Scientific method for medical practitioners: The case method of teaching pathology in early twentieth-century Edinburgh

Bulletin of the History of Medicine

Volumn 81, Issue 4, 2007, Pages 760-792

  Sturdy, Steve ^a  

^a UNIVERSITY OF EDINBURGH   (United Kingdom)

Author keywords

Clinical cases; Edinburgh; Medical education; Pathology

Indexed keywords

ARTICLE; CLINICAL MEDICINE; EDUCATION; HISTORY; HUMAN; MEDICAL EDUCATION; MEDICAL STUDENT; METHODOLOGY; PATHOLOGY; UNITED KINGDOM;

CLINICAL MEDICINE; EDUCATION, MEDICAL; HISTORY, 19TH CENTURY; HISTORY, 20TH CENTURY; HUMANS; PATHOLOGY; SCOTLAND; STUDENTS, MEDICAL;

EID: 38049139297     PISSN: 00075140     EISSN: None     Source Type: Journal    
DOI: 10.1353/bhm.2007.0093     Document Type: Review

References (159)

1. The most detailed analyses of the contested meanings of science in mid- to late nineteenth-century medicine have been conducted by John Harley Warner, working on the American context: Warner, "The Fall and Rise of Professional Mystery: Epistemology, Authority and the Emergence of Laboratory Medicine in Nineteenth-Century America," in The Laboratory Revolution in Medicine, ed. Andrew Cunningham and Perry Williams (Cambridge: Cambridge University Press, 1992), pp. 110-41;
2. Warner, "Ideals of Science and Their Discontents in Late Nineteenth-Century American Medicine," Isis, 1991, 82: 454-78.
3. L. S. Jacyna, "Theory of Medicine, Science of Life: The Place of Physiology in the Edinburgh Medical Curriculum, 1790-1870." in The History of Medical Education in Britain, ed. Vivian Mutton and Roy Porter (Amsterdam: Rodopi, 1995), pp. 141-52.
4. The precise role of physiological science, and especially of laboratory investigations, in clinical practice was becoming controversial by the 1850s: see John Harley Warner, "Therapeutic Explanation and the Edinburgh Bloodletting Controversy: Two Perspectives on the Medical Meaning of Science in the Mid-Nineteenth Century," Med. Hist., 1980, 24: 241-58. But this should not obscure the fact that Edinburgh clinicians generally considered a physiological understanding of health and disease to be vital for effective practice.
5. From 1751 the university professors of medicine, including the professor of the institutes of medicine, were granted the privilege of offering clinical lectures at certain times of the year in the wards, using patients set aside for that purpose. Over the course of the nineteenth century these privileges evolved, partly through changes of statute and partly through changes in accepted practice, such that by the end of the century each professor of medicine effectively had a set number of wards allocated to him. Though these professors were not officially physicians to the infirmary, by the late 1870s they were treated as such under the Infirmary Regulations. See Royal Infirmary of Edinburgh, "Notes and Excerpts from the Minutes, &c., as to the Relationship of the University and the Royal Colleges of Physicians and of Surgeons to the institution, 1728-1900," LHB1/42/4/(2), Lothian Health Services Archive, Edinburgh University Library (hereafter EUL), Edinburgh.
6. On the establishment of physiology as a scientific discipline in Britain, see Gerald L. Geison, Michael Foster and the Cambridge School of Physiology: The Scientific Enterprise in Late Victorian Society (Princeton: Princeton University Press, 1978);
7. Stella V. F. Butler, "Centers and Peripheries: The Development of British Physiology, 1870-1914," J. Hist. Biol., 1988, 21: 473-500.
8. On the international context see, inter alia, Gerald L. Geison, ed., Physiology in the American Context, 1850-1940 (Bethesda, Md.: American Physiological Society, 1987);
9. William Coleman and Frederic L. Holmes, eds., The Investigative Enterprise: Experimental Physiology in Nineteenth-Century Medicine (Berkeley: University of California Press, 1988).
10. William Rutherford, Edinburgh's first full-time professor of physiology, was a transitional figure who saw physiology as an independent research-led discipline, but continued to teach it in a way that stressed its relevance to the understanding of disease: Stewart Richards, "Conan Doyle's 'Challenger' Unchampioned: William Rutherford F.R.S. (1839-99), and the Origins of Practical Physiology in Britain," Notes & Rec. Roy. Soc. London, 1986, 40: 193-217;
11. S. W. Sturdy, "A Co-ordinated Whole: The Life and Work of John Scott Haldane" (Ph.D. thesis, University of Edinburgh, 1987), pp. 96-97. With the appointment of Edward Schäfer (later Sharpey-Schäfer) to the Edinburgh chair of physiology in 1899, these remaining links between physiology and clinical medicine were sharply severed. Schäfer was a keen advocate of physiology as a "basic" preclinical science, and his early years in Edinburgh were dominated by his efforts to build up an "institute" incorporating experimental physiology, chemical physiology, and histology, and by a campaign to clarify the distinction between the preclinical and clinical sections of the curriculum: see University of Edinburgh, Faculty of Medicine, minutes of meetings, 1900-1902, passim, EUL, Department of Special Collections (hereafter DSC), shelf ref. DA43.
12. Thereafter he seems to have played little part in the activities of the Faculty, and by the early 1920s his extreme isolationism marked him out, even to advocates of academic scientific independence, as an obstructive rather than a progressive influence within the school: see Richard Pearce, "Notes of R.M.P. on Medical School of the University of Edinburgh, 22-24 February 1923," p. 5, folder 5, box 1, series 405, RG 1.1, Rockefeller Foundation Archives, Rockefeller Archive Center (hereafter RAC), Sleepy Hollow, N.Y.
13. See also Merriley Borell, "Setting the Standards for a New Science: Edward Schäfer and Endocrinology," Med. Hist., 1978, 22: 282-90.
14. Greenfield had previously served as demonstrator and then lecturer in morbid anatomy and pathology at St Thomas's Hospital, London, from 1874, then from 1878 as professor of pathology at the University of London's Brown Animal Institution, a pioneering physiological and pathological research laboratory. While at the Brown Institution, he had conducted research into the bacteriology of anthrax, including developing a method to reduce the virulence of the bacillus that partly anticipated Pasteur's more celebrated work. See obituary, "William Smith Greenfield," Brit. Med. J., 1919, 2: 255-58;
15. H. R., obituary, "Professor W. S. Greenfield," Edinburgh Med. J., 1919, n.s., 23: 258-62.
16. Greenfield's lectures in "general pathology" included discussion of the germ theory as well as various other physiological and chemical disease processes, while those in "special pathology" aimed to show how an understanding of those processes served to explain the phenomena of disease as observed in human subjects: Notes of Pathology lectures by W. S. Greenfield, 1888-89, EUL, DSC, shelf ref. Dk.4.10. He also inaugurated a practical class in pathological histology, which showed how these processes were manifested in changes in the microscopic structures of the tissues: H. R., "Professor W. S. Greenfield" (n. 6), pp. 259-60.
17. H. R., "Professor W. S. Greenfield" (n. 6). p. 258.
18. The first full-time chair in pathology was established at the University of Cambridge in 1884. After a fierce contest between those who favored a style of pathology that concentrated chiefly on autopsies and pathological histology, and those who favored a more biological approach to research, the chair was awarded to the German-trained physiological pathologist C. S. Roy: Mark W. Weatherall, Gentlemen, Scientists and Doctors: Medicine at Cambridge 1800-1940 (Woodbridge: Boydell Press, 2000), pp. 135-40. Thereafter, full-time chairs were established in Manchester in 1891, Liverpool in 1894, St Andrews in 1898, and Glasgow and Birmingham in 1899. The remaining provincial university medical schools followed in quick succession. The London teaching hospitals, being only rather tenuously affiliated with the University of London before 1900, and rather reluctantly thereafter, were slow to appoint professors; but St Bartholomew's hospital appointed a full-time lecturer in pathology in 1893, and the other teaching hospitals followed suit: George J. Cunningham, The History of British Pathology (Bristol: White Tree Press, 1992). As with physiology, the model for the growth of pathology as a full-time science was initially established in Germany in the mid-century. Compared with physiology, the development of pathology as a scientific discipline - albeit one with strong clinical connections - has received surprisingly little attention from historians, but see, inter alia, Russell C. Maulitz, "Rudolph Virchow, Julius Cohnheim, and the Program of Pathology," Bull. Hist. Med., 1978, 52: 162-82;
19. Maulitz, "Pathology," in The Education of American Physicians: Historical Essays, ed. Ronald L. Numbers (Berkeley: University of California Press, 1980);
20. Maulitz, "The Pathological Tradition," in Companion Encyclopedia to the History of Medicine, ed. W. F. Bynum and Roy Porter, vol. 1 (London: Routledge, 1993), pp. 169-91;
21. Edward T. Morman, "Clinical Pathology in America, 1865-1915: Philadelphia as a Test Case," Bull. Hist. Med., 1984, 58: 198-214;
22. and the essays in Pathology in the Nineteenth and Twentieth Centuries: The Relationship Between Theory and Practice, ed. Cay-Rüdiger Prüll in collaboration with John Woodward (Sheffield: European Association for the History of Medicine and Health Publications, 1998).
23. J. Henry Dible, "A History of the Pathological Society of Great Britain and Ireland," J. Pathol. Bacteriol., 1957, 73: 1-35, quoting from p. 2. The new Society was not without support from at least some among the clinical elite, including William Osler and Clifford Allbutt, Regius Professors of Medicine at the Universities of Oxford and Cambridge, respectively.
24. University College London was even slower than Edinburgh, not creating a full-time professorship until 1915: W. R. Merrington, University College Hospital and Its Medical School: A History (London: Heinemann, 1976), p. 220.
25. J. S. Haldane, "James Lorrain Smith," Proc. Roy. Soc. London, B, 1931-32, 109: iv-ix;
26. R. M. [probably Robert Muir], "James Lorrain Smith 1862-1931," J. Pathol. Bacteriol., 1931, 34: 683-96;
27. J. W. Crerar, obituary, "James Lorrain Smith," Edinburgh Med. J., 1931, 38: 387-91.
28. J. Lorrain Smith, "The Place of Pathology in the Medical Curriculum. Inaugural Lecture Delivered on 9th October 1912," Edinburgh Med. J., 1912, n.s., 9: 391-99, at p. 394.
29. Ibid., pp. 396-97.
30. E.g., A. E. Boycott, who succeeded Lorrain Smith in the Manchester chair. Where the latter had negotiated an agreement that the professor of pathology should be ex officio honorary pathologist to the Manchester Royal Infirmary, Boycott "maintained that a professor of pathology in a University must devote all his energies to its advancement as a science and that the application of laboratory methods to clinical medicine was not part of his duty"; when he moved on to become the first full-time professor of pathology at University College London in 1914, "the same divergence in view as to the proper duties and responsibilities of a professor of pathology again rose to disturb the otherwise complete harmony between Boycott and clinical colleagues" (C. J. Martin, "Arthur Edwin Boycott 1877-1938," Obit. Not. Fell. Roy. Soc. London, 1936-38, 2: 561-71, at pp. 563-64.
31. Lorrain Smith, "Place of Pathology" (n. 13), p. 393.
32. On the establishment of the post of pathologist to the infirmary, and the careers of the early incumbents, see A. Logan Turner, Story of a Great Hospital: The Royal Infirmary of Edinburgh 1729-1929 (Edinburgh: Oliver and Boyd, 1937), pp. 170-72. A list of the pathologists and assistant pathologists is provided in ibid., pp. 377-79. Several of the later nineteenth- and early twentieth-century pathologists went on to occupy chairs of pathology in universities around Britain and the Empire. It was also increasingly common for these aspiring professional pathologists to combine work in the infirmary department with junior teaching positions in the university.
33. University of Edinburgh, Faculty of Medicine, minutes of meetings of 15 and 18 October 1912, EUL, DSC, shelf ref. DA43; "Agreement between the University Court and the Managers of the Royal Infirmary regarding clinical arrangements and pathology," 20 and 23 June 1913, University of Edinburgh Archives, Secretary's File, DRT 95/002, part 1, Faculty of Medicine, box 5. The agreement included a proviso that the professor of pathology would be appointed pathologist to the Infirmary "subject to the Board of Managers being satisfied that he is able to undertake and discharge the duties of the post"; it also specified that the current infirmary pathologist, Theodore Shennan, should remain in post until such time as he chose to move on, Lorrain Smith meanwhile serving as consultant pathologist. In the event, Shennan was appointed to the chair of pathology at the University of Aberdeen in 1914, at which point Lorrain Smith assumed the post of pathologist. See Turner, Story of a Great Hospital (n. 17), pp. 310, 378.
34. "Agreement" (n. 18).
35. Ibid. It is worth noting that, shortly after his appointment, Lorrain Smith was elected a Fellow of the Royal College of Physicians of Edinburgh - an honor usually reserved for senior clinicians. He quickly came to play an active role in the life of the College: W. S. Craig, History of the Royal College of Physicians of Edinburgh (Oxford: Blackwell Scientific, 1976), pp. 709, 736.
36. A. Logan Turner, Sir William Turner, K.C.B., F.R.S. (Edinburgh: Blackwood, 1919), pp. 393-401. Initially, the infirmary staff had been permitted to teach only for the diplomas of the Royal Colleges and other corporate licensing bodies. However, the most successful of these extramural teachers were also able to attract significant numbers of degree students, who supplemented the professorial teaching required by the university curriculum with extramural classes where these were deemed superior to what was on offer within the university. The competition between professorial and extramural teachers was if anything increased rather than diminished by regulations established by the Commissioners appointed under the Universities of Scotland Act of 1889, permitting students studying for the degree to take up to two of the five years of medical study, or half the subjects of the curriculum, with teachers outside the university.
37. C. J. Lawrence, Rockefeller-Money, the Laboratory and Medicine in Edinburgh 1919-1930: New Science in an Old Country (Rochester, N.Y.: Rochester University Press, 2005), pp. 71-79.
38. "Agreement" (n. 18). Under this agreement, control over appointments as assistant physician or assistant surgeon to the infirmary passed from the entire Board of Management of the infirmary to a selection committee comprising two of the university representatives on that board, one of the representatives of each of Edinburgh's two Royal Colleges, and three additional nominees of the board. This committee then selected two candidates from those seeking admission to the infirmary staff, and passed their names to the entire board to make the final selection.
39. The structure of the medical curriculum just prior to Lorrain Smith's assumption of the chair is outlined in Edinburgh University Calendar 1911-1912 (Edinburgh: Thin, 1911).
40. R. M., "James Lorrain Smith" (n. 12), p. 692. It is an acknowledgment of the leading role that Lorrain Smith played in organizing the curriculum, and of his colleagues' willingness for him to take that role, that he was elected dean of the Faculty of Medicine in 1919: ibid.
41. Brief outlines of the form and content of the pathology course can be found in Edinburgh University Calendar 1914-1915 (Edinburgh: Thin, 1914), pp. 515, 554-56;
42. and in James Ritchie, "Memorandum with regard to the Teaching of Pathology and Bacteriology in the University of Edinburgh," 27 April 1922, folder 7315 ("Medical Education by Abraham Flexner - Scotland 1922-24"), box 713, series 1.5, General Education Board Archives, RAC. The bacteriology teaching was overseen by Ritchie, who was appointed to a new chair of bacteriology in 1913. Ritchie had graduated in medicine at Edinburgh one year before Lorrain Smith. Like the latter, he went on to Oxford in 1889, initially as assistant to a successful local general practitioner. Shortly after arriving in Oxford he began conducting bacteriological research in the university medical school under the Regius professor of medicine, Sir Henry Acland. From 1896 he taught pathology and bacteriology; he was officially appointed to a lectureship in 1897 and to a personal chair in 1905. In 1907 he returned to Edinburgh as superintendent of the Laboratory of the Royal College of Physicians of Edinburgh - at that time one of the most productive medical science laboratories in the Scottish capital, despite much of the work being undertaken by medical practitioners in their spare time; he retained the superintendency when he was appointed university professor of bacteriology, only giving it up in 1919 to concentrate solely on his university duties. Like Lorrain Smith, he seems to have been respected by the local clinical élite, and in 1910 he was elected a Fellow of the Royal College of Physicians of Edinburgh. See Robert Muir, "James Ritchie," J. Pathol. Bacteriol., 1923, 26: 137-44;
43. J. Lorrain Smith, "James Ritchie," Edinburgh Med. J., 1923, 30: 124-27.
44. On the work of the Laboratory of the Royal College of Physicians of Edinburgh, see Steve Sturdy, "Knowing Cases: Biomedicine in Edinburgh, 1887-1920," Soc. Stud. Sci., 2006, 37: 659-89.
45. Ritchie, "Memorandum" (n. 26).
46. Edinburgh University Calendar 1914-1915 (n. 26), p. 516.
47. Lorrain Smith had begun to develop this method of teaching while at Manchester, but it became the centerpiece of his pathology course during his time in Edinburgh: R. M., "James Lorrain Smith" (n. 12), p. 685;
48. Crerar, "James Lorrain Smith" (n. 12), p. 389.
49. Lorrain Smith's activities in Manchester are briefly discussed in Helen K. Valier, "The Politics of Scientific Medicine in Manchester, c. 1900-1960" (Ph.D. thesis, University of Manchester, 2002), pp. 77-82.
50. Russell C. Maulitz, "In the Clinic: Framing Disease at the Paris Hospital," Ann. Sci., 1990, 47: 127-37;
51. L. S. Jacyna, "Au lit des malades: A. F. Chomel's Clinic at the Charité, 1828-9," Med. Hist., 1989, 33: 420-49.
52. For the background to these practices, see Russell C. Maulitz, Morbid Appearances: The Anatomy of Pathology in the Early Nineteenth Century (Cambridge: Cambridge University Press, 1987).
53. This redefinition of disease necessitated a reciprocal retiming of the clinician's senses. See Jens Lachmund, "Making Sense of Sound: Auscultation and Lung Sound Codification in Nineteenth-Century French and German Medicine," Sci. Technol. & Hum. Val., 1999, 24: 419-50;
54. Lachmund, "Between Scrutiny and Treatment: Physical Diagnosis and the Restructuring of Nineteenth Century Medical Practice," Sociol. Health & Illness, 1998, 20: 779-801.
55. Cay-Rüdiger Prüll, "Pathology and Surgery in London and Berlin 1800-1930: Pathological Theory and Clinical Practice," in Prüll, Pathology (n. 9), pp. 71-99. It might be noted that, within the British context, Edinburgh and Edinburgh-trained physicians were unusually receptive both to the Parisian approach to pathological anatomy and to a histological view of normal and pathological processes.
56. On pathological anatomy, see Maulitz, Morbid Appearances (n. 30), pp. 143-46;
57. Malcolm Nicolson, "The Introduction of Percussion and Stethoscopy to Early Nineteenth-Century Edinburgh," in Medicine and the Five Senses, ed. W. F. Bynum and Roy Porter (Cambridge: Cambridge University Press, 1993), pp. 134-53.
58. On cellular approaches to physiology and pathology in Edinburgh, see L. S. Jacyna, "'A Host of Experienced Microscopists': The Establishment of Histology in Nineteenth-Century Edinburgh," Bull. Hist. Med., 2001, 75: 225-53.
59. J. Lorrain Smith, "Studies from the Pathological Department of the University of Edinburgh. Introduction," Edinburgh Med. J., 1915, n.s., 14: 5;
60. A. Murray Drennan, "Studies from the Pathological Department of the University of Edinburgh. Case I: Case of Carcinoma of the Pylorus, Old Obstruction in Left Coronary Artery, with Organised Infarct of Heart Wall and Aneurysm Formation. Recent Pulmonary Thrombosis," ibid., pp. 6-14;
61. J. Lorrain Smith, "Case II: Case of Tuberculosis of the Bronchial and Mesenteric Glands, followed by General Tuberculosis," ibid., pp. 112-17;
62. J. Lorrain Smith, "Case III: Case of Tuberculosis Involving the Hip Joint, Bronchial Glands, Lungs, and Intestines," ibid., pp. 199-204;
63. James Ritchie, "Case IV: Pulmonary and Intestinal Tuberculosis with Tuberculous Empyema, Tuberculous Septicaemia, and Terminal Intestinal Haemorrhage," ibid., pp. 367-75;
64. D. Murray Lyon, "Case V: Case of Osteomyelitis with Pyaemia," ibid., 1915, n.s., 15: 18-28;
65. James Miller, "Case VI: Case of Myxœdema," ibid., pp. 253-60;
66. T. Y. Finlay and A. Murray Drennan, "Case VII: Clinical Observations on a Case of Haemophilia," ibid., 1916, n.s., 16: 425-43.
67. Lorrain Smith, "Studies from the Pathological Department" (n. 32), p. 5. Ritchie, writing seven years later, stated that the course "extends over two terms (about 21 weeks in all)": Ritchie, "Memorandum" (n. 26); it is not clear if this figure of 21 weeks represented an increase in the time devoted to the course or (as is more likely) included the three-week Easter vacation.
68. Ritchie, "Memorandum" (n. 26).
69. Lorrain Smith, "Studies from the Pathological Department" (n. 32), p. 5.
70. David L. Edsall, "Comparative Observations of Methods of Education in Clinical Medicine in Great Britain and the United States, 1922-23" (typescript), p. 29, folder 217, box 16, series 401, RG 1.1, Rockefeller Foundation Archives, RAC.
71. Ritchie, "Memorandum" (n. 26).
72. See, e.g., Drennan, "Case I" (n. 32), p. 12.
73. The use of pathology museums for teaching purposes deserves more attention. Their increasing importance as teaching resources during the late nineteenth and early twentieth centuries is noted by Jonathan Reinarz, "The Age of Museum Medicine: The Rise and Fall of the Medical Museum at Birmingham's School of Medicine," Soc. Hist. Med., 2005, 18: 419-37.
74. This chronology is confirmed by the history of the Pathological Museum of the Royal College of Surgeons of Edinburgh, which languished during the mid-nineteenth century but revived as a site of teaching and research from the 1880s: Helen M. Dingwall, "A Famous and Flourishing Society": The History of the Royal College of Surgeons of Edinburgh, 1505-2005 (Edinburgh: Edinburgh University Press, 2005), pp. 201-2.
75. For a brief consideration of the pedagogical intentions behind such use, including the importance of linking specimens with case notes, see Steve Sturdy, "Making Sense in the Pathology Museum," in Anatomy Acts: How We Come to Know Ourselves, ed. Andrew Patrizio and Dawn Kemp (Edinburgh: Birlinn, 2006), pp. 107-15.
76. Ritchie, "Memorandum" (n. 26).
77. Edsall, "Comparative Observations" (n. 36), p. 29; Ritchie, "Memorandum" (n. 26). See also Edinburgh University Calendar 1914-1915 (n. 26), p. 516.
78. Lorrain Smith, "Studies from the Pathological Department" (n. 32), p. 5.
79. In the exemplary cases selected for publication, the authors thanked the attending physicians and surgeons for providing the clinical notes to be used in teaching. Harold Stiles, surgeon to the Royal Hospital for Sick Children and soon to become Regius Professor of clinical surgery at the University of Edinburgh, provided the notes for Drennan's "Case I: Case of Carcinoma" (n. 32), and contributed a general discussion of the pathology and treatment of tuberculosis to the write-up of Lorrain Smith's "Case II: Case of Tuberculosis." John Thomson, physician to the Royal Edinburgh Hospital for Sick Children, attended Lorrain Smith's "Case III: Case of Tuberculosis." Harry Rainy, physician to the Royal Infirmary, provided Ritchie's "Case IV: Pulmonary and Intestinal Tuberculosis." David Wilkie, assistant surgeon to the Royal Infirmary and later professor of surgery at the university, was the attending surgeon for Murray Lyon's "Case V: Case of Osteomyelitis with Pyæmia." Thomas Lovell Gulland, professor of medicine at the university and physician to the Royal Infirmary, attended Miller's "Case VI: Case of Myxœdema," and Gulland and Alexander Miles, surgeon to the Royal Infirmary, were responsible for Finlay and Drennan's "Case VII: A Case of Haemophilia."
80. Edsall, "Comparative Observations" (n. 36), p. 29.
81. Lorrain Smith, "Studies from the Pathological Department" (n. 32), p. 5.
82. Michel Foucault, The Birth of the Clinic: An Archaelogy of Medical Perception, trans. A. M. Sheridan (London: Routledge, 1973), esp. chap. 8: "Open Up a Few Corpses";
83. Maulitz, "In the Clinic" (n. 30).
84. This diagnostic imperative is implicit, for instance, in the innovations in clinical histopathology discussed in L. S. Jacyna, "The Laboratory and the Clinic: The Impact of Pathology on Surgical Diagnosis in the Glasgow Western Infirmary, 1875-1910," Bull. Hist. Med., 1988, 62: 384-406.
85. Christian Bonah attributes the dominance of pathological anatomy and the failure of pathological physiology in late nineteenth- and early twentieth-century German physiology to a continuing concern with the demands of clinical diagnosis: "Pathological Anatomy versus Pathological Physiology: A Franco-German Dispute over a 'Province for Pathology,'" in Prüll, Pathology (n. 9), pp. 31-53.
86. Russell Maulitz adduces similar reasons for the stillbirth of physiological pathology in twentieth-century America: "Pathologists, Clinicians, and the Role of Pathophysiology," in Geison, Physiology in the American Context (n. 4), pp. 209-35.
87. For a detailed study of the work of constructing novel neurological disease entities from clinico-pathological case histories, and the continuance of primarily classificatory concerns throughout the nineteenth century, see L. S. Jacyna, Lost Words: Narratives of Language and the Brain, 1825-1926 (Princeton: Princeton University Press, 2000).
88. That clinical narratives were themselves progressively denuded of individuating features in the course of the nineteenth century, in part owing to the growing systematization of pathological categories around which those narratives could be standardized, is of course a commonplace of a growing literature on the literary construction of case histories. See, e.g., Kathryn Montgomery Hunter, Doctors' Stories: The Narrative Structure of Medical Knowledge (Princeton: Princeton University Press, 1991);
89. Julia Epstein, Altered Conditions: Disease, Medicine and Storytelling (New York: Routledge, 1995);
90. Harriet Nowell-Smith, "Nineteenth-Century Narrative Case Histories: An Inquiry into Stylistics and History," Can. Bull. Med. Hist., 1995, 12: 47-67. The implication is that the pathological systematization of disease categories in turn provided a basis for disciplining the construction of clinical histories.
91. Harry M. Marks, "'Until the Sun of Science . . . the True Apollo of Medicine Has Risen': Collective Investigation in Britain and America, 1880-1910," Med. Hist., 2006, 50: 147-66, at pp. 150-52;
92. the quotation in the title is from James Paget, "Some Rare and New Diseases" (1882), quoted at ibid., p. 152. Paget and his colleagues sought to understand the dynamics of disease in terms of the interaction between innate constitutional predispositions and such "accidents" as habit, environment, and infection. Such an understanding, declared Paget, would require "a much more complete and exact study of all the personal conditions of disease than is now usual" (ibid., p. 151).
93. Sturdy, "Knowing Cases" (n. 26). Pedro Laín Entralgo identified a more general tendency toward the construction of such narratives in later nineteenth-century pathophysiological studies of cases, in La historia clínica: Historia y teoría del relato patográfico (Madrid: Consejo Superior de Investigaciones Cientificas, 1950), chap. 6: "La historia clínica en el siglo XIX." Though writing from a rather progressivist and universalizing perspective, Lain nonetheless makes clear that the London and Edinburgh clinicians were not unique in their search for a more dynamic approach to pathological knowledge of cases.
94. Crerar, "James Lorrain Smith" (n. 12), p. 389.
95. This view resonates with the comments of William Gull, who joined Paget in calling for collective research by general practitioners into the biographical aspects of disease. According to Gull: "It is his [i.e., the general practitioner's] privilege to see the earliest beginnings of disease, and to have the opportunity of tracing its evolution and decline. . . . the steps of pathological progress are before him, whereas at the end of life when the whole organism crushes downwards into a chaos of pathological forms it is often impossible on the postmortem table to say where the failure began and how it has advanced" (William Gull, "An Address on the International Collective Investigation of Disease," Brit. Med. J., 1884, 2: 305-8, at p. 306,
96. quoted in Marks, "'Until the Sun of Science'" [n. 48], p. 151).
97. Lorrain Smith, "Case II" (n. 32).
98. Miller, "Case VI" (n. 32).
99. Murray Lyon, "Case V" (n. 32), p. 28.
100. Lorrain Smith, "Case III" (n. 32), p. 203.
101. Miller, "Case VI" (n. 32), p. 253.
102. Lorrain Smith, "Studies from the Pathological Department" (n. 32), p. 5.
103. Miller, "Case VI" (n. 32), p. 259.
104. Lorrain Smith, "Case II" (n. 32), p. 117.
105. Drennan, "Case I" (n. 32), p. 13.
106. Ibid.
107. Murray Lyon, "Case V" (n. 32), p. 28 (emphasis in original).
108. Miller, "Case VI" (n. 32), p. 260.
109. Drennan, "Case I" (n. 32), p. 10.
110. Postmortem isolation and culture of tubercle bacilli was reported in Ritchie, "Case IV" (n. 32), p. 370;
111. while staphylococci were isolated from the case discussed in Murray Lyon, "Case V" (n. 32), p. 24.
112. Charles J. Smith, Edinburgh's Contribution to Medical Microbiology (Glasgow: Wellcome Unit of the History of Medicine, University of Glasgow, 1994), pp. 134-35.
113. Bacteriological tests were in frequent use by the early 1920s, including Wassermann tests in practically any case where the symptoms might potentially be attributable to syphilis: see Lawrence, Rockefeller Money (n. 22), pp. 188, 271-72. By that time, the university pathology course also included a practical course in clinical bacteriology, consisting of about ten two-hour classes, which mirrored Lorrain Smith's case method of teaching in key respects. The course included practical exercises on material sent in for examination to "three clinical laboratories in connection with the School. Each day one or two specimens which have been sent in to these laboratories are given out to the class with a statement of the clinical condition from which the specimen has been derived and of the object with which the specimen was sent in. The students then proceed to apply the appropriate methods and draw up a report of their findings. At the end of the course an account of the work done is handed in and criticised and handed back to the student" (Ritchie, "Memorandum" [n. 26]).
114. Murray Lyon, "Case V" (n. 32), p. 19. On the adoption of clinical charts in hospitals around this time, see Joel D. Howell, Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore: Johns Hopkins University Press, 1995), pp. 51-56.
115. Finlay and Drennan, "Case VII" (n. 32).
116. Thomas Addis, "The Coagulation Time of the Blood in Man," Quart. J. Exp. Physiol., 1908, 1: 305-34.
117. Addis developed this method while conducting research toward an M.D. degree in the University of Edinburgh's Department of Physiology. The method was considered to be significantly more accurate than more commonly used techniques, but was too cumbersome for routine clinical use. Addis went on to conduct pioneering research into the chemical pathology of hemophilia, including a study with Finlay, coauthor of the case currently under discussion. See F. Boulton, "Thomas Addis (1881-1949): Scottish Pioneer in Haemophilia Research," J. Roy. Coll. Physicians Edinburgh, 2003, 33: 135-42.
118. Finlay and Drennan, "Case VII" (n. 32), pp. 429-34. In this instance, the account of these investigations conducted during life played a more prominent part in the presentation of the case than did the postmortem examination, which was simply appended to the case report without further comment or analysis: ibid., pp. 441-43.
119. On laboratory training in physiology, see Merriley Borell, "Instruments and an Independent Physiology: The Harvard Physiological Laboratory, 1871-1906," in Geison, Physiology (n. 4), pp. 293-321.
120. Kathryn Olesko traces the roots of this pedagogy of disciplined practice to the philosophy seminars taught in early nineteenth-century German universities: "Commentary: On Institutes, Investigations, and Scientific Training," in Coleman and Holmes, Investigative Enterprise (n. 4), pp. 295-332.
121. Andrew Warwick and David Kaiser, "Conclusion: Kuhn, Foucault, and the Power of Pedagogy," in Pedagogy and the Practice of Science: Historical and Contemporary Perspectives, ed. David Kaiser (Cambridge: MIT Press, 2005), pp. 393-409.
122. Lorrain Smith, "Studies from the Pathological Department" (n. 32), p. 5.
123. Lorrain Smith, "Place of Pathology" (n. 13), p. 397.
124. See, e.g., the papers in Research Schools: Historical Reappraisals, ed. Gerald L. Geison and Frederic L. Holmes, Osiris, 1993, 8,
125. and esp. Kathryn M. Olesko, "Tacit Knowledge and School Formation," pp. 16-29.
126. Thomas Kuhn early recognized this aspect of scientific research training: see T. S. Kuhn, "Second Thoughts on Paradigms," in The Essential Tension: Selected Studies in Scientific Tradition and Change, ed. Kuhn (Chicago: University of Chicago Press, 1977), pp. 293-319, at pp. 306-7.
127. The Edinburgh medical school was still a major producer of medical practitioners during the early twentieth century, second only to London in terms of the numbers produced, though the English provincial universities were quickly catching up. In the academic year 1909-10, 1,369 medical students matriculated at the university: John Dixon Comrie, "The Faculty of Medicine," in History of the University of Edinburgh 1883-1933, ed. A. Logan Turner (London: Oliver and Boyd, 1933), pp. 100-163, at p. 101; assuming that they were evenly distributed across the five years of the curriculum, that would mean 274 students per year passing through the pathology class.
128. For an analysis of the careers of medical students who studied at Edinburgh and Glasgow in the years around 1871, see Anne Crowther and Marguerite Dupree, "The Invisible General Practitioner: The Careers of Scottish Medical Students in the Late Nineteenth Century," Bull. Hist. Med., 1996, 70: 387-413. No comparable analysis is available for the period considered in the present paper.
129. Cf. William H. Brock, "Breeding Chemists in Giessen," Ambix, 2003, 50: 25-70: Brock observes that the great majority of the students who trained in Justus Liebig's famous chemical "research school" were bound for careers other than research, and considers how the practical skills they acquired might have assisted them in other forms of scientific work.
130. Lorrain Smith, "Place of Pathology" (n. 13), p. 393.
131. Harry Rainy, physician to the Royal Infirmary and a popular Edinburgh clinical teacher, was coauthor of the most successful textbook of clinical examination to be published in Britain during the late nineteenth century: Robert Hutchison and Harry Rainy, Clinical Methods: A Guide, to the Practical Study of Medicine (London: Cassell, 1897),
132. which continues to be updated and published as Hutchison's Clinical Methods, ed. Michael Swash, 21st ed. (Edinburgh: Saunders, 2002). Hutchison was a London clinician.
133. William R. Sanders, "Method of Examining and Recording Medical Cases," Edinburgh Med. J., 1873, 19: 429-38.
134. Obituary, "William Russell," Edinburgh Med. J., 1940, 47: 704-5; the quote continues: "and his opinion of a case was much more likely to be determined by the findings of his eyes, ears and fingers, than by the reports of chemists and electricians."
135. This should not be taken to mean that Russell was uncritically hostile to the role of laboratory methods in medicine, however; he had undertaken extensive laboratory studies on a diversity of topics, including the cytology of cancer, "some early studies in exact measurement of cardiac function," and later research on blood pressure: Obituary, "William Russell," Lancet, 1940, 2: 251;
136. E. B., obituary, "William Russell," Brit. Med. J., 1940, 2: 269.
137. Rather, it would seem that Russell, like many of his contemporaries, took the view that new laboratory-based diagnostic tests should not take precedence over the clinician's more holistic view of the clinical situation. Like Rainy, he coauthored a textbook on clinical methods: G. A. Gibson and William Russell, Physical Diagnosis: A Guide to Methods of Clinical Investigation (Edinburgh: Pentland, 1890), which ran to three editions. Gibson was another keen advocate of new physiologically informed methods of clinical investigation, and established an electrocardiography laboratory in the Royal Infirmary in 1911.
138. Editorial, "Clinical Methods," Edinburgh Med. J., 1913, n.s., 11: 481-82, at p. 481 (emphasis added).
139. Francis Darby Boyd, "An Inaugural Lecture in the Moncreiff Arnot Chair of Clinical Medicine," Edinburgh Med. J., 1919, n.s., 23: 284-95, at p. 290 (emphasis in original). Criticized in his own time for his overinsistence on the importance of laboratory knowledge as a guide to understanding disease, Bennett had by the 1910s become something of an exemplar of the scientific practitioner for Edinburgh doctors. Boyd was also editor of the third (1902) edition of Gibson and Russell's Physical Diagnosis.
140. Lorrain Smith to J. T. Wilson, 19 March 1889, J. T. Wilson Papers, University Archives, University of Sydney, Sydney, Australia. I am grateful to Patricia Morison for bringing these papers to my attention.
141. "William Smith Greenfield" (n. 6), appreciation by J. Lorrain Smith, p. 258. Greenfield's clinical teaching concentrated on the practice of diagnosis, but like Lorrain Smith after him he regarded this as less a matter of classifying a case than of understanding "the development and advance of disease": H. R., "Professor W. S. Greenfield" (n. 6), p. 258.
142. Quoted in Weatherall, Gentlemen, Scientists (n. 9), pp. 189-90.
143. A case-based approach to clinical teaching was first suggested in 1900 by W. B. Cannon, at that time still a medical student at Harvard, before being adopted by Richard Cabot and other clinical teachers there: Saul Benison, A. Clifford Barger, and Elin L. Wolfe, Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge: Belknap Press of Harvard University Press, 1987), pp. 65-70, 107, 233.
144. For discussions of the epistemological and pedagogical basis of Cabot's conferences see, inter alia, John Forrester, "If p then What? Thinking in Cases," Hist. Hum. Sci., 1996, 9: 1-25;
145. Stanley Joel Reiser, "Creating Form out of Mass: The Development of the Medical Record," in Tradition and Transformation in the Sciences: Essays in Honor of I. Bernard Cohen, ed. Everett Mendelsohn (Cambridge: Cambridge University Press, 1984), pp. 303-16;
146. Maulitz, "Pathology" (n. 9).
147. Christopher Crenner, "Diagnosis and Authority in the Early Twentieth-Century Medical Practice of Richard C. Cabot," Bull. Hist. Med., 2002, 76: 30-55, at pp. 37-40.
148. The rather ambiguous role of pathology and diagnosis in Cabot's practice and his professional identity is further explored in Crenner, Private Practice: In the Early Twentieth-Century Medical Office of Dr. Richard Cabot (Baltimore: Johns Hopkins University Press, 2005).
149. Maulitz, "Pathological Tradition" (n. 9), p. 188.
150. Edsall, "Comparative Observations" (n. 36), pp. 29-30. Edsall was generally unimpressed with what he found in the British schools, but commended Lorrain Smith's case method of teaching to the Rockefeller officers as "interesting and suggestive": Edsall to Richard M. Pearce, 18 October 1922, folder 217, box 16, ser. 401, RG 1.1, Rockefeller Foundation Archives, RAC.
151. Lawrence, Rockefeller Money (n. 22), esp. pp. 110-21, 141-43.
152. As Regius Professor of clinical surgery from 1919, Sir Harold Stiles, who had contributed to the case method of teaching pathology - including a discussion of one of the exemplary cases published in the Edinburgh Medical Journal (see above, n. 42) - was one of the main mediators between the Medical Faculty and the Rockefeller Foundation. He never quite secured Pearce's trust in the way that some of the full-time scientific members of the faculty did, and he confirmed Pearce's doubts when he declined to be promoted to a new Rockefeller-funded full-time chair of surgery in 1925.
153. Most obviously David Murray Lyon, another contributor to the case method of teaching pathology, who became professor of therapeutics (a clinical post, with beds in the infirmary) in 1924, then of clinical medicine in 1935: obituary, "David Murray Lyon," Brit. Med. J., 1956, 2: 1309-10;
154. obituary, "David Murray Lyon," Lancet, 1956, 271: 1167-68.
155. Obituary, "A. M. Drennan," Brit. Med. J., 1984, 288: 1464.
156. Edsall, "Comparative Observations" (n. 36), pp. 29-30.
157. J. Henry Dible, "Henry Roy Dean 19th February 1879-13th February 1961," J. Pathol. Bacteriol., 1962, 83: 587-97, at p. 590.
158. J. Mills et al., "James Henry Dible 29 October 1889-1 July 1971," J. Pathol. Bacteriol., 1973, 111: 65-76, at p. 67.
159. See, e.g., Diana F. Wood, "Problem Based Learning," Brit. Med. J., 2003, 326: 328-30.