THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION Hunterian Oration delivered at the Royal College of Surgeons of England on 14th February 1957 by Ernest Finch, M.D., D.Sc., M.S., F.R.C.S. Late Honorary Surgeon, Royal Infirmary, Sheffield, and late Professor of Surgery, 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 of (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 of the 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 of such 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 of William and John Hunter have been directed towards ascertaining and putting into practice the best methods for the education and training of their successors and have thereby contributed both directly and indirectly to " the improvement or extension of surgical science." 205 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 of knowledge. 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 staff because " 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 206 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 of the 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 of ten children, three of them 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 to old age and was the mother of Matthew Baillie who succeeded with William Cruikshank, on William Hunter's death in 1783, to the joint use of his museum for thirty years, and to the freehold of the premises of the 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 with beautiful copper plates, many of which were made from drawings by 207 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 or cared 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 of the child wears off as its attention is directed by factual education; in the adult the desire to know becomes dimmed until it is re-awakened by an education, of a 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 of becoming 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 (Fig. 5), who was in medical 208 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION practice at Hamilton, he decided to follow 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 (1739-40) and attended the anatomy classes of Professor Alexander Monro (primus).

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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 of in Latin. Cullen gave William Hunter an introduction to two Scots living in London, namely William Smellie (1687-1763) who, after practising in Lanark for nineteen years, migrated to London to practise as an apothecary 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 and a Quadruped. in the preface of his book The Anatomy of the Human Body (1713) refers to James Douglas as " that most accurate and indefatigable anatomist"; his eponymous fame will always be the pouch of Douglas (1730). He is not to be confused with his brother John who in 1719 advertised a course of lectures on anatomy, chirurgical operations and bandaging, and also introduced an 209 19 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 of James Douglas to help him in the dissections he was preparing for an anatomical atlas of the 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 of Articulating Cartilages. In 1742 he was joined by his elder brother James to whom the pursuits of William appealed more than did the law, but within a year he developed pulmonary tuberculosis so returned to Long Calderwood and died there in 1744. William's opinion of James was that had he lived to practise in London " nothing could have prevented him from rising to the top of his 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: " I learnt a good deal by my ears, but almost nothing by my eyes, and therefore 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 of anatomical 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 would be dangerous for his patients if he continued to live over a dissecting 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 that John did was to show the muscles and injected 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, 210 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION as dissections were not done, he attended classes 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 a pupil 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 , William Cheselden (1638-1752) taught by William Cowper was the first regular and established teacher of anatomy in London. He drew up a syllabus of lectures which he entered at Stationers' Hall on 8th October 1711 entitled "A syllabus or index of the anatomical parts of the Human Body in thirty-five lectures for use in the anatomical theatre." It was included as an appendix in the first four editions of the 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, so John entered St. Bartholomew's Hospital as a pupil under Percivall Pott, who was then at the height of his 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 of John'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 of this kind of education, returned to London to continue his dissections, and pursue his researches. Early medical education The art and craft of medicine 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 211 19-2 SIR E. FINCH great extent in the hands of the 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 earliest recorded medical cases in the Ebers and Smith papyri, the writings 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 of their disciples teach, and as all modern surgeons profess, that pus should be generated 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 of the wound." In principle what more than this did John Hunter hint, and 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 of B.A.) 3. The subsequent course (corresponding to the pre-clinical and clinical course) should last five years. 4. Before being allowed to practise the qualified student should show evidence that he had devoted himself during a full year to the practice ofmedicine under an experienced physician (the pre-registration year) and have studied the anatomy of the human body. 5. The law also provided for the inspection of drugs sold by Apothecaries, and control of the fees that they should charge (the Welfare State). The basis of education 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 of medicine 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 212 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 of the 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, one year before the publication of De Fabrica Humani Corporis by Vesalius, a book appeared by another anatomist who, like John Hunter later, would not separate function from structure, this was The Natural Part of Medicine by Jean Fernel. His methods and achievements have been described by the late Sir Charles Sherrington in his book The Endeavour of Jean Fernel. Fernel's book is not illustrated for he believed that the student should learn anatomy by actual dissection which was also the opinion of the Hunters. The book consists of seven parts 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 . The book passed 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 of Apothecaries also from the time of its 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 of the 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 to protect the community from the effect of treatment 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 distinction was made between so called teaching and non-teaching hospitals by placing each of the former under its own Board of Administrators with a definite attachment to a university. The history of these various 213 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 of London. " Every freeman enfranchised in the said fellowship occupying surgery shall come to the Hall to the reading of the lecture concerning surgery every day of assembly thereof." The Barber-Surgeons of Dublin were the earliest to be incorporated in 1446 by a Royal Charter of Henry VI which established the Fraternity or Guild of St. Mary Magdalene of the City of Dublin for the promotion and exercise of the Art of Surgery. The edict " Ecclesia abhorret a sanguine" from the Council of Tours (1163) conveyed the practice of surgery from the clerics to the barbers who had been their assistants. The Barbers Guild in London was incorpo- rated into the Company of Barber-Surgeons in 1462 by Edward VI and was the first attempt to organise the education and control of the practice of surgery in this country. The " Seill of Cause" a Charter granted by James IV in 1505 to the incorporated Barbers and Surgeons of Edinburgh 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 of the 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 finally sealed by Henry VIII in 1540, on the advice of his Serjeant Surgeon, Thomas Vicary, when the Barber-Surgeons and a small guild of surgeons, 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 of the Barbers and Surgeons of London." 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 of this College. It was the incorporation of these Barber-Surgeons in the three capital cities that ultimately led to the foundation of the 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 of surgery." 214 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION The charter forbade dissection to be carried out anywhere except in the Barber-Surgeons' Hall where regular lectures were to be given in anatomy and surgery, and later the attendance of all the members of the Company was made compulsory at the public dissections, thereby again emphasising postgraduate education. The Charter granted in 1629 by Charles I provided for a court of examiners to be appointed, and special examinations to be held to guarantee the competence of surgeons, and surgeon's mates serving in the Royal Navy, and the power to grant a diploma and also a grand diploma after passing a more difficult examina- tion. The universities of Oxford and Cambridge made only a small contri- bution to the development of medical education, but in 1549 Edward VI did appoint visitors to proceed to both with instructions to draw up a new set of statutes to regulate the curriculum for the degrees. These statutes stressed the importance of anatomy in the education of all intending candidates. In spite of the regulation in the Charter of the Barber- Surgeons that dissections were only to be carried out at their Hall per- mission had to be granted for them to be done also in other places. John Caius in 1564 obtained a grant from Elizabeth I that dissection of executed criminals could be done at Cambridge. The same privilege was granted to the College of Physicians, and the anatomy lecture was to be given by each Fellow in turn and had to be attended by all the candidates and " licentiates "; this custom gradually declined after the fire of London. The Royal Society also had the right to receive bodies for dissection but this custom soon fell into abeyance; it did however maintain a museum to illustrate comparative anatomy. The private schools of anatomy When William Hunter came to London in 1740 private schools of anatomy were well established and prosperous. His friends William Smellie and James Douglas had been teaching anatomy for years, so had William Cowper (1666-1709) who taught William Cheselden. Compen- diums of anatomy had been written and many surgeons on the staffs of the newly founded hospitals in London had begun to teach anatomy and surgery to their apprentices and pupils in the hospitals and thereby medical schools were inaugurated. The curious union between the barbers and surgeons was dissolved in 1745 and the newly founded Corporation of Surgeons in order to justify its position at once began to arrange curricula and examinations which had to be passed by candidates wishing to obtain the diploma. The method of examination has been described by many and caricatured by Rowlandson and others. The certificate of the Corporation had to be obtained by all who wished to be surgeons or surgeon's mates in the Navy or Army. In spite of the regulations many practised surgery without the certificate, but it added greatly to a surgeon's prestige to have passed the examination and obtain it. In 1740 the private anatomy school 215 SIR E. FINCH which had the greatest reputation was that of Dr. Frank Nicholls (1699-1778) which began in Oxford in 1721, and was transferred to London in 1727; William Hunter attended these classes. He described the course in his Two Introductory Lectures published posthumously in 1784: "At the only course which I attended in London which was by far the most respectable given there, the professor (Frank Nicholls) used only two dead bodies. The consequence was that the course was contracted into too small a compass (thirty-one lectures or thereabouts) and therefore several material parts of anatomy were left out entirely." Frank Nicholls ceased lecturing in 1743 and William tried unsuccessfully to take over the school. It was from Nicholls that he learnt the art of injection and the preparation of corroded specimens. William Hunter commenced his lectures and classes in anatomy in 1746. The advertisement of the course read: " Gentlemen may have the opportunity of learning the art of dissecting during the whole winter session in the same manner as in Paris." The same manner as in Paris meant that the pupils themselves did the dissections with the help ofdemonstrators. There were in December 1746 at least six lectures given every night at different schools in London, so to teach in the same manner as in Paris meant that each school would need two or three subjects every week. These could not be supplied only from the gallows at Tyburn so they had to be obtained by other means. Letters appeared in the press one of which urged that people should leave their bodies for dissection as " the only reason for burying the dead is that they may not be offensive to the living." The supply was not legally rectified until the Anatomy Act of 1832. In 1747 William Hunter increased his reputation as a teacher by taking over from , a surgeon on the staff of Guy's Hospital, the anatomy and surgery lectures to a Society of Naval Surgeons. He continued to give lectures at the various places where he lived and accumulated wealth by these and his practice so that in 1764 he conceived the idea that it would advance medical education if a central museum was founded " for the improvement of anatomy, surgery, and physic in London." He wrote to his friend Cullen who was then Professor of the Institutes of Physic (Physiology) in Edin- burgh suggesting that the two of them " should raise a School of Physic upon a noble plan in Glasgow I would propose to give all my museum, which contains things which cannot be bought, and my library, I could build a theatre at my own expense; and I should ask nothing for teaching but the credit of doing it with reputation." The scheme came to nothing. He then drew up a memorial to Lord Bute, the first Lord of the Treasury, for a grant of land from the Crown " that he might forthwith lay out six or seven thousand pounds upon it for the purpose." Sir Caesar Hawkins, a surgeon on the staff of St. George's Hospital and Serjeant Surgeon to the King, presented a petition to His Majesty with a report of Dr. Hunter's plan and details of several available sites amongst which were the present site of Scotland Yard, and that of the National Gallery. This scheme also came to nothing. In the meantime he had purchased a house in Great Windmill Street and 216 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION commenced rebuilding. In June 1768 William Hunter moved into this house which consisted of " a handsome amphitheatre and other convenient apartments for his lectures and dissections, there was one magnificent room fitted with great elegance and propriety as a museum." The lectures were henceforth given in this building, the Great Windmill Street School (Fig. 6). To return now to the activities of John Hunter who had been a demon- strator in William's school since 1750 and a pupil of William Cheselden, Percivall Pott, and surgeons at St. George's Hospital. He had been a student at St. Mary's Hall, Oxford, for two months, and a house surgeon at St. George's for five. He had continued from 1751 to 1759 with his research projects which had covered a wide field of enquiry. He had investigated the embryology of the chick, the process of respiration in birds, the absorption of the products of digestion which he concluded were entirely by the lacteals, the distribution of the fifth cranial nerve, the descent of the testicles and its relation to congenital hernia. He had used the injection method to trace arteries to their termination, the course of the lymphatics, and the structure of the testis and kidney. These research projects had to be abandoned in 1759 after an attack of pneumonia and the dreaded family disease was suspected. When he had recovered, being advised to be more in the open air, he applied successfully for a commission as a surgeon in the Army and was appointed on the staff of Robert (Robin) Adair, the Inspector-General of Hospitals. He served at the siege of Belleisle and afterwards in Portugal. It was the experience gained

Fig. 6. The Great Windmill Street School. during this campaign in the treatment of gunshot wounds which was the foundation for his book Treatise on the Blood, Inflammation, and Gunshot Wounds published posthumously in 1794. He returned to London in 1763 on his half-pay and commenced practice as a surgeon. 217 SIR E. FINCH On 20th June 1765 at great financial risk, he bought the leasehold of land at Earl's Court where he had previously rented a house, in order to establish an experimental research station. The details of his work there were the subject of the Hunterian Oration on John Hunter and Experi-

_ , __40_

Fig. 7. Percivall Pott. By Romney, at the College. mental Surgery delivered by Sir Cecil Wakeley in this College on 14th February 1955. At that time he had no hospital appointment, no surgical experience except that gained during his army career, and he possessed no surgical diploma. In February 1767 he was made a Fellow of the Royal Society whereas William did not have the same honour conferred upon him until the following April. It is difficult to understand why John should have received this honour before William, as it was not until five years later in 1772 that he made his first communication to the Society on post-mortem digestion of the stomach. During 1767 he commenced two research projects one of which, the self-inoculation with lues, ultimately caused his death twenty-six years later, and the other, having ruptured his Tendo Achillis, decided him to investigate the repair of tendons. During the summer of 1768 he was examined and approved as a member of the Corporation of Surgeons; one of his examiners was Percivall Pott (Fig. 7). When forty years of age on 9th December 1768 he was elected by the Governors of St. George's Hospital to be a member of the surgical staff; his friends David Garrick and Joshua Reynolds were at the meeting and supported his candidature. He had devoted twenty years of his life by arduous work in preparation for the practice of surgery. Many years later he wrote to the Governors of St. George's: " When I solicited to be appointed one of the surgeons to St. George's Hospital it was not with a view to augment my income, either immediately by the profits of the hospital or in a secondary way by increasing my practice, 218 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION but to acquire opportunities of extending my knowledge that I might be more useful to mankind." This appointment enabled him to treat the living, to examine the dead, and above all it gave him the opportunity to teach surgery; it has been estimated that during the twenty-five years he was on the staff he had more than 1,000 pupils. He was now assured of a competence as he was able to take apprentices and resident pupils, and he had a professional standing. Soon after his appointment to the staff of St. George's Hospital he showed his enthusiasm for teaching, much to the annoyance of his colleagues. Prompted no doubt by the example of Percivall Pott, who in 1763 commenced lecturing to the students of St. Bartholomew's without charging them, he suggested that the educational facilities would be increased if similar lectures were given at St. George's. He met with no encouragement from his two senior colleagues, Caesar Hawkins and William Bromfield ; both refused owing to lack of time, although each had lectured on anatomy and surgery for some years from 1735 at their own homes and elsewhere. John Hunter made several unsuccessful efforts to induce his senior colleagues to instruct the pupils at the hospital and so from 1770 until 1774 he lectured to his own pupils at his own house without a fee. His colleagues criticised the lectures as " ingenious but physiological rather than chirurgical." In 1780 John Hunter, being now a senior surgeon, made renewed efforts to induce his junior colleagues to lecture to students and thereby initiate a medical school at St. George's. He was quite unsuccessful and the following comment did not augur well for future happy relations between members of the surgical staff: " One gentleman said he did not choose to lose any reputation he might have in surgery by giving lectures, which at least was modest; and another confessed that he could not see where the art could be improved, the natural conclusion from this declaration being that such a man would never improve it." It is uncertain when John Hunter commenced public lectures, probably at the latest in 1774. He himself states that he had refused to lecture in anatomy in 1768. The first known advertisement of his lectures appeared in The Gazeteer and New Daily Advertiser in 1775. This date is confirmed by one of his early pupils, Henry Cline, in the Hunterian Oration he gave in 1824. A description of Hunter's course of lectures appeared in the European Magazine in 1782; they numbered about 100. In 1775 John Hunter conceived the same idea, as had occurred to William ten years earlier, of founding a school of natural history in London. He wrote to one of his favourite pupils, Edward Jenner, suggesting that he should find a little of the capital necessary to start the venture. He writes: " My scheme is to teach natural history in which will be included anatomy both human and comparative." Jenner would take no part, so John abandoned the idea as William had done. The communications he made to the Royal Society and the books he wrote, some of which he published from his own press, have all been recorded by Mr. William R. Le Fanu, the librarian of this College and 219 SIR E. FINCH are well known. He was indefatigable in his labours; his capacity for work has been described by his assistants William Bell, William Lynn, William Clift, and in his own correspondence. From 1785, when his health began to give rise to anxiety to himself and his friends, he continued to work at an ever increasing pressure which must invoke the most intense admiration. The pupils of William and John Hunter In tracing the progress of medicine, the influence and power of the great teachers becomes more and more apparent. It is not merely their written and spoken words so much as the spiritual legacy which they bequeath and the inspiration they instil into their pupils. It is this which gives the posthumous life and the true immortality. William and John Hunter absorbed this inspiration into their being from others, and having nourished it further by their own innate ability, they, in their turn passed it on to others. In studying the history of the various medical schools in this country it is obvious from what small beginnings they emanated. The seed of the idea is conceived in the mind of one, it germinates, and gradually the resulting plant by being cared for and pruned by others produces the fruit. It is this indescribable, imponderable, and often unrealised privilege of teaching which appeals to such an extent and makes the attraction to be on the staff of a teaching hospital. There has never really been such an institution as a non-teaching hospital, all in it are teaching someone by the best known method of true education which is by example. This is now literally true because the newly qualified student before he can be registered must fulfil a post-graduate year of hospital residence. The medical profession is the only one which compels all its members to fulfil a post-graduate course of study for one year at least, and encourages more. The teachers are now the members of the staff of the hospital where the graduate spends this pre-registration year; their character and enthusiasm will affect his outlook during the rest of his life. The responsibility of the staff is very great. It must never be forgotten that William Hunter taught his younger brother, and many of the methods and characteristics of John must have been developed by him during the eleven years they were so closely associated together in the study of anatomy. Several of William's pupils in due course were instrumental in the foundation and development of hospitals and also medical schools, but not to the same extent as those who had been taught by John. It might be said that William kept a school of anatomy and surgery, but John did more, he founded a school of surgery by his example to his pupils and the stimulation they derived from him who had spent twenty years as a novitiate, and explorer into the unknown on the fringes of knowledge, before he really commenced teaching. Contemporary opinions differ as to whether John was a good teacher; perhaps he was not sufficiently dogmatic on some occasions and too much so on others. This can be illustrated by quoting from his lectures: 220 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION " Never ask me what I have said or what I have written, but if you ask me what my present opinion is I will tell you." "You had better not write down that observation for very likely I shall think differently next year." He would begin his course of lectures in a tentative way: " In the course of these lectures I shall differ very much from what is taught in books on the subject of surgery. The ideas I have to communicate to you are mostly my own. I have reason to suppose them true because they are founded on fact." " Every art has its principles from which we are enabled to establish old facts and account for the new ones, the same holds good in surgery." " I have it not in view to give a full course of practical surgery but merely to trace the principles of the art. The principles are most necessary and these only shall be the subject of the present enquiry." In speaking of cancer he said: " No cure has yet been found; for what I call a cure is an alteration of the disposition and the effects of that disposition and not the destruction of the cancerous parts, which extirpation, however, will often cure as well as we could do by changing the disposition and action." Such methods will educate the aspirant, but they will not guarantee success in examinations. It was said: "He had not the happy talent of displaying the stores of his mind, nor of communicating to others the same perception of the importance of facts and opinions as he himself entertained."

Fig. 8. John Abernethy. In spite of his alleged unattractive qualities many were proud to have been his pupils and in after years taught his methods until he became a tradition in the school they helped to establish. His teaching attracted students 221 SIR E. FINCH from all over the world and the result has been that he is regarded as the founder of scientific surgery. It is by quoting the opinion expressed by some of his pupils that we can appreciate the characteristics which appealed to them. Henry Cline (1750-1827) in his Hunterian Oration (1816) said: " Having heard Mr. Hunter's lectures on disease I found them so superior to everything I had conceived or heard before that there seemed no comparison

Fig. 9. Sir Astley Cooper between the great mind of the man who delivered them and all who had gone before him." and again: " Much as Mr. Hunter did, he thought still more. He has often told me his delight was to think." This was confirmed by John Abernethy (1764 1831) (Fig. 8) who in his Hunterian Oration (1819) said: " Mr. Hunter disliked to read as much as he liked to think." " Such minds could not be satisfied with a mere notation of facts, without enquiring into their probable uses and causes." " His intelligent mind also perceived that no system of physiology could be perfect that did not equally explain the morbid as well as the healthy acts of life,"'' in other words the pathology of disease. This attitude of mind is epitomised in the well-known portrait painted by Joshua Reynolds in 1785. It must have been this portrait of which one of his biographers was thinking when he quoted the remark of William Clift : " He would stand motionless for hours, patient and watchful as a prophet, as if he were sure the truth would come, or as a sudden flash with which, as in an inspiration, the intellectual darkness becomes light." John Hunter had very definite ideas on medical education which were expressed by Abernethy in his Oration : 222 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION " Medicine is one and indivisible, it must be learnt as a whole for no part can be understood if learnt separately. The physician must understand surgery; the surgeon, the medical treatment of disease. Indeed it is from the evidence afforded by external diseases. that we are able to judge of the nature and progress of those which are internal." This axiom had already appeared so obvious to Boerhaave of Leyden (1668-1738) that, although his object was to teach his students the practice of medicine, he began by teaching them surgery so far as it was known at that time. Astley Cooper (1768-1841) (Fig. 9) another of John Hunter's pupils said: " His vast museum is a proof of what industry can accomplish for it contains matter for seven years' investigation." It actually took William Clift ten years to arrange and the investigation of all it contains would take much longer. The actual performance of John Hunter was truly prodigious but even more than this were the avenues of thought he opened up as we know from the work of Astley Cooper which has been so ably recorded by Sir Russell Brock, and we have also witnessed the new development of it by the latter in the surgical cardiac clinic at Astley Cooper's own hospital, and that of Sir Clement Price Thomas at the Westminster, and their inspiration has prompted others to imitate their example. The investigation into the fundamental principles of healing and repair which commenced almost ten centuries ago were resuscitated by the ideas of Hunter and realised by the researches of Joseph Lister

Fig. 10. Sir Anthony Carlisle. using Pasteur's knowledge, and have now become by other means spread over the entire world, not hidden in the recesses of surgical clinics and operation theatres, and are common knowledge in the ordinary man's household. The insight with which John Hunter seized upon the true 223 SIR E. FINCH method of investigation in each branch of enquiry he made, is demon- strated in every-day surgical procedures, examples of which could be multiplied indefinitely. He taught that medicine and surgery were some- thing more than the product of experience and the acquirement of technical skills which to-day are so much admired. It is said that his lectures were

Reproduced by kind permission of the Council of the Royal Society Fig. I11. William Clift. By Henry Schmidt. thinly attended but as Paget remarks, in spite of this his class included nearly every one who in the generation after him had any great reputation in surgery in this country. It is not proposed to consider his influence direct or indirect on the medical schools in London,. in the development of which his pupils played an important part ; such as John Abernethy, Astley Cooper, Anthony Carlisle (Fig. 10), Matthew Baillie, Henry Cline, Everard Home, William Blizard and others. His example and method of thought undoubtedly inspired one of his favourite pupils Edward Jenner to make an epoch-making contribution to preventive medicine, and also made this College for ever indebted to his three personal assistants, William Bell his artist and amanuensis, William Lynn who helped in the museum for fourteen years, and William Clift (1775-1849) (Fig. 11) who on 14th February 1792, his own seventeenth and Hunter's sixty-fourth birthday, was apprenticed to him for six years. When Hunter died on 16th October 1793 Clift had only known him for twenty months, yet in that short time Hunter's influence on him was such that he cheerfully lived in penury for ten years to show his loyalty and devotion to the memory of his late chief. After Hunter's death Clift wrote: " I never could understand how Mr. Hunter obtained rest, when I left him at midnight it was with the lamp just trimmed for further study and with the usual appointment to meet him at six in the morning." 224 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION George Peachey in his memoir confirms this from another source: " From six in the morning, or even earlier, until nine he was in the dissecting room; after breakfast he had patients at his house before going his round of visits. He dined at four, after which he slept for an hour ; and when not lecturing he dictated to Bell his amanuensis till one or two in the morning, leaving only four hours for sleep." I am also indebted to Miss Jessie Dobson for biographical details of no less than seventy pupils and apprentices of William and John Hunter and the names of many more including sixty who entered the service of the Navy or Army. She has collected these names and details during her wide reading and knowledge of what Mr. Lionel Norbury in his Hunterian Oration (1953) called " The Hunterian Era." These students came from thirty-two different counties in England and Wales, from America, Antigua, Jamaica, Ireland, Scotland, and elsewhere, and on their return

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Fig. 12. Title page of Primitive Physick by John Wesley. home to practise they interested themselves in the foundation of hospitals and the formation of medical schools. Many of them had had the privilege of residing in his house as pupils. 225 20 SIR E. FINCH The influence of John Hunter's teaching in America J. G. Mumford in his Surgical Memoir-s writes: "' The best American surgery grew out of English surgery with Hunter as its prophet." Dr. Finney, of Baltimore, in his Oration to the Hunterian Society in 1927 said: " The seed sown by John Hunter is being continually replanted and per- petuated by succeeding generations." How did this come about ? In the earliest colonial settlements in North America the calling of the clergyman and the doctor were often combined. .:.....~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... ',.:....vs;m~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... " '

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,... Fig. 13. Thomas Cadwalader. This priest-physician syndrome was no new combination. John Wesley wroteabookentitledPrimnitivePhysick (Fig. 12). One ofhis biographers says: " You may laugh at John Wesley but the fact remains that wherever the spirit of the Revival spread, there also were spread the accompanying influences of temperance and abstemiousness, of cleanliness and sanitation, of sick visitation and domestic hygiene, of self-respect and self-restraint." This combination of religion and medicine, as of old, was not sufficient; with the spread of the means for education, the need for skilled medical aid was also felt. The principal centres for education in North America were , New York, Boston, and Charleston. The College at Philadelphia became the University of Pennsylvania and the King's College at New York became the Columbia University. The first medical school was founded about the middle of the eighteenth century but when the War of Independence began there were less than fifty medical men in the country who had been trained wholly in an American medical school. One of the first American students to study in London of whom we have reliable records was Thomas Cadwalader (1707-1779) (Fig. 13). He was of Welsh extraction but born in Philadelphia. The original spelling of the name was Kadwaladyr which in Welsh means " battle arranger." In 1725 he was apprenticed to his uncle, a doctor, and after two years went 226 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION to London where like John Hunter he was taught anatomy and surgery by William Cheselden. In 1730 he returned to Philadelphia and gave lessons in dissection to his colleagues one of whom was William Shippen (senior) who then made up his mind to send his own son to London at the appropriate time. Cadwalader's fame rests on his famous Essay on West Indian Dry-gripes which was dedicated to and published by Benjamin Franklin in 1745. This condition was really lead poisoning contracted by drinking Jamaican rum which had been distilled in leaden vessels. It was one of the earliest medical papers written and published in America, and did not deal merely with the " iliac passion "as has been stated. It embodies a very excellent and full description of lead poisoning; the abdominal symptoms, the paralyses, and the encephalopathy. One statement is very apposite and might well be remembered in these days namely " The stomach is the kitchen of the body whose office is to digest and convert the aliments into laudable chyme." He was one of the founders of the Pennsylvania Hospital, the Philadelphia Medical Society, and the first library to be instituted at the College; he also promoted the scheme for the foundation of the Medical School in Philadelphia. He owed much, as did John Hunter, to William Cheselden. His interest in surgery was a stimulus to the young practitioners in Philadelphia one of whom was his nephew John Jones (1729-1791) who was probably the first student from America to attend John Hunter's classes. John Jones became a well-known surgeon in North America. He attended both Benjamin Franklin and George Washington in their last illness. He was one of the founders of the New York Hospital in 1771 and in 1775 wrote the first book on surgery in North America, Plain, Concise, Practical Remarks on the Treatment of Wounds and Fractures. He dedicated this book to his uncle. He came to London twice, the first time he studied under Percivall Pott and the second time attended John Hunter's lectures. He describes the book as " simply a compilation from Ranby, Pott, Hunter and others." It contains an appendix on camp and military hospitals being primarily intended for naval and army surgeons, and was of great use to them during the War of Independence. The two men who had most to do with the foundation of what is now the Medical Faculty of the University of Pennsylvania were William Shippen (junior) and John Morgan. Both had obtained a degree in Arts before leaving Philadelphia, both were resident pupils in John Hunter's house, both obtained an M.D. degree at Edinburgh, and both travelled round the medical schools of Europe in order to observe anything which might be incorporated in the future medical school which they hoped to see inaugurated in Philadelphia. They corresponded about this common interest and project while away from their homes. They worked together after their return to Philadelphia for more than ten years and then with the outbreak of the war between the Colonies and England their paths diverged; their happy association ended owing to mutual jealousy and the intrigues of others, so that at the end of their lives they were enemies. 227 20-2 SIR E. FINCH As young men they had much in common, both being good looking, debonair, and a social success amongst their Quaker townsfolk, but when ambition intervened a rift was inevitable. William Shippen (1736-1808) (Fig. 14), having obtained a degree in Arts, showed great aptitude in languages and public speaking, so much so that the Reverend George Whitfield, a colleague of the Wesleys and a famous preacher, tried to persuade him to enter the ministry instead of following medicine as a vocation. His father trained him for three years but on the advice of Cadwalader decided to send him to London. For- tunately he kept a diary which sheds some light on Hunter's methods. Monday, October 1st. " Busy in packing my things for Mr. Hunter's. In the evening attended Mr. Hunter's first lecture." The next day he took up his residence in Hunter's house and from then there is almost a daily note of how he spent his time; it was mostly in the dissecting room. October 6th. " I spent the day in the dissecting room till 5 o'clock. Dr. Hunter's lecture till 7.30. Bed at 10.30, talking anatomy with Mr. Hunter from supper." Although Shippen's days were spent dissecting, injecting, and discussing anatomy with Hunter, the diary also contains references to visits to theatres, dancing, and other enjoyments. "Attended a new farce entitled " High Life below Stairs" very good and appropriate to the times." He also attended St. Bartholomew's Hospital. November 7th. " Rose at 7, Mr. Hunter dissecting muscles for lecture, went to see patients under my care. After lecture went to St. Bartholomew's Hospital and saw the neatest operation for bubonocele I ever saw, by Mr. Pott a clever neat surgeon." A student's typical comment And again " went to a Ball in the City after lecture, danced with Miss Knox, an agreeable lady and good dancer. Thirty-five ladies genteely dressed. Bed at two." He knew William Hewson, who was William Hunter's assistant and had letters of introduction to various Quakers in England amongst whom was Dr. John Fothergill, the friend of John Coakley Lettsom. Before returning to Philadelphia he graduated M.D. at Edinburgh with a thesis on obstetrics. On his arrival in Philadelphia he was determined to teach anatomy and practise midwifery. His friend John Fothergill, thinking that the students might have difficulty in learning anatomy, arranged with Rymsdyck, one of the best artists in Great Britain, to make life size crayon paintings of various dissections done in London by an anatomist named Jenty under the supervision of John Hunter. The paintings cost two hundred guineas and to show his regard for Shippen, Fothergill also sent an additional one hundred and fifty to the funds of the hospital in Philadelphia, and presented the first book to the library. The paintings arrived in 1763 and with their assistance Shippen continued with his extra-mural classes until 1765 when the medical school was established. 228 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION John Morgan (1735-1789) (Fig. 15), is regarded as the Father of Medical Education in North America. It was who wrote " The historian who shall hereafter relate the progress of medical science in American will be deficient in candour and justice who does not connect

Fig. 14. William Shippen, Jr. the name of Dr. Morgan with that auspicious era in which medicine was first taught, and studied as a science in this country." He graduated B.A. with the first graduation class of the Academy and College of Philadelphia, he was then apprenticed to Mr. Redman for six years, and was also the apothecary at the Pennsylvania Hospital for a year. He then served for four years as a commissioned officer in the French and Indian wars, which experience was extremely valuable during the War of Independence. He came to Europe for five years and during one at least lived in Hunter's house as a resident pupil where he studied anatomy, dissected, and made anatomical preparations by the method of corrosion. He went to Edin- burgh, with a letter from Benjamin Franklin to William Cullen who was then Professor of the Institutes of Medicine (Physiology), and graduated M.D. His thesis, delivered in Latin, entitled De Puopoiesi, was dedicated to John Hunter. In it he advanced the new theory that the formation of pus was due to an excretion from the blood vessels. The theory was John Hunter's but as Morgan published it first, he was credited with it by Cohnheim a century later. Morgan formed a great friendship, an almost filial devotion, for William Cullen who advised him in his subsequent schemes. He demonstrated the preparation of anatomical specimens by the corrosive method before the Academie Royale de Chirurgie of Paris which impressed the members who were present and later he was made a corresponding member of the Academie. He also visited Padua, where he met Morgagni, then eighty-two years of age, who claimed that there must be some relationship between them on account of the similarity of 229 SIR E. FINCH the names. He presented Morgagni with a copy of his M.D. thesis and he in turn presented Morgan with an inscribed copy of his epoch-making book De Sedibus et Causas Morborum. He and his companion William Powell, visited at the Chateau de Ferney and talked of their interest in, and schemes for, improving medical education in America. When saying farewell Voltaire added: " I commend you, Gentlemen, go on, love truth and search diligently after it, and hate hypocracy." In Turin he noted the prevalence of many with thyroid enlargement and subsequently wrote a paper ascribing it to drinking snow water. It was in 1764 that he corresponded with Shippen and commenced to prepare his Discourse on the Institution of Medical Schools in America. He discussed it with John Hunter and John Fothergill and obtained their approval. He returned to Philadelphia in the spring of 1765. In his farewell letter to William Cullen he wrote: " I am now preparing for America to see whether after fourteen years' devotion to medicine, I can get my living without turning apothecary or practising surgery. My scheme of instituting lectures you will hereafter know more of. It is not prudent to broach designs prematurely and mine are not yet ripe for execution." He arrived in Philadelphia loaded with honours being a licentiate of the College of Physicians of London, and of Edinburgh, a Fellow of the Royal

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" He appears to be the same social friendly man, not assuming the solemn badge so accustomed to a son of Aesculapius." He also had the distinction of being the first man in Philadelphia to use an umbrella which gave him the necessary publicity. Morgan and 230 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION Shippen immediately commenced agitating for the foundation of a medical school; this idea was really Morgan's and not Shippen's who had already been lecturing on anatomy for three years. Morgan commenced practising solely as a physician and the Board of Trustees of the new College unani- mously elected him to be the Professor of the Theory and Practice of

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Fig. 16. Title page and inscription of Morgan's Inaugural Discourse at the College of Philadelphia on 30th May 1765. Physic on 3rd May 1765. This was the first professorship of medicine to be established in North America. On 30th May he gave the discourse as his inaugural address (Fig. 16). Many notable quotations could be made from this essay but one will suffice: " It is anatomy which guides the doubtful steps of the young votary of medicine throuah an obscure labyrinth, so every follower of medical pursuits should be intelligent in anatomy if he wishes to practise with ease to himself and to the benefit of his patient - Anatomy, Materia Medica, Botany and the Institutions are the ladder by which we are to mount up to practise." The Medical School was founded in 1765. Shippen was appointed the first Professor of Anatomy and Surgery in September, Benjamin Rush, then aged twenty-four, the first Professor of Chemistry and Morgan to the Chair of Medicine. Thomas Cadwalader was on the Board of Trustees which made the appointments. Morgan helped to found the first Medical Society in North America in 1765 and the College of Physicians in 1767, his and Cadwalader's name appear in the list of founders on the marble plaque in the entrance hall. John Sargent, Esq., merchant of London and a member of Parliament, had endowed a prize essay for competition for which a gold medal was awarded ; the subject was one which at that time, as it is to-day, was much in the thoughts of many, being The Reciprocal Advantage of a Perpetual Union between Great Britain and her American Colonies. John Morgan was awarded the prize and it seems an appropriate time to quote from it: 231 SIR E. FINCH " If the superstructure of a Government be raised on any other foundation than the general interest of the whole community, it cannot be durable. Like the image of Daniel's vision, the head whereof was of fine gold, the chest and arms of silver, the belly and thighs of brass, the legs of iron, and the feet part of iron and part of clay, which cannot cleave together, it must when smote upon be broken to pieces. But the constitution of a country in which the happiness of a whole community is regarded, is like an oak that withstands the fury of the jarring elements, raised up in a storm, fixes its roots deeper in its native earth, and lifts its majestic head to the skies." Medical education affects the general happiness ofthe whole community. When this essay was written the clouds of war which had gathered were momentarily dispersed. They gathered again and in 1775-1776 the American Colonies engaged Great Britain in a revolutionary struggle. The medical school in Philadelphia closed, Morgan was appointed Director-General to the Military Hospitals and Chief Physician to the American Army, as fifteen years later his old teacher John Hunter was appointed to a similar post in Great Britain (1790) succeeding Robert (Robin) Adair. The jealousies and intrigues to which Morgan was subjected and his ultimate replacement by his former friend and colleague William Shippen can be left in oblivion. The undergraduate medical societies in Pennsylvania were later amal- gamated, and named the John Morgan Medical Society. Morgan was succeeded in the Chair of Physic by Benjamin Rush (1745-1813), being

Fig. 17. Philip Syng Physick. transferred from the Chair of Chemistry, who later was one of the signa- tories of the Declaration of Independence. Philip Syng Physick (1768-1807) (Fig. 17), known as the " Father of American Surgery " was the favourite American pupil of John Hunter and became one of the most famous. He graduated in Arts at the Uni- versity of Philadelphia in May, 1785 and then proceeded to study medicine. 232 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION Philip's father was an Englishman who before the secession of the American Colonies was Keeper of the Great Seal of the Colony of Pennsylvania, and confidential agent of the Penn family. In January 1789 he was accepted as a resident pupil by John Hunter and lived in his house for two years. His father accompanied him to the interview with Hunter and naturally asked what books his son should buy to help him in his studies. The answer was given in a typical Hunterian manner " Then Sir, follow me and I will show you the books your son has to study " and led the way from his study to the dissecting room; then pointing to several subjects on the tables said " There are the books which your son will learn under my direction, the others are fit for very little." His description of his pupillage is the same as the others, always anatomy, but studied in the broadest sense. He writes: " I visited Mr. Hunter in the evening, after being entertained with tea, coffee, and general conversation; Mr. Baillie exhibited a preparation." He was a house surgeon under Hunter for a year at St. George's Hospital and obtained the diploma of the Corporation of Surgeons. Hunter then invited him to become his personal assistant but he refused, however for a few months he did assist him at his operations and helped in preparing specimens for the museum. Hunter's opinion of Physick is shown by his reference to him in his lectures on the blood: " Many of these experiments were repeated at my desire by Dr. Physick, now of Philadelphia, when he acted as my house surgeon at St. George's Hospital, whose accuracy I could depend upon." In May 1792 Physick graduated M.D. at Edinburgh. He gave his thesis in latin on De Apoplexia and returned to Philadelphia in the following September. He was anxious to go to the University of Edin- burgh as it had served as the model for the one in Philadelphia. He commenced practice in Philadelphia and had hard work to make a living; he even thought of starting what in this country would have been called a club practice. His prospects soon improved owing to an epidemic of yellow fever as he was appointed to be the resident physician at the special hospital which was opened to accommodate the patients. Physick was elected to the Chair of Surgery in Philadelphia in 1805 and occupied it for thirteen years. He practised and taught the methods he had learned from Hunter. He followed Hunter's practice by ligaturing varicose veins for the treatment of leg ulcers, treated haemorrhoids by using a double wire snare, resected varicose aneurysms, and advocated the use of leather or buckskin for ligatures as, being animal products, they might be absorbed. He recommended that lacerated fingers and inflamed joints should be splinted to obtain physiological rest. He had learned from Hunter the value of the experimental method for the establishment of a surgical principle. He used it to disprove the contention of some of his medical colleagues that inflammation was caused in a wound by being exposed to the air. He describes it thus: 233 SIR E. FINCH "I once tried an experiment on a kitten. I made an incision through the pleura and through the orifice I passed a tube and filled that side of the chest with air. I then withdrew the tube and closed up the wound. In that situation it remained three days without any remarkable change; it was then killed and an examination made, when no perceptible difference could be observed on the two sides. I mention this lo show that air is not so noxious, as is often supposed, to prevent surgeons from being too anxious about closing up a wound with a view of keeping the air from the internal surface." We must remember that the date of this experiment was in the first decade of the century. He is reputed to have been the first American surgeon to wash out the stomach with a syringe and tube in a case of poisoning, though he acknowledges the priority of Monro (secundus) in the invention of a similar instrument. In 1828 he invented a tonsillotome for the removal of the tonsils which were not suitable for removal with snares. He published a description of it in the journal of the Medical Society of Philadelphia. The principle of the instrument is practically the same as of those in use to-day. The Professor of Anatomy at Phila- delphia, Caspar Wistar, died in 1818 and was succeeded by Physick's nephew who unfortunately died the next year, so in order to strengthen the staff Physick was transferred to the Chair of Anatomy but continued to practise surgery. In the biography of Philip Syng Physick by Randolph, which was dedi- cated to John Hunter, it is stated: "The ties which bound him to Mr. Hunter were of no ordinary description. ... These obligations could only be acknowledged on the part of Dr. Physick by the most sincere and ardent devotion to his beloved preceptor. Indeed I think I am warranted in saying that the admiration felt for Mr. John Hunter by Dr. Physick amounted to a species of veneration." Dr. Welch of the Johns Hopkins wrote " Physick was as much a mouthpiece for the doctrines of John Hunter in America as Abernethy, was in London." One of his pupils writes that his chief " cherished the memory of John Hunter for whom he felt greater admiration and a more profound veneration than for any other man." Samuel Bard who had been a student under John Hunter was one of the founders together with John Jones, who has already been mentioned, of the first medical school in King's College, New York, now the Uni- versity of Columbia. He gave the first course of lectures as the Professor of the Theory and Practice of Physic (1768-69). He wrote an essay on Diphtheria in 1771 described by Osler as " An American Classic of the first rank." Wright Post (1766-1828) another student of Hunter's was appointed Professor of Surgery in the newly constituted department of Medicine at Columbia University. He introduced vascular surgery into America and successfully ligatured the femoral artery for a popliteal aneurysm by Hunter's method, and in other cases ligatured the common carotid and third part of the subclavian artery. The introduction and develop- ment of vascular surgery into America, indirectly due to Hunter and more 234 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION directly to Astley Cooper, has been described by Sir Russell Brock in his book The Life and Work ofAstley Cooper. John Hunter's pupils from America were also active in methods of post-graduate education as exemplified in the foundation of museums, medical societies, and journals; the earliest of the latter to be published

Fig. 18. Caspar Wistar. was The Medical Repository, of Newv York (1797-1824), one of the editors being Samuel Mitchell Flihue Smith, who it is said studied under John Hunter. It was probably-due to Hunter's influence that the two of the best known museums connected with medical schools in America were founded. John Warren (1753-18 15) was one of the founders, and the first professor of anatomy and surgery of the Harvard Medical School (1783). His son John Collins Warren of Boston had been a pupil of Astley Cooper in London and of Dupuytren in Paris. He succeeded to his father's professorship in 1815 and played an important part in the foundation of the Massachusetts General Hospital (1811). On 16th October 1846 he performed the first operation to be done under general anaesthesia produced by sulphuric ether administered by William Morton. Later John Collins Warren founded the Warren Museum at Harvard on Hunterian methods. His grandson when writing about this museum stated " I have no doubt that Hunter's example stimulated my grandfather to carry out this work." It was probably due to the influence of John Hunter that Caspar Wistar (Fig. 18) the professor of anatomy at the University of Penn- sylvania (1791-1818) wrote his System of Anatomiy (I1811-1814) ; this was 235 SIR E. FINCH the earliest treatise on the subject published in America. Sir William Osler, in his essay The Leaven of Science, wrote: " It is pleasant to think that direct from John Hunter came the influence which made anatomy so strong in this school and in the acquisition of specimens which ultimately led to the splendid collection of the Wistar-Horner Museum." Caspar Wistar's memory will survive in the Wistar Institute of Anatomy and Biology in Philadelphia, and also in the cultivation of the Wistaria vine, so popular with gardeners. How did Hunter influence these young men, who became what might be designated his apostles, and by their own disciples have spread his doctrines throughout North America and elsewhere? It may perhaps have been that not being himself a bookman he impressed upon them the importance of personal observation and experiment, for it must be remembered that all his pupils agree that " John Hunter loved to think." It may have been that he emphasized to them the importance of morbid anatomy both in clinical and operative surgery, and above all convinced them that there is throughout animate nature a vital principle we call LIFE, which, if proper respect is paid to it, will mobilise all the recuperative powers of the body. The spirit and ideals inherent in the teaching of John Hunter, even to-day, still pervade the medical and surgical thought in the University of Pennsylvania. On 12th December 1956 the Moynihan Lecture at the Royal College of Surgeons of England was given by Professor I. S. Ravdin, the John Rhea Barton Professor of Surgery at the University of Pennsylvania. The subject of the lecture was " The complexity of liver disease-surgical steps toward solution." The last sentence of the lecture has a very distinct Hunterian echo: " The time is coming when the practice of medicine will rest securely upon a firm scientific foundation, upon a systematic understanding of the life processes in all their complexity, and no longer upon the insecure and shifting basis which partially supports it to-day." (Annals of the Royal College of Surgeons of England, February 1957, p. 95.) The Hunterian influence in Ireland It has already been mentioned that the earliest corporate body of medical practitioners in the British Isles was the creation by Henry VI in 1446 of" The Fraternitie or Guild of St. Mary Magdalene of the City of Dublin" and thereby was " the earliest recognition by a ruling monarch of the Craft of Surgery in these Islands." Ireland can also claim the foundation of the first voluntary hospital, Dr. Steeven's (1732) and " the first hospital built in Europe for woman in her hour of travail," the Rotunda, founded (1745) by Bartholomew Mosse (William Doolin, Vicary Lecture, 1950). Trinity College, Dublin, received its Charter from Elizabeth I in 1592. In 1711 due to the influence of Sir Patrick Dun, a medical graduate of , the Anatomy House was built in the immediate vicinity of the Physic Garden. The house con- tained a dissecting room and a museum. George Cleghorn (1716-1785) a 236 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION pupil of William Hunter, was appointed first as lecturer and later as professor. He was a Scot who had been a favourite pupil of Alexander Monro (primus); after graduation he entered the Army from which he retired in 1749, and attended the classes of William Hunter. He died in 1789 and the reversion of his professorship passed to his nephew James, who had been a student under John Hunter: he occupied the Chair in Trinity College until 1799. When in London he attended the Great Windmill Street School, and also Guy's Hospital as a pupil of Astley Cooper whom he helped with the dissections for the illustrations of Cooper's monograph on hernia. The systematic teaching of anatomy in the medical schools of Dublin can therefore be credited to two anatomists who had been students under the Hunters. The influence of the teaching of the Hunters in Scotland It is well known how much the Edinburgh Medical School in its early days owes to the three Alexander Monros, primus, secundus, and tertius (1720-1846), but it was also influenced by the teachers of anatomy in London. John Monro (1670-1740), the father of Alexander Monro (primus) was an army surgeon and while serving in the Low Countries visited Leyden, where at that time Boerhaave was the best known teacher. He was so impressed with the medical school that he determined that Edin- burgh should have one of a similar pattern and that his son should play an important part in its formation. He therefore sent his son to London to study under William Cheselden, who also taught John Hunter. Before he returned to Edinburgh, Monro studied in Paris, and then Leyden, where he became a favourite of Boerhaave. In 1720 he was appointed as the first Professor of Anatomy in Edinburgh, the appointment being for life. His son, Alexander Monro (secundus), after graduating M.D., pro- ceeded to London and attended the classes of William Hunter. He returned to Edinburgh after a period of study in Leyden and Berlin and succeeded his father in the Chair of Anatomy (1754-1798), and in 1798 was succeeded by his son Alexander Monro (tertius) who occupied the Chair until 1846. All three taught anatomy and surgery but the latter two unsuccessfully petitioned the University to be appointed as Professor of Medicine " particularly of anatomy and surgery." The quarrel between the Hunters and Monros on the priority in the discovery of the lymphatic system is well known. There was more than a touch of asperity when on 2nd April 1765 William Hunter again wrote to his friend Cullen, after his unsuccessful effort to found a central museum in London, suggesting Cullen and Black should join him in raising a School of Physick on a noble plan in Glasgow. " You, Black, and I, with those we could chuse I think could not fail of making our neighbours stare. We should at once draw all the English, and, I presume, most of the Scotch students. Among other reasons I should not dislike teaching anatomy near my two friends, the Monros, to whom I owe so much." 237 SIR E. FINCH The importance and popularity of Edinburgh is obvious from the number of students who were taught by the successive Monros. According to Douglas Guthrie 4,464 students were taught by Primus, and no less than 14,000 by Secundus, but there was a considerable diminution in the classes taught by Tertius as he had to meet the competition of the extra-mural schools. James Russell, the Professor of Natural Philosophy at Edinburgh, sent his son James to London in 1776 to be a pupil of John Hunter, and in 1803 he was appointed the first Professor of Clinical Surgery in the University of Edinburgh. He did not lecture on systematic surgery so as not to interfere with the rights of Alexander Monro (primus). Russell gave clinical lectures in the Royal Infirmary and this privilege was granted to him for life. He was the senior member of the College of Surgeons of Edinburgh when the new Hall was used for the first meeting on 16th May 1832. He offered to resign the Chair in 1833 when he was eighty-one years of age provided his successor paid him £300 a year. Liston was offered the post but refused the condition, which was accepted by James Syme, who was succeeded by Joseph Lister. The father of John Thomson (1765-1846) (Fig. 19) was a silk weaver in Paisley to whom the boy was, at the age of eleven years, apprenticed for seven years. At the end of his apprenticeship, being anxious to follow

Fig. 19. John Thomson. Original in the Royal College of Surgeons, Edinburgh. a medical career he was apprenticed for a further three years to a Dr. White in Paisley He studied in Glasgow and Edinburgh Royal Infirmary. In 1792 he became a pupil of John Hunter and was probably the last one he accepted. In 1800 Thomson was appointed, by the Town Council of 238 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION Edinburgh, as one of the surgeons at the Royal Infirmary. For some years there had been differences of opinion about the " teaching of surgery between the Managers of the Royal Infirmary and the College of Surgeons. In comparison with other branches of medical education surgery had received but little attention, and with the exception of Mr. Russell's course of clinical lectures had been taught simply as an appendage to the courses of anatomy." In order to rectify this unsatisfactory position the authorities of the College decided to elect John Thomson to the position of Professor of Surgery at the Royal College of Surgeons stating as a precedent that the College of Surgeons of London and of Dublin each appointed Professors by their own election. This appointment led to a quarrel between the University and the College so after occupying this new Chair for two years he was appointed by the Crown to the Professorship of Military Surgery in the University. Thomson was reputed to be also a very learned physician, and in 1821 he resigned his Chair of Surgery and unsuccessfully became a candidate for the Chair of Physic in the University. He then turned his attention to Pathology and when in 1831 a Chair of Pathology was created by the Crown he was the first to occupy it. His interest in the various branches of medicine was truly Hunterian and he passed it on to his sons, one of whom, William, became Professor of the Practice of Physic at Glasgow (1841) and the other, Alan, was Professor of Anatomy at Aberdeen (1839) and later at Glasgow (1848). The Chair of Anatomy at the University of Glasgow during the second half of the eighteenth century was occupied by a dynasty of Hamiltons. Dr. Robert Hamilton, a son of the manse at Bothwell, occupied it from 1742-1756 and was succeeded by his younger brother Thomas from 1756- 1781. Bothwell is within a short distance of both Long Calderwood, the home of the Hunters, and also the town of Hamilton where Dr. Cullen com- menced his practice of medicine in 1736. Cullen was the friend and mentor of both the Hunters and the Hamiltons. When John Hunter set off on horseback in September 1748 to join his brother William in London, he was accompanied by a Mr. Hamilton who joined him at Bothwell. It is known that Thomas Hamilton, the future professor, came to London in the autumn of 1748 to work in William Hunter's dissecting room at the same time as John. The late Sir Arthur Keith was convinced that it was this Thomas Hamilton who rode side by side with John Hunter during the fifteen days that the latter spent on the journey to London. Thomas Hamilton sent his son William to be a pupil of John Hunter and he succeeded his father as Professor of Anatomy in 1781 and died, aged thirty-two, in 1790. The influence of the Hunters on the provincial medical schools in England It must be remembered that the medical faculties of the provincial universities in England originated in the private medical schools which were inaugurated by the medical men on the staff of the various voluntary 239 SIR E. FINCH hospitals which were founded in the large towns during the latter half of the eighteenth century. Many of the pupils and apprentices of the Hunters took a prominent part in the foundation of these hospitals and so indirectly in the establishment of the medical schools. In order to become a legally qualified medical man at that time a term of apprenticeship to a physician or surgeon had to be fulfilled followed by

Fig. 20. Charles White. a period of "walking the hospitals " to obtain the necessary clinical instruction which would entitle the aspirant to receive a certificate which would enable him to sit for the diploma examinations of the licensing bodies, usually the Society of Apothecaries and the College of Surgeons. At one time the recognised clinical instruction could only be obtained in London, Edinburgh, Glasgow, Aberdeen, and Dublin. This involved the candidate in considerable expense so the staffs of the hospitals in large towns formed a private school, undertook the teaching, and applied to the licensing bodies for recognition of their certificates of instruction. There was often more than one school in the same town, but as recognition would only be given to one, the various interests involved had to settle their differences. Later the pre-medical subjects were studied at the local College of Arts and Sciences or similar Institution, later at the newly founded University College, and when the provincial Universities were established by Royal Charter in the late nineteenth and early twentieth century what had commenced as private ventures became the medical faculties. It is difficult to ascertain in which city or town courses of lectures to the local medical apprentices were first established. Bristol claims that the first course was given in that city in 1744. A course of twenty-eight lectures 240 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION mostly in anatomy were given by Mr. John Tomlinson in Birmingham in 1767; but Manchester was the first provincial town in England to have a recognised medical school. Charles White (1728-1813) (Fig. 20), a pupil of William Hunter at the same time as John, took a prominent part in the foundation of the Manchester Infirmary in 1752 as was related by the late Mr. Arthur Burgess in his Vicary Lecture (1941). The present Medical Faculty of the University of Manchester owes its origin to the foundation of the Royal Infirmary. Edward Alanson, of Liverpool, having served his apprenticeship at the Liverpool Infirmary, became a resident pupil of John Hunter for two years at the same time as Edward Jenner. He was appointed a surgeon to the Infirmary in 1770 and in 1779 published a book on Practical Observations on Amputations in which he advised that muscles should cover the end of the bone, and " arteries should be tied as naked as possible." It is recorded that he always washed his hands before doing an operation. He advocated the establishment of convalescent homes in the country for patients during the post-operative period. William Hey, of Leeds (1736-1819) (Fig. 21), was a student at St. George's hospital in 1757 and came under John Hunter's influence and remained one of his great friends. He commenced a course of lectures on Anatomy

Fig. 21. William Hey. and Surgery in 1800, and in 1803 published a book, Practical Observations in Suirgery. He is known eponymously by a ligament, a saw, an amputa- tion, and descriptions of infantile hernia and internal derangement of the knee joint. 241 21 SIR E. FINCH There was a Company of Barber-Surgeons in Newcastle upon Tyne which local historians claim was incorporated by Royal Charter in 1442. Be that as it may, the Hall of this Company was used as the premises of the first medical school founded in Newcastle in 1834. The Hall was described by Celia Fiennes, when she visited it in 1698. Thomas Young (1773-1829) (Fig. 22), known as " Phenomenon Young," was born at Milverton and became probably" the most learned, profound,

Fig. 22. Thomas Young. ,v,ariously accomplished scholar and man of science that has appeared in our age, perhaps any age." He could read when he was two years old and when four had read through the bible twice. By the age of eighteen he is said to have had a working knowledge of fourteen languages including Hebrew, Coptic, and Persian. He went to London when nineteen years of age (.1792) and attended John Hunter's School of Anatomy. He was given to dissect the eye of an ox which had very recently been killed, in which the ciliary muscles were still actively compressing the lens. This gave him the clue to the explanation of the " accommodation " of the eye which he described in a contribution to the Transactionis of the Royal Society, which gained for him the Fellowship of the Society at the early age of twenty-one. This paper was no sooner published than John Hunter claimed this discovery as his own ; but Young was acquitted of the charge of plagiarism. He completed his medical studies in Edinburgh but also obtained an M.D. degree at the University of Gottingen for a thesis on "The Human Voice." He himself said that this work laid the foundation of his subsequent researches on the undulatory theory of light which gained 242 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION for him the title of " The Founder of Physiological Optics." He com- menced deciphering the Rosetta Stone in 1814, and his priority in this achievement is now admitted. Post-graduate education It has already been stated that the medical profession is the only one which demands post-graduate education ; this is almost automatic for the consultant on a hospital staff surrounded by his colleagues and a team of junior assistants. It is much more difficult for the busy practitioner through lack of opportunity, insufficient time, professional isolation, and lack of incentive. It can only be achieved by attendance at lectures, meetings of medical societies, perusal of scientific papers and medical journals, the use of libraries and to-day by the visual aid of films. John Hunter was naturally interested in post-graduate education and as early at 1767 suggested to a few friends that they should adjourn after the meetings of the Royal Society to a tavern and discuss matters of mutual interest. In 1783 he and his friend Dr. George Fordyce, a physician at St. Thomas's hospital, founded the society for The Improvement of Medical and Chirurgical Knowledge. This society originally consisted of nine members but later the number was increased to twelve and ultimately numbered thirty when it was dissolved in 1818. It published three volumes of Transactions between 1793 and 1812 containing some of the papers and dissertations which had been delivered at the meetings. The first volume contains a paper by John Hunter on Intro-susception and also one on Paralysis of the Muscles of Deglutition. The success of this Society stimulated the same two founders to establish in 17.85 the Lyceum Medicum Londinense. This was a much bigger venture and consisted of honorary, corresponding, and ordinary members. The honorary members were six in number, these included two anatomists, John Hunter and William Cruikshank, two physicians and two man-midwives. There were twenty- one corresponding members consisting ofteachers and members ofhospital staffs, and between three and four hundred ordinary members; the latter included qualified and practising doctors, those who had already attended a course of lectures, and seven who had just commenced their studies. The Society met once a week in John Hunter's museum when interesting and instructive additions were displayed. A library was formed and each year a gold medal was awarded for the best dissertation on a set subject. In 1789 Hunter was elected a member of the Court of Assistants of the Corporation of Surgeons, the precursor of the Council of the College, to fill the vacancy caused by the death of his old teacher Percivall Pott, so he must have taken part in many discussions on the education and examination of apprentices during the four years he was a member. His health was not good but it is established that he attended fourteen meetings out of a possible twenty-six. 243 21 -2 SIR E. FINCH When the Company of Barber-Surgeons was dissolved in 1745 the library of the Company was a matter for dispute so the books were sold. The history of the library of this College was told by our librarian, Mr. William R. Le Fanu, in his Vicary Lecture in 1951. He told us that the Corporation of Surgeons formed no new library even after the Court of Assistants had received a letter from John Hunter dated 14th August 1786, from which the following is a quotation: " Gentleman, At this period, in which the surgeons of Great Britain have deservedly. acquired the highest reputation in Europe, both by their practice and puLlications, it appears to be a reflection upon them that the Corporation of Surgeons of Lcndon should not be possessed of a public surgical library, a circumstance so extraordinary that foreigners can hardly believe it." He enclosed copies of his publications, and continues: " I shall consider it as one of the happiest events of my life to have been at all instrumental in such an establishment." The Library of our College is now one of the most popular in the country for post-graduate education. The records of the first and last years of John Hunter's professional life provide material for thought for those interested in medical education. All his biographers stress the fact that he had practically no formal education at school or what is now called general education. When he commenced dissecting in his brother's school he could have passed no examination in any pre-medical subject even if there had been any; it is doubtful if he could have written an intelligent answer to any question in an examination on general knowledge. This failure of the schoolmaster to exercise control over budding genius is a common feature in the biography of many great men. It should cause us to pause and think over the effects of forcing each one of us into a common mould. The end of his life was hastened by his own evaluation of the evils of tradition in educational matters. The excitement that led to the fatal heart attack in the board room of St. George's Hospital was due to his vigorous protest about the advantage of his teaching to two would-be pupils whose preliminary education fell short of official requirements. The future of medical education It is well to remember that in England, with the exception of Oxford, the medical schools and the teaching hospitals attached to them are older than the universities which absorbed them to form their medical faculties. The function of a university in education has a very special significance. The late Sir Clifford Allbutt, a Regius Professor of Physic at Cambridge, stated: " The function of a university is not qualification for the practice of any art or trade, but a training of the mind, a formation of habits of study, of insight, of easy handling of ideas, and the development of imagination." In the last of his Reith Lectures, Sir Edward Appleton defined a university and its function as " a place of intellectual roads and bridges, it provides the student with opportunities for contact with other minds 244 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION and disciplines, contact of student with students ... for university students educate one another as much as they are educated by their teachers." These opportunities should enable the student to appreciate the relation- ship between his own subject and others. The advantages are not so obvious in London where the students at the twelve schools have little or no opportunity to meet university students studying other subjects. The result should be that a university should produce educated men and women with the power of independent thought and a broad outlook; these qualities should take precedence over a vocational training. In the case of medicine it is the standard of the vocational training that matters to the State and how that standard should be maintained and judged. This is the responsibility of the General Council for Medical Education and Registration, and since the National Health Act (1946) has become even more important, if possible, than it was before. The public will demand the attainment by the undergraduate of a minimal standard as they are paying for the education of what has been called the basic medical graduate, and they have a right to demand this standard of competency, but by the advances in natural science the responsibility placed on the universities for the education of the medical undergraduate has become very great. During the last hundred years there has been a spate of reports of various committees, both ad hoc and representative of medical bodies, which have tried to solve the problem presented by an expanding curriculum, which must be kept within a time limit, and include the great number of ancillary specialties which have grown up within each basic discipline. The vocational standard up to the present time has been governed by examinations, but this has resulted in competition between universities and other licensing bodies. A solution of this problem was attempted in the last thirty years of the nineteenth century by a co-ordinated examina- tion, but no agreement was reached and the name " Conjoint" is all that remains. The time seems opportune for a reconsideration as all the factors are now quite different. The contributions of William and John Hunter to medical education are very pertinent in considering these problems. What did John Hunter contribute ? In reading the extensive literature relating to him, his lectures, and the Orations of others, it is obvious that he presented medicine to his pupils as a fully integrated subject. With the growth of natural sciences and consequent specialties, these subjects have gradually been presented to the modern student as indepen- dent and not interdependent disciplines. It appears to be a possible function of the universities to restore that integration and co-ordination; the achievement of this can be tested by any type of examination the authorities may wish, and they might even be relieved of teaching to a definite curriculum with which they do not agree. In the meantime, Mr. President, the function of this Royal College of Surgeons remains clear. It must, with its sister colleges, maintain in its qualifying examinations the minimal vocational standard required by 245 SIR E. FINCH the statutory obligations, and above all proceed with the schemes for post-graduate education which embody ideals which would have appealed to John Hunter. You and the Presidents of tha College since it was destroyed in 1941, with the help of the Council, the financial support of the Fellows and Members, and the munificent generosity of its well-wishers throughout the English-speaking world, have raised, from the ruins, a shrine worthy indeed to house the spirit of John Hunter and be a permanent memorial to him. Those students, who have the good fortune to live for a time in the unique adjacent Nuffield College of Surgical Sciences, should indeed feel that they are resident pupils with John Hunter (Fig. 23). They will have his museum which is John Hunter's great unwritten book, the pages of which, had it not been for William Clift, would never have been available for them. They will have the use of the library which he was so anxious to see inaugurated and contains his lectures, publications, correspondence. and biographies. They will be able to study his portraits, those of his teachers, and many of his pupils some of whom in due course were mem- bers of the Council and occupied the Presidential Chair; aind those of

Fig. 23. John Hunter. subsequent generations of surgeons who have been influenced by his ideas, ideals, and work. They will receive instruction in the basic medical and surgical sciences, fully correlated with regard to function and struc- ture, which was his fundamental contribution to medical education. They will have the opportunity to see medical and surgical problems solved by experiment, and thereby justify the claim that he was the 246 THE INFLUENCE OF THE HUNTERS ON MEDICAL EDUCATION founder of scientific surgery. They should return to their homes as his apostles imbued with the Hunterian tradition and pass it on to their disciples. The President and his advisers, like John Hunter, will have anxieties and tribulations; I would respectfully refer them to the words of St. Paul in the fifth chapter of his Epistle to the Romans: . . . we glory in tribulation also: knowing that tribulation worketh patience' and patience, experience; and experience, hope; and hope maketh not ashamed.... ACKNOWLEDGMENTS I wish to acknowledge the assistance I have received in the preparation of this Oration from Mr. William R. Le Fanu, M.A., the Librarian of the Royal College of Surgeons of England; Miss Jessie Dobson, M.Sc., the Anatomy Curator of the Royal College of Surgeons of England; and Mr. C. R. Rudolf, L.D.S., the Honorary Secretary of the Hunterian Society of London.

REFERENCES BARBER, G. (1957) Medical education and the General Practitioner. Practitioner 176, 66-78. BROCK, Sir R. C. (1952) The life and work of Astley Cooper. Livingstone, Edinburgh. BURGESS, A. H. (1941) Development of provincial medical education (Hunterian Oration). Lancet 1, 235-240. BROCKBANK, E. M. (1936) The foundation of medical education in England. Manchester Univ. Press. CASTIGLIONE, A. (1934) The renaissance of medicine. Baltimore. COPE, Sir Z. (1953) William Cheselden. Livingstone, Edinburgh. COPPLESON, V. M. (1952) Trends in modern medical education. Sydney Univ. Press. DOBSON, J. (1954) William Clift. Heinemann, London. DOOLIN, W. (1947) Wayfarers in medicine. Heinemann, London. (1950) Dublin's surgeon anatomists. Ann. Roy. Coll. Surg. Engl. 8, 1-22. FINNEY, J. M. T. (1927) The influence of John Hunter on early American surgery. Lancet 1, 420. FLEXNER, A. (1925) Medical education. Macmillan, New York. Fox, R. H. (1901) William Hunter. H. K. Lewis, London. GUTHRIE, D. (1945) A history of Medicine. Nelson, Edinburgh. HUNTER, JOHN (1835) The Works of, edited by J. F. Palmer. Longman, London. 4 volumes. (1928) Bicentenary celebrations. Brit. med. J. 1, 271; Lancet 1, 306, etc. HUNTERIAN ORATIONs by various authors. KEITH, Sir A. (1928) The portraits and personality of John Hunter. Brit. med. J. 1, 205. KRUMBHAAR, E. B. (1922) The early history of anatomy in the United States. An,,. Med. Hist. 4, 271-286. LAMBERT, G. (1881) The Barbers' Company. LE FANU, W. R. (1946) John Hunter, a list ofhis books. Cambridge Univ. Press. (1951) The history of the library of the College. Ann. Roy. Coll. Suirg. Engl. 9, 366-382. LETT, Sir H. (1943) Anatomy at the Barber-Surgeons' Hall. Brit. J. Surg. 31, 122. LIEBOW, A. A. (1956) Medicine taught as human biology. Brit. med. J. 1, 305. McNALTY, Sir A. (1945) The Renaissance and its influence on British medicine. Chris- topher Johnson, London. MATHER, G. R. (1893) Two great Scotsmen. Maclehose, Glasgow. MIDDLETON, W. S. (1922) Caspar Wistar, Junior. Ann. Med. Hist. 4, 62-76. (1927) John Morgan, father of medical education in North America. Ann. Med. Hist. 9, 13-26. (1929) Philip Syng Physick, father of American surgery. Ann. Med. Hist. 3 ser., 1, 562-582. 247 SIR E. FINCH (1931) Thomas Cadwalader and his Essay. Ann. Med. Hist. 3 ser., 3, 101-113. NEWMAN, Sir G. (1898) The disciples of Boerhaave in Edinburgh. Univ. Edin. J. 1, 26. (1918) Some notes on medical education in England. H.M. Stationery Office. (1923) Recent advances in medical educat.on in England. H.M. Stationery Office. NORBURY, L. E. C. (1953) The Hunterian era. Ann. Roy. Coll. Surg. Engl. 12, 303-327. PAGET, S. (1897) John Hunter. Fisher Unwin, London. PEACHEY, G. C. (1924) A memoir of William and John Hunter. William Brendon, Plymouth. (1928) The homes of the Hunters. Brit. med. J. 1, 276. PETTIGREW, T. J. (1838) Medical portrait gallery: Biographical memoirs of the most celebrated physicians and surgeons. Fisher & Son, London. 4 volumes. POWER, Sir D'A. (1895) The rise and fall of private medical schools in London. Brit. med. J. 2, 1388. PYBUS, F. C. (1929) The Company of Barber-Surgeons and Tallow Chandlers of New- castle on Tyne. Proc. Roy. Soc. Med. 22, 287-296. ROLLESTON, Sir H. D. (1929) The Right Honourable Sir Thomas Clifford Allbutt. Macmillan, London. RUDOLF, C. R. (1951) Trans. Hunterian Soc. 9, 84-93. SINGER, C. (1931) A short history of biology. Clarendon Press, Oxford. SPRIGGE, Sir S. (1910) Some considerations of medical education. Balliere, London. TURNER, G. Grey (1946) The Hunterian Museum, yesterday and to-day. Cassell, London. WAKELEY, Sir C. (1955) John Hunter and experimental surgery. Ann. Roy. Coll. Surg. Engl. 16, 69-93. WESTON, F. (1915) Some account of the Barbers' Company. Bedford Press, London.

SEVENTH INTERNATIONAL CANCER CONGRESS THE PRELIMINARY PROGRAMME of The Seventh International Cancer Congress, which is to be held at the Festival Hall, London, from 6th to 12th July 1958, under the Presidency of Sir Stanford Cade, is now available, and can be obtained from the following address: The Secretary- General, Seventh International Cancer Congress, 45, Lincoln's Inn Fields, London, W.C.2.

NUFFIELD COLLEGE OF SURGICAL SCIENCES THE OFFICIAL OPENING of the Nuffield College of Surgical Sciences took place on Friday 5th April. An illustrated account of the proceedings will appear in the next issue of the Annals.

LIFE OF SIR GEORGE BUCKSTON BROWNE, F.R.C.S. A BIOGRAPHY HAS been written of Sir George Buckston Browne, one of the greatest benefactors the College has had. It will appear in May of this year and is to be published by Messrs. E. & S. Livingstone. This book has been written by Miss Jessie Dobson and Sir Cecil Wakeley. 248