Fielding H. (Fielding Hudson) Garrison.

An introduction to the history of medicine, with medical chronology, bibliographic data and test questions online

. (page 70 of 84)
Online LibraryFielding H. (Fielding Hudson) GarrisonAn introduction to the history of medicine, with medical chronology, bibliographic data and test questions → online text (page 70 of 84)
Font size
QR-code for this ebook


usually taught, not in the wards, but in the amphitheater. "The
dullest rustic, " says Flexner, "has long since grasped the idea that
the professor is chosen for his skill and learning. " The hospitals
are full of patients, but to get in close touch with them, one must be
either a Hospiiant (Famulus) or a Praktikantj and the former has
the advantage. The Hospitant can follow his chiefs through the
wards and examine patients, but otherwise, as a professor's fag,
engaged in recording cases, examining urine, preparing slides,
and other things which Sir CliflFord Allbutt designates as "merely
clerks' work," his opportunities are not overwhelmingly sought
for by German students. The Praktikant is "a non-resident in-
terne of vague status, "^ abruptly chosen from his class and pitch-
forked into the clinical arena, where, as a raw student, his ignor-
ance is thrown into the limelight, and his chief has little time to
correct his fumbling. He must sink or swim on his own merits.
The German professor, a high priest of his science and its teaching,
his brain stored with classified knowledge, sometimes acquires,
it is said, a heaviness of mind which may degenerate into top-
heaviness, and his autocratic position may sometimes be manifested
as a "stiff Vomehmheit,*' an impleasantly impersonal manner



1 Flexner: Op. cU,, 163.



Digitized by



Google



648 HISTORY OF MEDICINE

toward pupik or patients,^ which is in odd contrast with the easy
informality of the best modem English, French and American
traditions. The advantages of modem French and English clinical
teaching are precisely in the latter direction. The relations between
teacher and pupil, professor and patient, are less oflBicial and formal,
and the ideal is, in Huxley's phrase, to make the greatest possible
number fit to survive. Parisian patients are even said to contribute
much to the success of clinical instruction by their quick, intelligent
replies.^ In Paris, the hospitals, being public charities, are thrown
open to students everywhere, and the whole aim of French teach-
ing is bedside instmction. Ward teaching is cleverly exploited by
means of stagiaires or student assistants, of whom each professor
has to instmct a large number, and to whom two or three beds each
are allotted for instruction. Stagiaires, extemes and internes, are
quizzed, in succession, by a running fire of questions from the chief,
as he considers each case, and, so informal is procedure that it is
no discourtesy for even an outsider to ask pertinent questions.'
Clinical study is optional in the first year and obligatory from the
second on. Upon graduation, the student must write and publish
a thesis and it is open to him to compete for the position of agrig^
or assistant professor by means of the concours or public examina-
tion. The French graduating theses differ from the German or
Russian in that, as a rule, they are exceedingly clever and well-
written resumes of what is known rather than records of original
work. They are invaluable for reference. As with the French, the
strong point of English medical teaching is clinical instmction.
Emerson said of the English that "theirs is a logic that brings salt
to soup, hammer to nail, oar to boat, " and, necessarily, the physician
to the bedside. The English hospitals are not, as with the Ger-
mans and French, governmental institutions or public charities, but
are supported by volimtary contributions, and, with the exception
of Oxford, where medical teaching is academic, and Cambridge,
where it is confined to the fundamental sciences, the English type
of instmction is that of the hospital medical school. Here, the
student is given the same clinical advantages that obtain in Paris,
the nursing system is the finest in the world, but the institutions
not being connected with universities, little opp>ortunity for post-
graduate or other instmction for outsiders has been afforded imtil
recently. Of the English clinical teacher, Flexner says, "No
matter who or how many attend his lectures, his pupils are speci-
fically those with whom he talks at the bedside." These make



^ This may be regarded as of little moment, since the general testimony
is in accordance with Flexner's view that, all things considered, patients and
pupils are very fairly treated in Germany.

« Flexner: Op. cU., 229-230. » Flexner: Op. cU., 229-230.



Digitized by



Google



MODERN PERIOD 649

their rounds daily with the house physician, rendering complete
case histories with microscopic findings. All are put through
their paces twice weekly, in a rigorous but urbane, informal
spirit, by the senior physician. The same thing obtains at the
fbial examinations, which are a severely practical grilling, although
the bearing of the examiners is said to be "informal, sympathetic,
and easy, even to the point of joining in tea with the onlookers
who happen to be present when that national function becomes
due."i

In modem teaching of the fundamental sciences, the principal drawback
has been the descriptive or expository lecture. In anatomy, this vogue was
started by the eighteenth century men, the so-called "surgeon-anatomists,"
and particularly bv the Monroe at Edinburgh, of whom the "evergreen ter-
HuSy up to 1846, unconcernedly at noon ate cranberry tarts in the midst of
grinning students at a small pastry cook's, and with digestion unimpaired
the next hour read his grandfather's essays on hydrophobia as part of an ana-
tomical course."* Honest John Bell tilted vainly against these ineptitudes of
"the windy and wordy school," pointing out that "in Dr. Monro's class, unless
there be a fortunate succession of bloody murders, not three subjects are dis-
sected in the year," while " nerves and arteries which the surgeon has to dissect
at the peril of his patient's life" were demonstrated on a subject fished up from
the bottom of a tub of spirits and exhibited at a distance of a himdred feet.'
But even after Bichat, Bell and Knox, and the Warburton act of 1832, anatomy
was still treated as the handmaid of surgery (or of the fine arts) until the modern
Germans — Henle, Gegenbaur, Waldeyer — correlated it with histology, mor-
phology and embryology. The dingy, ill-lighted, malodorous dissecting room,
where, as Flexner savs, "eight or ten inexpert Doys hack away at a cadaver
until it is reduced to shreds," still survives in some localities in the United States.
The anatomical laboratory or institute, such as the Clover-Leaf Hall at Munich,
with 500 students dissectmg at once imder the eye of the professor, or Mall's
series of separate rooms at the Johns Hopkins, or Harvard, with its extensive
cold-storage plants, is an innovation of recent date. Dearth of material and too
many students are the great handicaps, and, even in Germany, Flexner argues,
the most scientific lecturing will never compensate for insufficient experience in
dissecting. In England, wnere the utilitarian view has prevailed, it is significant
that there have b^n no great anatomists since the time of Sir Charles Bell.
Homer, Holmes, Harrison Allen^ Leidy and Dwight were able teachers in
America, but the modern scientific methods were introduced by Minot at
Harvard and by Mall at the Johns Hopkins. Mall has isolated his students in
separate rooms and done away entirely with didactic, descriptive lectures.*
France has had no physiologists of the first rank since Claude Bernard, unless
we regard Pasteur as an example. In England, Foster at Cambridge and Bur-
don-Sanderson at Oxford, botn pupils of Sharpey, set the pace in physiological
teaching. In America, advanced instruction began when Bowoitch opened
the first physiological laboratory at Harvard in 1871 and Huxley brought Ne-
well Martin to the Johns Hopkins (1890), the traditions being ably kept up by
Porter in Boston, Howell in Baltimore and others. Two of the most original

1 Flexner: Op. ciL, 188-205, 282.

'Lonsdale: Cited by Stirling (Some Apostles of Physiology, London,
1902, 119).

• John Bell: Letters on Professional Character and Manners, Edinburgh,
1810, cited by Flexner.

* For a full account of the status of anatomy and its teaching in America,
see C. R. Bardeen, Bull. Univ. Wisconsin, Madison, 1905 (No. 115), scient.
ser. iii. No. 4, 85-208.



Digitized by



Google



650 HISTORY OP MEDICINE

of American physiologists. Beaumont and Weir Mitchell, had no afifiliations
with European teaching whatever. German physiological teaching, the highest
development of the century, aew out of the great laboratories of Johiumes
Miiller at Berlin, Ludwig at Jjeipzig and Voit at Munich, but, even in Ger-
many, it is urged that there is too much elaborated lecturing and too little
laboratory work (Flexner). In patholo^, all Europe sat at the feet of
Virchow and his pupils, of whom Cohnheim was the teacher of Welch, who,
with Prudden, brou^t experimental pathology and bacteriolo^ to America.
He established a research laboratory at the Johns Hopkins m 1884. The
French indiflference to pathology is shown by the fact that two neurologists,
Charcot and Marie, held the chair for years, the former succeeding Vulpian
in 1872. Marie was appointed to Victor Comil's chair, "very much, as
Osier puts it, "as if Allan Starr or Dana were selected as successor to
Prudden.'' Bact^riologv has been best taught in France at the Pasteur
Institute and its branches; in Grermany, at tne institutes of Koch, EhrUch,
von Behring and others; in Belgium, by Bordet; in America, by Welch.
Simon Flexner. Vaughan, Novy, Abbott, Ernst and others. "Bacteriology,
sa^ Flexner, tranoormed hygiene from an empirical art into an experimental
science," and the teaching of the two has gone hand in hand since the founda-
tion of Koch's Institute. Experimental pharmacology was first taught by
Magendie in France and by Buchheim, Traube, and Schmiedeberg in Germany.
Brunton, Ringer, Langlev and Cushny in London, Eraser in Edinburgh, repre-
sent the hdght of English teaching. Wood founded clinical pharmacology in
America. Cushny at Ann Arbor, and Abel at the Johns Hopkins introduced
the modem German methods. Legal medicine is best taudit at Vienna, where
all judicial autopsies, coroner's cases, and anything medical connected with
court-room procedure, is under the control of the universitv professor; in Paris
and Lyons, in connection with the admirable service of the Prefectures of
Police; and at Edinburgh, where the professor is also police surgeon. It is
abl^ argued by Abraham Flexner that tne most scientific lecturing in all the
subjects mentioned will be imperfectly assimilated if the student has not
received proper preliminary instruction in physics, chemistry, and general bi-
ology. In clinical medicine, not even the splendid lectures of a Charcot or
a Fnedrich Miiller can take the place of bedside teaching, which it is one of
the chief merits of English medicme to have consistently followed.

America, beginning with Elizabeth Blackwell's graduation
in 1849, was the pioneer in medical education for women. In
the United States and Canada, women can now study medicine
anywhere on the same terms as men. The Woman's Medical
College of Pennsylvania (Philadelphia) was organized in 1850, and
the Woman's Medical College of Baltimore m 1882. The English
Medical Register of 1858 contains the name of a single lady gradu-
ate of Geneva, and a second was examined and qualified in 1865.
In 1874, the London School of Medicine for Women was opened
with fourteen students; and, in 1896, they acquired. the privilege
of resident posts at the Royal Free Hospital. In the same year,
the Royal College of Physicians in Ireland and the London Uni-
versity admitted them to the privilege of examination. No other
London hospital schools are open to women, but the universities
of Durham, Manchester, Liverpool, Birmingham, Leeds, and
Bristol are co-educational. At Glasgow, Aberdeen, Dundee, and
St. Andrew's they are given every facility, but there has been
much opposition in Edinburgh. On the continent, the Swiss
universities took the lead in 1876, the German states followed,



Digitized by



Google



MODERN PERIOD 651

one by one, Prussia being the last to tlirow open the right of uni-
versity instruction and graduation to women in 1908. Paris,
Vienna, Rome, Brussels, Upsala, and Copenhagen are all co-
educational. The faculties of Paris and Bern are the most fre-
quented. Crowds of enthusiastic young Russian Jewesses flock to
the latter, and tnm out huge annual batches of inaugural disserta-
tions. The number of women graduates who get into practice is
said to be relatively small, probably by reason of marriage.

Of the many admirable hospitds constructed in the modem
period, the pavUlion system attained a high plane of development
in the Johns Hopkins Hospital, planned by J. S. Billings and opened
in 1889, and the Hamburg-Eppendorf pavillion, opened in the same
year. In hygienic advantages and economy of administration,
these structures marked a great advance upon the huge, many-
storied buildings of the past. The Peter Bent Brigham Hospital
at Boston (1913), also originally planned by Billings, follows the
same idea. With the opening of the Rudolf Virchow Hospital
at Berlin (1906) a new idea was introduced, that of a commimity
of separate pavillions as detached hospital imits, and upon this
plan are based such hospitals as the new AUgemeines Krankenhaus
at Vienna and the Cincinnati General Hospital, both in process of
construction.

The first sanitarium for phthisical patients was established at
Gorbersdorf , in the Waldenburg Moimtains, by Hermann Brehmer
in 1859. It still exists, and its success has led to the foimdation
of many similar institutions in moimtain and winter resorts,
notably those of Karl Spengler at Davos and Edward L. Trudeau
at Saranac Lake m the Adirondacks. In 1876, Peter Dettweiler
foimded the sanitarimn at Falkenstein in the Taimus, introducing
the reclining chair for rest-cure in the open-air, portable recep-
tacles for sputa, and other novelties. The sanitarium movement
in Germany was especially fostered by Ernst von Leyden and there
are now thousands of these institutions all over the world. Be-
sides the moimtain and winter resorts, like Asheville or Sankt
Moritz, the climatic treatment includes the arid and semi-tropical,
like Arizona or Yalta in the Crimea, and the maritime, like the
Riviera and Algiers. The seashore sanitaria also include those
for scrofula, with which the coast-lines of countries like Italy
and Norway are dotted. The first international congress for
tuberculosis was held July 25-31, 1888, at Paris, and, after the
sixth (1901), an International Association was formed, which holds
annual "conferences" in different cities and prepares for the now
triennial international congresses, of which three have already
been held at Paris (1905), Washmgton (1908), and Rome (1911).
A French society of similar title exists in Paris, and publishes a



Digitized by



Google



652 HISTORY OF MEDICINE

Revue, Since the gift of the Phipps Institute in 1903, the sub-
ject has awakened keen interest in America, especially through
the labors of Trudeau, Vincent Y. Bowditch, L. F. Flick, Araold
Klebs, S. A. Knopf, Henry Barton Jacobs, Frank Billings, and
others.

The nursing of the sick at the hands of trained, well-bred
women is an institution of modem times. The period from the
latter part of the seventeenth century up to the middle of the
nineteenth has been called the "dark age" of sick nursing, in
which the status and competence of female attendants had sunk
as low as the hospitals in which they served. Outside the Roman
Catholic orders, in which discipline and decency still prevailed,
this was almost imiversally the case. The pudgy, slatternly,
dowdy looking female, of drunken and dubious habits, was the
type from the old colored prints to the time of Sairey Gamp.
In 1857, the servant nurses in the larger London hospitals were
referred to in the Times as follows:

"Lectured by Committees, preached at by chaplains, scowled on by treas-
urers and stewards, scolded by matrons, sworn at by surgeons, bullied by
dressers, grumbled at and abused by patients, insulted if old ana ill-favored,
talked flippantly to if middle-aged and good-humoured, tempted and seduced
if young and well-looking — ^they are what any woman might be under the same
circumstances."^

The idea of training nurses to attend the sick in a special
school for the purpose originated with Theodor Fliedner (1800-64),
pastor at Kaiserswerth on the Rhine, and his wife Friederike, who,
in 1833, turned the garden-house of their pastorate into an asylum
for discharged female prisoners, and in October, 1836, foimded the
first school for deaconesses (Dtoconmenan^tott), which became the
model for similar institutions in Germany and elsewhere. To the
Fliedners came, in 1840, Elizabeth Fry, famous for her extension
of John Howard's work in reforming prisons, and later Florence
Nightingale (1823-1910), an English lady, bom at Florence,
Italy, who devoted her whole life to sick nursmg and, mdeed,
made it the model institution which it is in English-speaking coun-
tries today. When the Crimean war broke out in March, 1854,
Miss Nightingale, at the instance of Lord Sidney Herbert, then
Secretary of War, went out with a body of nurses to take charge
of the barrack hospital at Scutari, where her ministrations and re-
forms soon became a matter of history. In the face of the in-
difference of public oflScials and the opposition of narrow bureau-
crats, she received the loyal supp>ort of Lord Raglan and the hard-
working army surgeons, and, within ten days, was feeding nearly
1000 men from her diet kitchen, and, in three months, was pro-

1 London Times, April 15, 1857. Cited by Nutting and Dock, History of
Nursing, New York, 1907, i, 505.



Digitized by



Google



MODERN PERIOD 653

viding 10,000 men with clothes and other necessities from her own
supplies. The effect of her unexampled success was such that
after her return to England a siun of £50,000 — the Nightingale
fimd — ^was raised to estabUsh a school for nurses at St. Thomas's
Hospital, which was opened on June 15, 1860, with fifteen proba-
tioners, who were scientifically trained as "new style nurses."
These soon filled up vacancies in the larger hospitals, which
brought about a wholesale regeneration of English nursing. Night-
ingale nurses were sought for everywhere. The adoption of the
Geneva Convention, in 1864, created the necessity for better nursing
on the continent; and, in America, the movement was especially
furthered by Marie Zakrzewska and Elizabeth Blackwell, the first
training-school for nurses in the United States having been founded
by the former ux 1873. EUzabeth Blackwell (1821-1910), of Bristol,
England, the first lady medical graduate (1849), Clara Barton
(1830- ), of Oxford, Massachusetts, and Louise Lee Schuyler
were instnunental in organizing sick muring and medical aid
during the Civil War. In 1873, three training-schools were estab-
lished at the Bellevue, New Haven, and Massachusetts General
Hospitals, and the Johns Hopkins Training-School for Nurses
was superintended by Miss M. Adelaide Nutting, who, with Miss
Lavinia L. Dock, wrote a "History of Nursing" (1907). Miss
Nightingale's "Notes on Hospitals" (1859) and "Notes on Nurs-
ing" (1860) are true medical classics, distinguished by the rarest
common sense and simplicity of statement. She defined niursing
as "helping the patient to live, " introduced the modem standards
of training and esprit de corpsy and early grasped the idea that
diseases are not "separate entities, which must exist, like cats
and dogs," but altered conditions, qualitative distiu^bances of
normal physiological processes, through which the patient is pass-
ing. While she did not know the bacterial theory of infectious
diseases, she realized that absolute cleanliness, fresh air, pure
water, light and efficient drainage are the surest means of pre-
venting them.

Since the time of Pinel and Reil, Tuke and Conolly, the proper
study and care of the insane has been an object of ambition, often
dimly realized. When Esquirol succeeded Pmel at the Salp^tridre,
in 1810, he made great reforms in housing and regimen, traveled
all over France to carry out Pinel's ideas, foimded ten new asylums
and was the first to lecture on psychiatry (1817). Gardner Hill
introduced the idea of "no restraint" at Lincoln Asylum, England,
in 1836, and in 1839, in the face of bitter opposition, John Conolly
discarded all mechanical restraints at the Hanwell Asylimi. The
abuses attending the commitment and care of the insane in private
asylums were vigorously attacked by Charles Reade in "Hard



Digitized by



Google



654 HISTORY OF MEDICINE

Cash" (1863). Early American institutions were the Blooming-
dale Asylmn, New York (1809), now the Bloomingdale Hospital
at White Plains, the Friends Aiyylum, at Frankford, outside Phila-
delphia (1817), the McLean Hospital, Boston (1818), the Hartford
Retreat (1824), the South Carolina Hospital at Columbia (1828),
and the New Jersey State Asylum at Trenton (1848). The latter
was established through the propagandism of Miss Dorothea
Lynde Dix, of Maine, whose work in ameliorating the condition
of the insane in America is similar to John Howard's prison and
hospital reforms. She is said to have been instrumental in foimd-
ing no less than thirty-two asylums. With the opening of the
Utica State Hospital in 1843, began what Hurd calls "the era of
awakening,"^ and by 1850 the movement for State provision for
the insane was well on its way. The State asylums at Willard
(1869) and Binghamton, New York (1881), were founded to set
off the barbarities in the treatment of the chronic insane in coimty
asylums. Pliny Earle, in 1867, emphasized the importance of
suitable employment for the insane. In 1885, Daniel Hack Tuke
made a sweeping attack on American and Canadian asylums,
and in 1894,* Weir Mitchell pointed out the deficiencies in the
proper care and treatment of the insane, discussed the general
'*woodemiess"of boards, the evils of pohtical control, and indicated
the absolute lack of any scientific study of insanity in American
hospitals. The latter idea originated with the Germans. The
very first article which Griesinger penned for his Archiv (1868)'
proposed a reorganization of the German hospitals and outlined
the idea of a psychiatric clinic, where the patients should be
studied and treated, as in hospital, before commitment or discharge.
In Berlin, Ideler had demonstrated cases at the Charity in 1832, to
be followed by Griesmger (1866), Westphal (1869), and Jolly
(1890). Psychiatric clinics were opened at Strassburg (1872),
Basel (1876), Breslau (1877), Bonn (1882), Freiburg (1887), Halle
(1891), and elsewhere, the movement culminating in the fine insti-
tution opened by Kraepelin at Mimich November 7, 1904. On April
16, 1913, the Psychiatric Clinic, donated to the Johns Hopkins Uni-
versity by Henry Phipps, and modeled along the German lines, was
opened at Baltimore under the direction of Professor Adolf Meyer.
In the development of national and international regulation
of public hygiene, necessity has been the mother of invention.
There was nothing spontaneous about the movement. It was



» H. M. Hurd: Am. Jour. Insanity, 1913.

»S. Weir Mitchell: Proc. Am. Med.-Psychol. Ass., 1894, Utica, N. Y.,
1895, i, 101-121.

» W. Griesinger: Arch. f. Psychiat., Berlin, 1868-69, i, 8-43.



Digitized by



Google



MODERN PERIOD 655

simply forced upon the attention of legislators by the modem
outbreaks of epidemic disease and by the evils resulting from
crowded cities and slums, factories, ateliers, and the like, and
its developments have been slow. The first big scare came
from the invasion of Asiatic cholera (1826-37), which had been
endemic in India for centuries, was pandemic in Asia during
1816-^30, had spread over Russia by 1830, skirted Northeastern
Germany in 1831, reaching England in Jime of the same year,
and Calais, March, 1832, and invaded America vid Quebec and
New York. Heinrich Heine has left a graphic and memorable
account of its outbreak in Paris. On the twenty-ninth of March,
the night of mircar^me, a masked ball was in progress, the chahut
in full swing. Suddenly, the gayest of the harlequins collapsed,
cold in the limbs, and, imdemeath his mask, "violet-blue" in
the face. Laughter died out, dancing ceased, and in a short
while carriage-loads of people were hurried from the redotUe
to the H6tel Dieu to die, and, to prevent a panic among the



Online LibraryFielding H. (Fielding Hudson) GarrisonAn introduction to the history of medicine, with medical chronology, bibliographic data and test questions → online text (page 70 of 84)