medical education

44 Pages·2008·6.61 MB·English

THE INFLUENCE OF THE HUNTERS ON
MEDICAL EDUCATION
Hunterian Oration delivered at the Royal College ofSurgeons of England
on
14th February 1957
by
Sir Ernest Finch, M.D., D.Sc., M.S., F.R.C.S.
LateHonorary Surgeon, Royal Infirmary, Sheffield, and late ProfessorofSurgery,
University of Sheffield
I MUST FIRST of all thank you, Mr. President, for the honour you have
conferred upon me and my School by asking me to deliver this the
eighty-ninth Hunterian Oration in memory ofJohn Hunter (Fig. 1) on this
the two hundred and twenty-ninth anniversary of his birth. When his
F.z 1. John Hunter. Born 1728. Died 1793. Froti thestatiuehbY H. Weekes, RA.
at tie College.
museum was first opened to the public in the year 1813, twenty years
after his death, his executor3, who were Sir Everard Home his brother-in-
law, and Matthew Baillie his nephew,
Being desirous of showing a lasting mark of respect to the memory of
John Hunter endowed an annual oration to be delivered in the Theatre ofthe
College on his birthday, the 14th of February; such oration to be expressive
of the merits of Comparative Anatomy, Physiology, and Surgery, not only of
John Htinter but also ofsuch persons as should lx from time to time deceased,
whose labours have contributed to the improvement or extension of surgical
science."
In 229 years much has happened, ideas and ideals have changed, and
the thoughts and labours of many like those ofWilliam and John Hunter
have been directed towards ascertaining and putting into practice the
best methods for the education and training oftheir successors and have
thereby contributed both directly and indirectly to " the improvement or
extension ofsurgical science."
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SIR E. FINCH
I would at once stress the difference between training and education.
Training implies what might be designated as a drill, the acquirement of
skill and precision, and the desire to achieve; but education implies
Fig. 2. William Hunter. Posthiim7?oiis por-trait by Reynolds at Gla.sgow.
many additional disciplines and demands growth unlimited and perpetual.
William Hunter (Fig. 2) and his brother John were both great teachers.
practitioners, and workers in research projects to extend the boundaries
ofknowledge. In later years William wrote " To acquire knowledge and
to communicate it to others has been the pleasure, the business, and the
ambition of my life." In 1793 when John wrote to the Governiors of
St. George's Hospital in order to stimulate his colleagues to undertake
more teaching to the pupils, he said that he had been anxious to gain an
appointment on the staffbecause
" My motive in the first place was to serve the hospital and in the second to
diffuse the knowledge of the art, that all might be partakers of it this indeed
is the highest office in which a surgeon can be employed."
They, by their example, have influenced, perhaps more than is usually
realised, many who have been interested in the development, reform.
and even the present day trends in medical education. My purpose is to
attempt to estimate the extent and ultimate effect of that influence, not
only in our own country but also in others, on those who teach. practise,
and by their research pursue projects on the fringe of knowledge.
The immediate influence of John Hunter on those who had actually
been his pupils was such that, when the London Medical and Phvsical
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THE INFLUENCE OF THE HUNTERS ONl MEDICAL EDUCATION
Society had its first full meeting on 11th February 1819 after being
inaugurated on 3rd February, it was proposed from the Chair, which was
occupied by one of his pupils Sir William Blizard (Fig. 3), and agreed.
that the Society in the future should be known as The Hunterian Society
(Fig. 4). William Clift was present, and as Miss Jessie Dobson, the
Anatomy Curator of the College, has related in his biography. it is due
to him, who was its first conservator, that this College owes the preserva-
tion and arrangement of the original Hunterian Museum. During the
meeting Clift took part in a discussion on tape worms, and later on that
occasion was made an Honorary Member ofthe Society.
The biographical details of William and John Hunter have been
related by many previous orators, they are the subject of many books
which are well known, so any reference I may make will be somewhat
cursory. The family home was at Long Calderwood, in the parish of
East Kilbride in Lanarkshire about seven miles from Glasgow; an appeal
is being made at the present time for financial assistance to preserve the
house. There was a family often children, three ofthem died in infancy
probably from tuberculosis of the lung, and four in the prime of life
probably from the same cause, but William and John lived till they were
sixty-five and Dorothea lived toold age andwas the mother of Matthew
Baillie who succeeded with William Cruikshank, on William Hunter's
death in 1783, to thejoint use of his museum for thirty years, and to the
freehold ofthe premises ofthe Windmill Street School Baillie continued
_h.
Fig. 3. Sir William Blizard.
to lecture there till 1799 and then retired. He became a physician to
St. George's Hospital in 1789 and in 1793, the year of John Hunter's
death, published the first book in English on morbid anatomy illustrated
withbeautifulcopper plates, many ofwhich were made from drawings by
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SIR E. FINCH
William Clift. William Hunter's museum was taken to Glasgow in 1807.
John being the youngest of the family was probably a somewhat spoilt
child. He had little education, one biographer states he could neither
read nor write with confidence when he was seventeen years of age and
HUNTERIAN SOCIETY
Fig. 4. Hunterian Society prograninie.
could have passed no modern examination. He consequently had no
love of books nor would he apply himself to any employment for very
long. In his own words, later in his life, he remarked:
When I was a boy I wanted to know all about the clouds and the grasses,
and whv the leaves changed colour in the autumn, I watched the ants, the bees,
the tadpoles. and caddis worms; I pestered people with questions about which
nobody knew orcared anything."
This statement has been interpreted by some as evidence of his natural
proclivity for research, but this is to regard such an inclination from a
very narrow point of view. A persistent and repeated desire for new
knowledge is natural in all. It is a main occupation of childhood as all
parents know, and can be very trying to them to be always answering
Why'? and How? This inclination ofthe child wears offas its attention
is directed by factual education; in the adult the desire to know becomes
dimmed until itis re-awakened by an education, ofa different type, which
is directed to preserve and increase it. The eldest son to grow up was
James who was educated in law with the object ofbecoming a Writer to
the Signet. William at the age of thirteen obtained a bursary at the
University of Glasgow, and became a student in Arts intending to enter
the Ministry. After leaving the University he applied unsuccessfully for
the post of schoolmaster at East Kilbride, but having in the meantime
become acquainted with William Cullen (Fig. 5), who was in medical
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THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION
practice at Hamilton, he decided to follow medicine as his vocation and
resided in Cullen's house for three years as his apprentice. When he was
twenty-two, on Cullen's advice, he went for a year to Edinburgh (1739-40)
and attended theanatomy classes ofProfessor Alexander Monro (primus).
. .~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ c. f.
. . .
Fig. 5. William Cullen. By Clchirante, in Hunteria,i Museum, Glasgow.
Cullen also advised him to spend a year or two in London and then
return to Hamilton where they would practise as partners. Fortunately,
for both of them and for medicine, the arrangement did not materialise
and in later years while William was becoming the best-known surgeon
man-midwife and anatomist in London, William Cullen became Lecturer
in Chemistry and later Professor of Medicine (1751) at the University of
Glasgow. In 1757 he was appointed as Professor of Chemistry at Edin-
burgh University and later occupied successively the Chair of " The
Institutes of Medicine" (Physiology), and of Medicine. He played a
prominent part in the development of the medical school in each uni-
versity; he is also credited with being the first in 1757 to give lectures in
the vernacular at Edinburgh instead ofin Latin.
Cullen gave William Hunter an introduction to two Scots living in
London, namely William Smellie (1687-1763) who, after practising in
Lanarkfornineteenyears, migratedtoLondontopractiseasanapothecary
and man-midwife, and James Douglas, a surgeon anatomist who was well
established as a teacher of human and comparative anatomy. Douglas
had already published a book (1707) The Comparative Description of
Muscles in a Man anda Quadruped. William Cheselden in the preface of
hisbook The Anatomy ofthe Human Body (1713) referstoJamesDouglas
as " that most accurate and indefatigable anatomist"; his eponymous
famewill always bethepouch ofDouglas (1730). Heis notto beconfused
with his brother John who in 1719 advertised a course of lectures on
anatomy, chirurgical operations and bandaging, and also introduced an
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SIR E. FINCH
operation for suprapubic lithotomy which in 1723 was superseded by
that described and used by Cheselden. William Hunter lived in Smellie's
house for some months and then in 1741 accepted the invitation ofJames
Douglas to help himinthedissections hewaspreparing for ananatomical
atlas ofthe skeleton and also to act as a tutor to his son. From these two
fellow Scots William learnt much about books, a zeal for anatomy, and
the desire to make obstetrics his vocation.
James Douglas arranged that William should enter St. George's
Hospital as a surgical pupil, and attend the classes in anatomy of Dr.
Frank Nicholls; these will be referred to again. William's urge for
research was soon apparent, as in 1743 he communicated a paper to the
Royal Society on The Structure and Diseases ofArticulating Cartilages.
In 1742 he wasjoined by his elder brother James to whom the pursuits
ofWilliamappealedmorethandidthelaw, butwithinayearhedeveloped
pulmonary tuberculosis so returned to Long Calderwood and died there
in 1744. William's opinion ofJames was that had he lived to practise in
London " nothing could have prevented him from rising tothetopofhis
profession as a physician." George Peachey in his Memoir of William
and John Hunter says:
" It would have been a remarkable circumstance that three brothers should
have acquired the first reputation in three different branches of the same
profession."
In 1743 William accompanied young Douglas to Paris and while there
attended Ferrein's classes in anatomy which were reputed to be the best
in Europe. He criticises them thus:
" Ilearntagooddealbymyears,butalmostnothingbymyeyes,andtherefore
hardly anything to the purpose."
The future ability to teach is obvious. The visit had, however, widened
his outlook and taught him the methods used in Paris for instruction in
anatomy and the preparation ofanatomical specimens. It is not known
what William did in London from 1743 to 1746, but it is certain that in
the latter year he commenced teaching anatomy at his house in the
Little Piazza in Covent Garden.
In 1748 he was appointed surgeon man-midwife at the Middlesex
Hospital, and realising, a century before Semmelweis (1818-1865), that it
wouldbedangerous forhispatientsifhecontinuedtoliveoveradissecting
room, he moved to a house in the Great Piazza but retained his old
quarters for dissections.
Meanwhile John, his younger brother, realising that East Kilbride
offered no opportunities, asked and William agreed that he should join
him in London, which he did in September 1748 and took part in the
dissections for the course in anatomy which commenced in October. The
first dissection thatJohn didwas to show the muscles andinjected arteries
in the arm. It was so successful that for the next eleven winters his life
was spent in William's dissecting room, but during the summer months,
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THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION
as dissections werenotdone, heattendedclasses in surgery at St. George's
and St. Bartholomew's hospitals and continued the researches and
investigations which interested him.
In 1749 and 1750 John was accepted as apupil at the Chelsea Hospital,
for old and disabled soldiers, under William Cheselden who had been
appointed as the resident surgeon after he had resigned his surgical
appointment at St. Thomas's and St. George's hospitals, and also that
at the Westminster Infirmary. There could not have been much surgery
practised in this hospital, yet from Cheselden he must have learnt the
principles as then understood, and, much more important, he must have
had many conversations and arguments on anatomy and have been told
much to think about.
According to Sir Zachary Cope, William Cheselden (1638-1752) taught
by William Cowper was the first regular and established teacher of
anatomyinLondon. Hedrewupasyllabus oflectures whichheenteredat
Stationers' Hall on 8th October 1711 entitled "A syllabus or index of
the anatomical parts ofthe Human Body in thirty-five lectures for use in
the anatomical theatre." It was included as an appendix in the first four
editions ofthe book, which has already been mentioned, which remained
the student's manual of dissection for a century. In 1750 William
appointed John as the demonstrator in the dissecting room; they were
never in partnership. In 1751 Cheselden became very ill, soJohnentered
St. Bartholomew's Hospital as a pupil under Percivall Pott, who was then
at the height ofhis fame as a surgeon anatomist; and many years later
John Hunter in his own lectures referred to the instruction he then
received. In 1753 Percivall Pott and William Hunter were appointed by
the Master, Wardens, and Court of Assistants of the Corporation of
Surgeons to act as Masters in Anatomy, their duty being to read the
lectures in anatomy held at Surgeons' Hall.
George Peachey in his Memoir states that it was John and not William
who was appointed, but this is highly improbable. It is unlikely that
anyone would be appointed as a Master in Anatomy who had had only
five years'experience, and three ofJohn's biographers state that it was in
the summer of 1753 that William arranged for him to be entered at
St. Mary's Hall, Oxford, to absorb what was then regarded as culture;
he stayed for two months and, desiring no more ofthis kind ofeducation,
returned to London to continue his dissections, and pursue his researches.
Early medical education
The art and craft ofmedicine arose from superstition, empiricism, and
observation. In the dawn of history it had been born from terror; later
it developed in the conception of magical power attributed to super-
natural facts and beings, still later it was shrouded by religious rites
resulting in care rather than cure. The Church was more important than
the Clinic, so that by the middle ages medicine had become the hand-
maiden of theology; medical education and practice was therefore to a
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great extent in the hands ofthe clerics. Surgery, with its dependence on
some knowledge of Anatomy, must have been taught in a crude form
ever since the first accident happened to man. This is testified from the
earliestrecorded medical cases in the Ebers and Smithpapyri, thewritings
of the Hippocratic School, of Claudius Galen, Cornelius Celsus, and
many others. Medicine must necessarily be based on anatomy which we
know was studied in 300 B.C. by Herophilus and Erasistratus at Alexan-
dria. The Cyrurgia of William of Saliceto (1215-1289), the Chirurgia
Magna of Lanfranchi of Milan (1250-1306) and the Chirurgia of his
contemporary Henri de Mondeville (1260-1320) and others all contained
some anatomical information. We owe much to these surgeons of the
thirteenth and fourteenth centuries who were obviously interested in
medical education, practice, and research. Henri de Mondeville in
discussing the treatment and healing of wounds wrote:
" For it is not necessary as Roger and Roland have written, as many oftheir
disciples teach, andasallmodernsurgeonsprofess, thatpusshouldbegenerated
in wounds. No error can be greater than this, such a practice is indeed to
hinder nature, to prolong the disease, and to prevent the conglutination and
consolidation ofthe wound."
In principle what more than this did John Hunter hint, and Joseph
Lister say?
Roger II of Sicily made the earliest regulations to control medical
practice and outlined a curriculum which was later expanded by the
Emperor Frederick 11 (1190-1250). This enacted that:
1. No physician could practise unless he had passed an examination.
2. The pre-medical course should last three years and be devoted to the
seven liberal arts, namely the Trivium, which consisted of grammar, rhetoric
(theology) and logic, and the Quadrivium which included arithmetic, geometry,
astronomy and music. (This would correspond with the course to-day for a
degree ofB.A.)
3. The subsequent course (corresponding to the pre-clinical and clinical
course) should last fiveyears.
4. Before being allowed to practise the qualified student should show
evidencethathehaddevotedhimselfduringafullyeartothepracticeofmedicine
under an experienced physician (the pre-registration year) and have studied the
anatomy ofthe human body.
5. The law also provided for the inspection ofdrugs sold by Apothecaries,
and control of the fees that they should charge (the Welfare State).
The basis ofeducation in, and practice of, medicine during the middle
ages was literary, didactic, and dogmatic; its inspiration was authority
and tradition.
The intellectual upheaval of the Renaissance led to the foundation of
universities in Europe and in England, Scotland, and Ireland. Faculties
ofmedicine were established, curricula laid down, and degrees conferred
in medicine, but the teaching included very little clinical medicine.
All through the ages up to the middle of the nineteenth century the
basic subject of medical education was anatomy, but from the middle
of the sixteenth century this subject also included its daughter sciences
of physiology, pathology, and pharmacology as then understood. The
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THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION
study of anatomy owes much to the development of naturalism in Art
in the late fifteenth century especially in Italy. The artists wished to
depict the anatomy of the living and in order to do this they had to
dissect the dead. It was not until.three centuries later in 1768 that the
necessity for anatomical knowledge by an artist was realised in England
when George III appointed William Hunter to be the first Professor of
Anatomy at the Royal Academy. The most accurate of these artist
anatomists of the Renaissance was Leonardo da Vinci (1452-1519).
When his antomical studies, completed in the last decade ofthe fifteenth
century, were found by chance more than two centuries later in the Royal
Library at Windsor, they were submitted to William Hunter for his
criticism, which was " I am convinced that Leonardo was the best ana-
tomist in the world at that time."
In 1542, oneyear before thepublication ofDeFabrica Humani Corporis
by Vesalius, a book appeared by another anatomist who, like John
Hunter later, would not separate function from structure, this was The
NaturalPart ofMedicine by Jean Fernel. His methods and achievements
have been described by the late Sir Charles Sherrington in his book
The Endeavour ofJean Fernel. Fernel's book is not illustrated for he
believed that the student should learn anatomy by actual dissection which
was also the opinion ofthe Hunters. Thebookconsists ofsevenparts and
deals successively with things natural, unnatural, and contra-natural.
In the edition of 1554 the word " Physiologia " is used to describe the
first part and " Pathologia " to describe the last; that is two centuries
before these words were used by Boerhaave and Albrecht von Haller.
Thebookpassed through thirty-one editions, and contained the statement
that the spinal cord is hollow, a fact missed by Vesalius.
The development of medical education
The history of the continual development of education for, and the
control of, the practice of medicine in Great Britain and Ireland can be
traced through the activities of the Barber-Surgeons, the College of
Physicians, and Corporation of Surgeons founded in the three capital
cities. The Society ofApothecaries also from the time ofits incorporation
in 1617 by James I up to, and subsequent to, the Apothecaries' Act of
1815 gradually and finally established the status of the family doctor or
general practitioner. The activities ofthe Colleges and Corporations were
made possible by the Royal Charters by which they were incorporated
and those subsequently granted by successive monarchs. They were very
necessary toprotect thecommunity fromtheeffect oftreatment by quacks
and unqualified practitioners. The culmination of the various Acts of
Parliament was that in 1858 the General Council of Medical Education
and Registration was formed with definite statutory obligations, and
finally by the National Health Act of 1946 for the first time a definite
distinctionwasmadebetweensocalledteachingandnon-teachinghospitals
by placing each of the former under its own Board of Administrators
with a definite attachment to a university. The history of these various
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SIR E. FINCH
corporations has been told by many in great detail, suffice it to say that
regulations were laid down by each of them which aspirants had to
satisfy; these included a term of apprenticeship and the passing of an'
examination after studying a definite curriculum. From the very first
postgraduate study was emphasized, as for example by the Barber-
Surgeons ofLondon.
"Every freeman enfranchised in the said fellowship occupying surgery shall
come to the Hall to the reading ofthe lecture concerning surgery every day of
assembly thereof."
The Barber-Surgeons ofDublin were the earliest to be incorporated in
1446 by a Royal Charter of Henry VI which established the Fraternity
or Guild ofSt. Mary Magdalene ofthe City ofDublin for the promotion
and exercise ofthe Art ofSurgery.
The edict " Ecclesia abhorret a sanguine" from the Council of Tours
(1163) conveyed the practice of surgery from the clerics to the barbers
who hadbeentheirassistants. TheBarbers GuildinLondonwasincorpo-
rated into the Company of Barber-Surgeons in 1462 by Edward VI and
was the first attempt to organise the education and control ofthe practice
of surgery in this country. The " Seill of Cause" a Charter granted by
James IVin 1505 to theincorporated Barbers and Surgeons ofEdinburgh
established them as the first guardian of surgical practice and teaching
there, with power to conduct an entrance examination in Anatomy, and
the right each year to the body of one executed criminal for dissection.
The practice of medicine in England being still very chaotic, an Act of
Parliament was passed in 1511 which required all who practised medicine
or surgery, after examination, to have been licensed by the Bishop ofthe
Diocese and in addition in London by the Dean of St. Paul's; thus
establishing what may be said to correspond somewhat with a function
of the General Medical Council.
The real union between the surgeons and the barbers in England was
finallysealedbyHenryVIIIin 1540, ontheadvice ofhis Serjeant Surgeon,
Thomas Vicary, when the Barber-Surgeons and a smallguildofsurgeons,
which up till then had remained outside the Company, were united and
made one body corporate and named " The Masters and Governors of
the Mystery and Commonality ofthe Barbers and Surgeons ofLondon."
This union is depicted in the famous painting of Holbein, the original
being in the possession of the present Company of Barbers and a copy
made in 1618 at the request of James I is one of the most treasured
possessions ofthis College.
It was the incorporation of these Barber-Surgeons in the three capital
cities that ultimately led to the foundation ofthe three Royal Colleges of
Surgeons.
This union had a real influence on medical education as the charter
granted
"four bodies annually of executed malefactors for public dissection and to
provide further and better knowledge, instruction, insight, and experience in
the science and faculty ofsurgery."
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