Patrick Fiddes
Australia

The perception that medicine’s contemporary teaching practices were introduced by innovative Modern Era¹ physicians does not recognize the original contributions of ancient forefathers.

Medicine’s earliest teaching records exist in ancient Sanskrit. They provide “detailed information concerning the training of doctors”² in Akkadian where “the master’s interpretation of texts were preserved as [an] oral tradition….[which] would have formed the basis for later commentary texts.”³ And from Egyptian papyri: “There can be little doubt that the medical papyri fulfilled a role no less important than that of medical texts today.”⁴ Data from the Edwin Smith and Ebers papyri describe physicians’ semiotic skills: “First they listened to their patients’ symptoms and then examined them using their eyes and hands.”⁵ On reaching a diagnosis, they explained to the patient the disease and its treatment, a practice that “has been followed in unbroken succession to the doctor of today.”⁶

Another durable succession involved the humoral theory of disease that existed in Ayurvedic,⁷ Babylonian,⁸ and Egyptian mythologies long before the emergence of the Hippocratic bodily fluid humoral theory.⁹ The Egyptians believed the heart controlled twenty-two mtw (vessels) that carried bodily fluids such as food, air, blood, semen, mucus, and excrements which, if blocked, would induce disease.^10,11 All natural substances, including humans, were believed to share four indivisible and essential elements: land, water, fire, and air.¹² Empedocles¹³ introduced the four element theory into Greek philosophy, which merged with the existing concept of four seasons that shared qualities of dry, cold, hot, and moist. Health existed when each were in balance and illness followed any imbalance.^14,15

Subsequently, the humoral theory of blood, yellow bile, black bile, and phlegm¹⁶ was “established by the work of Galen”¹⁷ despite considering it an interpolation¹⁸ from the apocryphal Hippocratic book On the Nature of Man.¹⁹[xix] Its attribution to Hippocrates had a far-reaching influence on medical teaching as Galen’s extensive commentaries on the Hippocratic Corpus became textbooks for Christian monastic medical schools, medieval universities, and Islamic scholars in their schools. In consequence, Galen’s theories dominated Western medical theory and practice from the second century AD to the nineteenth.²⁰

As human dissection was prohibited,²¹ Galen undertook extensive animal dissections and vivisectional physiological experiments to establish his anatomical and physiological theories and believed his animal studies were sufficient representations of human anatomy. However, that Galen knew of the human anatomical and physiologic works of the earlier Alexandrian physician-anatomists Praxagoras, Herophilus, Erisistratus, and Rufus of Ephesus²² is evident in discussions of their works in his surviving books.²³ Rufus (70–110 AD) wrote the oldest surviving anatomical text, On the Names of the Parts of the Human Body,²⁴ and his De l’Interrogatoire des Malades²⁵ described a method of obtaining patient medical histories that rejected the Hippocratic reliance on observation and histories obtained from patient attendants.

Through the seventh to twelfth centuries, Galen’s books and those by Hippocratic, Neoplatonic, Alexandrian, Syrian, Persian, and Indian writers were translated into Arabic by Islamic scholars such as Ḥunayn ibn Isḥāq (808–873), Rhazes (865–925), Avicenna (980–1037),²⁶ and Averroes (1126–1198),²⁷ and were texts for student teaching in the larger hospitals of Arabia, North Africa, Iberia, and Sicily,²⁸ where medical and surgical specialties existed, women practiced medicine, and students received ward-based clinical teaching.²⁹

In the ninth century, the Islamic invasion of southern Italy occupied both Sicily and the commercial city of Salerno,³⁰ one frequented by Islamic traders and populated by Jewish, Muslim, and Christian citizens. Its medical school,³¹ Europe’s oldest,³² had scholars from different cultures. Given its diverse cultures and exposure to Muslim influence, it is probable that Islamic medical practices were known or had existed there. In 1065, Constantine of Africa³³ moved to Salerno where he studied and taught and translated his extensive library of Galenic and Arabic books into Latin. Five of these, known as the Articella,³⁴ together with Avicenna’s Cannon of Medicine, were used throughout Europe until the sixteenth century.

However, Salerno’s importance diminished as Bologna’s and Padua’s increased, and in 1260 Bologna University’s Professor of Philosophy, Taddeo Alderotti (1215–1295), introduced a dialectic method of teaching medicine, the empirical observation of clinical cases³⁵ and the Greco-Arabian traditions of the school of Salerno.³⁶ But by the sixteenth century, Padua had become the more important center and its Professor of Practical Medicine, Giovanni Battista da Monte (Montanus, 1498–1552), began teaching students at the San Francesco Hospital where “students as a group accompanied their teacher to the bedside of the ill, both to observe their physician-teacher’s methods and to practice those methods under his observation and direction.”³⁷

That practice lapsed after his death but was restored by professors Albertino Bottoni (1528–1596) and Marco Oddo (1526–1591),³⁸ who taught Johann Heurnius (1543–1601). Following his 1581 return to Leiden, Heurnius recommended that clinical teaching be introduced at Leiden University.³⁹ However, it was not until 1640 that Leiden established a 12-bed teaching ward, and 1658 when Franciscus Sylvius (1614–1672) commenced teaching students at the bedside.⁴⁰ He described his practice:

I have led my pupils by the hand to medical practice, using a method unknown in Leiden …. taking them daily to visit the sick at the public hospital. There I have put the symptoms of disease before their eyes; have let them hear the complaints of the patients and have asked them their opinions as to the causes and rational treatment of each case, and the reasons for those opinions … [and] they have assisted in examining the body when the patient has paid the inevitable tribute to death.⁴¹

Despite such advances, Oxford and Cambridge retained their classical curricula and Galenic-Hippocratic theories without clinical teaching. Accordingly, after completing an Oxford MB, Thomas Sydenham (1624–1689)⁴² undertook his clinical training at Montpellier Medical School.⁴³ Sydenham became famous for his nosological and epistemologic observations of the natural phenomena of many epidemics and diseases, and his 1676 book of aphoristic observations, Observationes Medicae, became Britain’s standard textbook for two centuries.

Sydenham’s book, the Hippocratic-Galenic texts, and his assiduous reading of medical texts were the basis of Herman Boerhaave’s (1678–1738) self-directed learning which, with visits to anatomical museums and one public dissection attendance,⁴⁴ established his medical knowledge.⁴⁵ Though Boerhaave had neither enrolled at a medical school nor experienced bedside clinical teaching, he graduated from the Harderwijk Academy⁴⁶ with a Doctorate of Medicine after a brief examination and a thesis dissertation.⁴⁷

Despite not having a university medical degree, Boerhaave was appointed Leiden’s Reader in Medicine in 1701,⁴⁸ Professor of Medicine and Botany in 1709, and Professor of Practical Medicine in 1714. His auditorium-based clinical lectures centered on having a selected patient brought from a 12-bed teaching ward⁴⁹ for Boerhaave to present their history, demonstrate physical findings, and discuss his iatro-mechanical theories in establishing their diagnosis and treatment. His lectures were famous, and as his fame spread throughout Europe and Britain, so did the popularity of his two theory-based aphoristic books.⁵⁰

Boerhaave’s fame was augmented by students who became Edinburgh’s first professors, where in the 1840s an infirmary was opened for students to “walk the Infirmary” during physician ward rounds for observational learning followed by Boerhaave-like auditorial clinical lecture-demonstrations. In 1750, William Cullen⁵¹ established a special teaching ward with Sylvius-like patient-centered bedside clinical teaching. In 1784, he published his four-volume textbook, First Lines of the Practice of Physic, which was used in London, Dublin, and North America, where his students were to later introduce clinical teaching in Philadelphia,⁵² Montreal,⁵³ and Dublin.⁵⁴

In 1753, Boerhaave’s students Van Swieten and Anton de Haen established Vienna’s medical school where de Haen introduced Sylvius-like clinical teaching, “where patients [were] examined and handled by the students under his guidance…and attended any autopsies.”⁵⁵

In 1781, Samuel Tissot⁵⁶ introduced student clinical clerkships to Pavia as “hands-on” clinical learning. Patients were assigned to two students to take their histories, perform physical examinations, write clinical histories, and determine diagnoses.⁵⁷ And in Germany in 1815, students at Heidelberg were being taught in a 28-bed clinic.⁵⁸

In contrast, in France, “one of the main failures in university medical teaching up to the end of the eighteenth century was the lack of bedside teaching…and the insufficiency of practical teaching to Parisian students in comparison…to Italy and Montpellier.”⁵⁹ Consequently, in 1794, Fourcroy⁶⁰ recommended: “That which up to now had been lacking in schools of medicine, the practice of the art and observation at the patients’ bedside, would become one of the main parts of teaching.”⁶¹ However, the practice of auditorial discussions after walking the wards and observing teacher-patient examinations prevailed.^62,63

In London, clinical clerkships were introduced,⁶⁴ and in 1814, Richard Bright, as a physician’s clerk at Guy’s Hospital, “was able to visit patients daily, record the features of each case and carry out the orders of his mentor.”⁶⁵ In 1819, Edinburgh physicians selected two senior pupils as clinical clerks “to write accurate histories of the cases, to report the effects of medicines and record the symptoms which might have occurred since the physician’s last visit.”⁶⁶

In the US, clinical instruction varied from walking the wards to auditorial teaching until, in 1857, New Orleans became the first North American school to introduce bedside teaching and clinical clerkships.⁶⁷ Thereafter, such teaching was introduced at Montreal,⁶⁸ at several other North American universities,⁶⁹ and at the Johns Hopkins Medical School in 1894.⁷⁰

As the fundamentals of bedside clinical teaching have a history extending over millennia, it is evident that the method has progressed through the augmentation of existing practices rather than the introduction of entirely new concepts by physicians of the Modern Era.

End notes

1. Modern Age or Modern Period; the historical time period 1500 to 1945. 
2. Puschmann, T. (1891), A History of Medical Education: from the Most Remote to the Most Recent Times. (London, England: H.K. Lewis), 8.
3. Geller, MJ. (2010), Ancient Babylonian Medicine. (Oxford, Wiley-Blackwell), 130.
4. Nunn, JF. (1996), Ancient Egyptian Medicine. (London, England: British Museum Press).131.
5. Ibid, 113.
6. Ibid, 114.
7. Elendu, C. “The evolution of ancient healing practices: From shamanism to Hippocratic medicine. A Review.” Medicine 2024;103:28. Ayurvedic medicine believed in elements and humors similar to those of the Egyptians.
8. Metwaly, A., et al. “Traditional ancient Egyptian medicine.” Saudi Journal of Biological Sciences.2021; 28, 5.
9. Porter, Roy. 1997. The Greatest Benefit to Mankind: a Medical History of Humanity. (New York: W.W. Norton), 138.
10. Metwaly et al (n. 8), 3.
11. Audouit, C. “Current Research in Egyptology.” Archéopress, 2021, 142-156.
12. Hicks, R. “Egyptian Elements in Greek Mythology.” Transactions and Proceedings of the American Philological Association. 1962; 93, 90-108.
13. Cartwright, FF. (1977). A Social History of Medicine. (London, Longman), 3.
14. Jacques, J. “Greek Medicine from Hippocrates to Galen.” Trans., Allies, N., Ed., Eijk van der, P. (Brill: Leiden, 2012), 24.
15. Ibid, 3.
16. Castiglioni, A. (1941) A History of Medicine. (New York, Knoff), 162.
17. Ibid, 8.
18. Adams, F. (1985) The Genuine Works of Hippocrates. (Birmingham, Classics of Medicine Library). 61. A theory from the apocryphal Hippocratic book On the Nature of Man.
19. Ibid, 61. Galen regarded On the Nature of Man “an interpolation,” and perhaps the work of Hippocrates’ son-in-law Polybus.
20. Wear, A. “The History of Galenism.” History of Science. 1975;(13): 122.
21. The Alexandrians were permitted by the pharaohs to undertake human dissection whereas both the Greeks and the Christian Church prohibited such.
22. Galen perhaps had rejected their works as resulting from vivisection.
23. Nutton, V. 2004. Ancient Medicine. (London: Routledge). Nutton discusses Galen’s commentaries about these Alexandrians in pp. 138-139
24. Fiddes, P. 2021. The Myth of William Osler. (London: Austin Macaulay), 164.
25. Letts, M. “Rufus of Ephesus and the Patient’s Perspective in Medicine.” British Journal for the History of Philosophy 22 (5):996-1020.
26. Avicenna’s Canon of Medicine was an encyclopedia of medicine in five books, which was translated into Latin and used widely in Western Medical teaching.
27. Ullmann, M. Islamic medicine. 1978, Chapter Two, The Age of Translations. (Edinburgh, Edinburgh University Press.)7-20.
28. Chiarelli, L. “Muslim Sicily and the Beginnings of Medical Licensing in Europe.” Journal of Indian Medicine. 1999; 31, 79-82.
29. O’Malley, C. (Ed). (1970) The History of Medical Education. (Berkeley: University of California Press). Chapter 2. Hamarneh, S. “Medical Education and Practice in Medieval Islam,” 39-71.
30. Salerno had previously been the regional capital city of Lombard.
31. Ferre, L. “The Multi-Cultural origins of the Salterrnian Medical School.” Journal of Mediterranean Studies. 2018, (270), 1.
32. The date of its establishment is unknown, but it officially closed in 1811.
33. Constantinus Africanus (1020–1087) lived and died at Monte Cassino.
34. It contained an introduction to Galen’s Art of Medicine, the Hippocratic Aphorisms and Prognostics and Galen’s De urinis and De pulsibus.
35. “Taddeo Alderotti. Physician and Master of Medicine – Fixica” (Florence 1223 – Bologna 1295). https://www.unibo.it/en/university/who-we-are/our-history/famous-people-and-students/taddeo-alderotti-1
36. Castiglioni, (n. 16), 333.
37. O’Malley, (n. 29), 95-96.
38. Puschmann, T. 1891. Trans, E. Hare. A History of Medical Education. London: H.K. Lewis, 332.
39. Castiglioni, (n. 16) 442-443.
40. Fiddes (n. 24), 216.
41. Withington, T. (1894). Medical History from Ancient Times. (London, England: The Scientific Press) 312-313.
42. The Father of English Medicine.
43. Montpellier’s clinical teaching was comparable to Padua’s and had had an Islamic influence.
44. Fiddes, (n. 24), “Herman Boerhaave’s Clinical Teaching: A Story of Partial Historiography.” Bioethical Inquiry. 2023, 20, 298.
45. Ibid, 33.
46. Ibid, 27. Harderwijk was not a medical school. It was a low fee academy with one professor, little teaching, and a poor reputation where degrees could be easily obtained.
47. Ibid, 42.”On the utility of examination of the excreta of patients as signs of disease.”
48. While Reader he wrote The Institutes of Medicine and The Aphorisms Concerning the Knowledge and Cure of Diseases.
49. That in which Sylvius had taught his students.
50. The Institutes of Medicine and The Aphorisms Concerning the Knowledge and Cure of Diseases.
51. He graduated from Dublin Medical School.
52. Moll, W. (1968). “History American Medical Education.” British Journal of Medical Education. 2, 173-181.
53. Hanaway J. & Cruess, R. (1996) McGill Medicine, Vol.1. The First Half Century 1829-1885. (Montreal; McGill-Queens University Press), 59-60.
54. Graves, Robert James. Dictionary of Irish Biography. https://www.dib.ie/biography/graves-robert-james-a3588.
55. Puschmann (n. 2), 414-415.
56. Tissot graduated from Montpellier in 1749.
57. Risse, G. “Clinical Instruction in Hospitals.” in Clinical Teaching Past and Present (Amsterdam: Rodolpi, 1989), 13-14.
58. Ibid, 110.
59. O’Malley, (n. 29), 137.
60. Physician, member of the Royal Society and Academy of Sciences and Secretary of the National Convention.
61. O’Malley, (n. 29), 147.
62. Bonner, T.N. (1995) Becoming a Physician. (New York, Oxford University Press.), 113-114.
63. Foucault, M. 1969. The Birth of the Clinic. (London, Routledge. Trans, A.M. Sheridan), 86.
64. Poynter, FNL. “Medical Education in London since1600.” in O’Malley (n. v), 235-249.
65. Risse, G. “Clinical Instruction in Hospitals.” in Clinical Teaching Past and Present (Amsterdam: Rodolpi, 1989), 1-19.
66. Comrie, JD. History of Scottish Medicine to 1860. (London: Published for the Wellcome Historical Medical Museum by Baillière, Tindall & Cox, 1927), 130.
67. Norwood, W. (1971). Medical Education in the United States before the Civil War. (London: University of Pennsylvania Press), 485.
68. Hanaway, (n. 53), 59-60.
69. Fiddes, (n. 24), 249.
70. French, JC. 1946. A History of The University founded by Johns Hopkins. (Baltimore; The Johns Hopkins Press), 8-9. The influence of Dr. Patrick Macaulay’s 1823 address “Medical Improvement” on the design of the medical course is noted on p.109.