him from all parts of the world. This man was Boerhaave, called "Medicorum Universæ Europæ Præceptor," under whom the medical school of Leyden attained an extraordinary fame. As a teacher his influence has probably never been equaled. The son of a clergyman, he was himself prepared for theology but preferred medicine. His teaching consisted in lectures and beside demonstrations in which he followed the cases through their course. His, to us, absurd theories of fluida and solida and of temperaments, are characteristic of his time, but could not endure when morbid anatomy in the epoch-making work of Morgagni (1682-1771) showed that disease had a local habitation. Boerhaave had a good deal of common sense and attributed many diseases either to poverty or to luxurious living, "nibil citius debilitat quam luxus." It does not appear that he made any autopsies, being in this respect far behind his predecessor in the Leyden chair, the famous De La Boë, or Sylvius (1614–1672). Considering that the seat of diseases was in the blood or the bile, he naturally could not appreciate the importance of local pathologic processes. The methods of the Leyden Clinic, which had only twelve beds, were carried to all parts of Continental Europe and by Pringle and others to England. In Edinburgh a number of men, directly or indirectly pupils of Boerhaave, established clinical teaching early in the eighteenth century. It appears that one Daniel Duncan inaugurated such teaching in 1720, but the first regular courses were given by Rutherford and afterwards by Cullen, Gregory and Drummond. The last two were the first to teach in the English language, Latin having been used prior to that time. In the days of which I am speaking, every physician had to know Latin virtually as well as his mother tongue, and the better educated also knew Greek. It was the possession of the Latin language that made it possible for men to study and to teach in any university in Europe,

enabling Sydenham to go to Montpellier and Harvey to Padua. I am one of those who regret to see the Latin language disappearing from the college curriculum. A fair amount of Latin and a little Greek are of inestimable value to the medical student and the physician.

The Edinburgh school is of special interest to Americans, as it was there, under Cullen and others, that John Morgan, the founder of the medical school of the University of Pennsylvania, the first medical school in this country, was educated as well as William Shippen, Jr., Benjamin Rush, Samuel Bard and many other pioneers.

One of Boerhaave's greatest pupils, Van Swieten, was called to Vienna by Maria Theresa and there laid the foundation for Vienna's subsequent position as a center of clinical teaching. Being overwhelmed with practice, Van Swieten in 1754, called Anton de Haen, also a pupil of Boerhaave, from the Hague to take charge of clinical teaching in Vienna. De Haen received the enormous salary of five thousand florins in order that he might devote himself exclusively to teaching. He was thus the first of full-time clinical teachers; but as the position yielded the munificent income just mentioned, his problem was not quite as difficult as that of professors in American schools confronted with the question of deciding between full- or part-time teaching. There are other reasons why De Haen should be remembered. He reintroduced the Hippocratic practice of allowing fever patients to have fresh air. On the basis of the doctrine of crises it had become the custom to swathe and cover fever patients and keep every breath of air from them, a practice that has not altogether died out among our foreign population, especially among the Italians.

De Haen espoused the study of bowel excretions as a means of diagnosis and prognosis. This study, though not pursued in quite as unscientific a manner as was

that of water casting, was very popular among medical men, which fact led the satirical Gideon Harvey, physician of Charles II, to speak of doctors as "medici stercorarii qui morbos per anum expellunt." One of De Haen's assistants, a Jesuit priest by the name of Stoll, deserves to be mentioned in a history of clinical teaching. Aside from having the questionable honor of being the father of the bilious diathesis, which has dragged itself through the ages to this day, he has the greater distinction of being one of the first to insist upon thorough physical examinations. He did not, however, resort to percussion, though he writes that in pleurisy the percussion note is like that of the thigh.

The impetus given to clinical teaching by these men endowed the Vienna school with a wonderful reputation, which later great clinical teachers maintained until the outbreak of the world war.

The French school of clinical teaching began a little later and passed through numerous vicissitudes. Although clinical teaching was proposed as early as 1562 by one Pierre de la Ramée, practically nothing was done until the close of the eighteenth century. It is doubtful whether anything could have been done in Ramée's time, for one physician then had charge of about a thousand beds in the Paris hospitals. Lamenting the utter inadequacy of the teaching of medical students, Ramée exclaimed: "de nouveau médecin, cimetière boussu." About two hundred years later (1778) Duchannoy and Jumelin proposed the reintroduction of clinical teaching. Arguing in favor of such teaching they expressed themselves as follows: "Young medical students may reasonably be regarded after their studies as a body of young soldiers who, abandoned to themselves and without leaders, ravage the provinces of a country which they should protect and succor." Their suggestion and protests were of no avail, and as late as 1787 the Royal Society of Medicine

was compelled to make the statement that in France no physician had studied his art at the bedside of a patient. In not a single one of the thirty-two medical faculties of France was there any clinical teaching worthy of the name prior to the Revolution. Desault, in 1787, and Corvisart, in 1788, must be looked upon as the founders of clinical teaching in Paris. During the French Revolution all the old institutions and corporations were overturned. The medical faculty and the academy of surgery were abolished; the masters of medicine had no place to exercise their teaching, and the students had no schools, no instruction. Two courageous men, Forcray and Thorat, protested publicly against the prevailing political spirit which "seeks to destroy everything and to build up nothing"; an utterance that reminds us of the charge so frequently made to-day against Bolshevism.

On an earlier page I spoke of Morgagni and the influence of his work in morbid anatomy upon the teaching of medicine. Morgagni, as the founder of the anatomic school, placed the habitat of disease in the organs instead of in the humors. But neither he nor his immediate successors divined any relation between the diseases of various organs. Another great generalization was necessary, and that we owe to François Xavier Bichat (1771-1802), who by showing that there was a similarity in the tissues composing the different organs of the body, became the founder of general anatomy. From his day onward disease was placed not in the organs as a whole but in the tissues composing them, and the fact became established that the same tissues in different organs might be subject to the same disease processes. It remained for the great Rudolph Virchow to carry the anatomic idea one step farther by his formulation of the cellular doctrine, under the ægis of which morbid anatomy has made enormous strides and maintains itself until this day.

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 Even his great fellow

citizen, 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, 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 rival in the Dublin school, in which perhaps the best clinical instruction of the world was given in the middle of the last century. Graves and Stokes took their students with them into the wards of Meath Hospital and inaugurated the type of clinical bedside teaching in vogue at the present day. I have elsewhere published the history of these great Irish clinicians, as well as that of Corrigan and Cheyne, all men who in power of observation, in keenness of analysis, and in the exercise of common sense, have not been surpassed in any land. In England medical teaching early took on a practical character. The reasons for this change are to be found partly in the practical type of mind of the English and their innate aversion to philosophical hypotheses, and partly in the fact that in England medical schools were not as on the Conti

The Johns Hopkins Hosp. Bull., Balt. vol. xxiv, no. 270, August, 1913.

nent, integral parts of universities, but were in intimate relation with the metropolitan hospitals where some of the physicians took pay pupils with them on their rounds.

The preeminence of the French school did not last long. Dominated by the spirit of Laennec, its great fault was a disregard of physiology. In overemphasizing anatomy, gross and microscopic, it ignored the fundamental fact of biology—that form is an expression of function. The Vienna school soon became preeminent as the center of clinical teaching, and, as I have said above, remained so until the outbreak of the War.

I shall not carry the subject beyond this point. The next great step in the progress of clinical teaching came through the conjunction of the work of the laboratory with the work at the bedside. That step, which constitutes the greatest advance contributed to the teaching of medicine by our own time, lies beyond the scope of this essay.

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.