these causes are owned to, the danger is much less; and it can be decided in a day and a night whether this facial appearance is due to these causes or no. If not, and if the symptoms do not subside, then death is at hand. HIPPOCRATES. “Prognostics.” 2.
By REGINALD FITZ, M.D.,
scription of that phase of supplies could be sent over. Such a plan Napoleon's history dealing with his pro- demanded a large sum of money and the posed invasion of England between 1803 suitable organization of a combined army and 1805. The events leading up to the establishment and demolition of the French A reference to the history of the United camp at Boulogne, and an outline of its States explains Napoleon's method of financmedical organization are of interest, how- ing his expeditionary force. During the ever, to all medical officers who have been seventeenth century, the French had gradustationed in that city between 1914 and ally extended their explorations in America 1918.
westward along the Great Lakes. In 1673 At the beginning of the nineteenth cen- Joliet and Marquette penetrated to the tury France was at war with Austria and
upper waters of the Mississippi River, and Great Britain, and in a condition of armed in 1681 Robert Cavelier de la Salle went neutrality with Russia, Prussia, Sweden, down the river to its mouth where he tried and Denmark. A successful Italian cam- to form a colony. This first attempt failed, paign against Austria resulted in the but in 1699 Louis XIV detailed two CanaTreaty of Lunéville in 1801. The Peace of dian Frenchmen named Iberville and BienAmiens was concluded with the British in ville to found a second colony at the same 1802, after they had driven the remains of place, which became permanent. The territhe French Army from Egypt and had cap- tory on the western side of the river was tured Malta. The essential question in the called Louisiana, in honor of the King, and latter negotiation was the control of the a few years later the city of New Orleans Mediterranean. After a long controversy,
was founded. England agreed to withdraw from Malta After this, French colonies gradually dein favor of some neutral power, although veloped along the river with the idea of deferring evacuation because the island lay uniting Canada and Louisiana by a chain. in an important strategic position between In the meantime, the English had begun the western and eastern extremities of the to direct their attention to trade in the Mediterranean, and because Napoleon's land west of the Alleghanies so that in 1755 recognized ambition was to acquire a colo- French and English interests in America nial empire. In May 1803, a year after the conflicted and a war broke out. A year Treaty was signed, Napoleon demanded the later this merged into the Seven Years' immediate release of Malta. England an- War in Europe in which were involved swered by seizing 1200 French and Bata- England and Prussia against France, Spain, vian ships and by withdrawing her ambas- and Austria. England and Prussia were sador from Paris. Napoleon, feeling that successful. By the Treaty of Paris, 1763, the state of Europe was sufficiently quiet, France was compelled to give Great Britdetermined to invade England with a force ain all French possessions in North Amerof 150,000 men, 10,000 to 15,000 horses, and ica east of the Mississippi River, Spain 1 Major, United States Army Medical Corps, Base Hospital No. 5.