1350 "TEACHING OF ANATOMY-ITS AIMS AND METHODS." "

’were recorded without any idea that they would be used for.the purpose to which I have applied them. I have it vouchedfor on unimpeachable authority that the particulars were’regularly entered in the logs, and, so far as refers to the’Southern Hemisphere, they are supplied at the conclusion ofeach voyage to the Hydrographer to the Admiralty. My’belief in their accuracy is as implicit as it is in Dr. Dutton’s,own figures.

Coming to the figures themselves, I notice that Dr. Dutton’mentions neither the year of the voyage nor the line by whichhe travelled ; I find, however, in the Medical Directory thathe was surgeon to the R. M. S. Tongariro. The ships of the- company to which this vessel belongs pass in the tropicsthrough practically the same course as those of the companywhose data I used, and therefore there is no reason why the’tropical temperatures of the two lines should differ. As amatter of fact, the figures of the January sailings in my-tables closely agree with those of Dr. Dutton in this

particular; but with reference to the Southern Hemispherethe lower temperatures encountered by his vessel are ex-

plained by the fact that the ships of that line habitually gofurther south than do those of the line I referred to. Thetrack chart of the latter line on the voyage from the Cape of"Good Hope passes along the forty-fourth degree of southlatitude towards New Zealand, and in the South Pacific itfollows the forty-ninth degree nearly to Cape Horn.

Finally, in order to show how cautiously conclusions shouldbe drawn from a single voyage, let reference be made toMr. Dixey’s article in THE LANCET of Aug. llth, 1888,where will be found another series of temperatures of theRound-the-world trip, those to New Zealand being taken onthe Tongariro and those home by another ship of the same’lire. It will be seen there that the lowest recorded tem-

perature is seven degrees above Mr. Dutton’s minimum.I am, Sirs, yours truly,

LEOPOLD HUDSON.

"TEACHING OF ANATOMY—ITS AIMS ANDMETHODS."

To the Editors of THE LANCET.

SIRS, -I am grateful for the support publicly given to me byMr. Holmes and for that which I have received privatelyfrom many of almost equal professional rank. Amongothers a very prominent lecturer on anatomy at one of thelargest London schools, who is an eminent surgeon and adeading scientist, favours me, on the subject of anatomicalteaching, with a letter of sixteen pages containing severalimportant queries. I should like to reply on one pointboth to Mr. Holmes and to the very eminent friend abovereferred to. Both these gentlemen stand up somewhat forembryology and morphology. "These sciences." says Mr.Holmes, "throw light on the facts of anatomy, and, if

properly used, may make these facts more interesting and,more attractive to the learner." Let us see how the

thing works in the teaching, as illustrated by his own con-tentions, of the eminent anatomical lecturer I have venturedto introduce. Mr. A. B- (as I will take the liberty of callingthis gentleman) has his class before him ; he is going over,’we will say, the axilla, and has come to the subclavius"muscle. " Is there any inconvenience," this gentleman asks,"in my telling my class about the subclavius muscle inMenobranchus-how it arises from the precoracoid, envelopsthe head of the humerus, and is muscular from origin toinsertion ; or in my dilating upon its poor little human repre-sentative. the degenerated remains of an old and powerfulfamily ’ " "I I can conceive of no more harm in this than couldresult, in a somewhat kindred line of thought, from a historicalstudy of the curious windings of certain London streets.Have we not, many of us, wondered, for example, at thetortuous course of Marylebone-lane ? Is there any danger insubmitting, as is known to be the fact, that Marylebone-lanesimply follows the course of an old departed London stream?Generalising, may I not explain the why and wherefore ofthe different courses of the right and left recurrent laryngealr.erves, or even refer to Flood’s ligament? " "Do so by all,means," I reply. "Let the whole mind, heart, and soul of thelecturer always flow forth freely and sympathetically to his- class. Every thoughtful man would deem it a privilege to liste nto you on such topics." But you are specially qualified tospeak about the subclavius muscle of comparative anatomy,.about Flood’s ligament, about the right and left recurrent

laryngeal nerves, and so forth. You speak on these pointsof what you know in the ordinary sense of the term, of whatyou have dissected in the lower animals, of what you have" seen and handled, " and can show. For myself, I humblyconfess that if I were to discourse on the subclavius ofMenobranchus I should simply be repeating what I mighthave learnt from you or read in some book or other. I con-

fidently aver that if teachers continued to study and discussMenobranchus and serial homology and such like topics,most of them would have but a feeble grasp of ordinaryhuman anatomy.But if to the lecturer pertains the high privilege of free,

and, I would say, loving, intercouse with his class, it isotherwise, I would submit, with the writer. In a text-bookthe corollary cannot by the absentee-the reader-be dis-tinguished from the thought it aimed at introducing, as itcan in the case of the oration, where the living voice is heard.Text-books are but as finger-posts, whose brief indicationsmust be taken in verbatirn et literatim, or not at all. If thetext-book should explain why the recurrent laryngeal nerveloops round the arch of the aorta on the left side and thesubclavian artery on the right, must it not also dilate uponthe course of the chorda tympani, upon that of the facialnerve, upon that of the nasal nerve? If it is to restcertain statements on a consideration of the aortic arches,must it not bring in the "sacral"-nay, the "coccygeal"aorta ? Must it not submit that the internal iliac is but thefirst part of the original umbilical artery, that the externaliliac is but an enlarged intercostal, and so forth? Must itnot give the reason why we have usually a right, but some-times a left, superior vena cava? Can it leave out the

vestigial fold, the venæ azygos ? Is not the anatomistlanded, in fact, in the vexed question of the origin of thevenous system? Where can you draw the line? wherecan you say, This is enough? Give at least credit to theleaders of the new school of being intelligent and wise intheir generation. If they could have brought in this newmatter without revolutionising anatomy as taught beforetheir time-that is, as taught in the dissecting-room-theywould have done so. But the thing is impossible. Youmust found your anatomy either on the facts of the dissect-ing-room or on embryology and morphology-on what isvisible and tangible, or on what is not so. In the formercase you get a practical knowledge of anatomy-in the lattercase you get an abstract and theoretical knowledge ; in theformer case you get anatomy familiar to the eye and finger-in the latter case you get anatomy as a mental conception;in the former case you get the anatomy of the surgeon-inthe latter case you get the anatomy of the scientist. Thetwo things are absolutely distinct. One mode of study-theright mode, to my mind-cannot better be compared thanto learning a bone with bone in hand. The other mode islike learning about a bone without ever seeing it. All plead-ings in favour of embryology and morphology have reference,I submit, not to the practical learning contemplated in thestudy of anatomy for medical men, but to a kind of learningwhich savours of merely remembering, as one remembers astatement that has been heard, and not as one rememberssomething that has been seen or done.

In text-books for students of human anatomy all suchdigressions are foreign matter, and, to my mind, simplydeplorable. They mislead the student. They mislead theteacher. They mislead the examiner himself. The examinermust read the text-books, and to some extent he necessarilyexamines from them. Then what happens ? Heasksaques-tion quite incidentally about, say, the fourth meatus, " orthe "fossaduodeno-jejunalis." The candidate is rejected, wewill say. He immediately, student-like, attributes his failurenot to his not having known about some big thing like thearch of the aorta-which, by the bye, is now redescribedembryologicè:-but to his not having known about the fourthmeatus, " or the " fossa duodeno-jejunalis," or whatever new-fangled thing or name he may have been asked about. The"news from the front" is soon sounded forth in trumpettones by some score of comrade voices, and the whole schoolsets to I Macalisterise’’ for the next three or six months.Our great leader will pardon me. A short expression is

badly wanted to designate such anatomy as is not dissecting-room anatomy, whether it be based on embryology or onmorphology, or simply be such as goes beyond what theordinary dissector can see in the dissecting-room. It can bebut a just tribute of respect to Professor Macalister, thefounder and apostle of such anatomy, to use his namein designation of the same. The terms ’advanced’’ anatomy,

1351"DIAGNOSIS AND TREATMENT OF TYPHOID FEVER."

"scientific" anatomy, are but question-begging appella-tions, which cannot meet the need for a short but correctterm.There is, however, one leading feature in which the new

school would at first seem to be right, and through which itenlists much public sympathy. It asserts that it facilitates

study. Professor Macalister, after drawing an admirable, in-deed, an unusually vivid, picture of the crushing weight of pre-sent requirements as they lie on the poor students’ shoulders,comes to his solution of the difficulty, "Anatomy is simplifiedby being viewed from a morphological standpoint." I willendeavour once more to focus Professor Macalister’s argument:1. "Morphology brings into line "-these words are borrowedfrom another eminent writer of the same school, but conveytersely and pointedly what is substantially ProfessorMacalister’s meaning-Morphology brings into line "whatwould otherwise be a number of facts without a nexus." "

2. °°Morphology supplies a valuable form of memoriatechnica. " 3. " Morphology obviates the necessity ofcommitting to memory.’" I will grant that this is so : :

morphology may make it easier to learn anatomy, as anumber of facts arranged in a line, like a, set of nine-pins tobe knocked down with one cast of the wooden ball -e.g., tobe spouted out with volubility at the examination table, orgrandly talked about at society meetings. "This is in-finitely better," says Professor Macalister, "than anysystem of mnemonics." But it is a system of mnemonics.Worse still-I quote Professor Macalister’s own admission-"It invests things of little practical importance with thedeepest interest," with the same interest, that is, as more

important things; "it places the vestigial fold of the peri-cardium on the same platform as the superior vena cava,the ductus arteriosus as the aorta, the vena azygos as thesuperior vena cava." I would submit that, even on thescore of mnemonics, morphology is not even an unworthysolution of our difficulties, and that it but adds to ourembarrassments.

I come very briefly to the practical aspect of the subject.What can the surgeon know of a simple rupture if he hasnot carefully dissected the parts concerned in inguinal andfemoral hemiae ? How many students are there now in ourschools who have ? Here is a case, urgent if any case canbe, a case of strangulation: * Up, Sir, in the dead of thenight, to yon lonely cottage ; without assistance, lighted bya half-crazed old woman holding a halfpenny dip, and doyour best with your hernia knife ...... or ...... "Well, it’sonly just one other case of malpractice." "Few medicalstudents," you know, "expect to become competent surgeons inafter life." The above italicised sentence-will the readerbelieve me ?-is quoted verbatim from a "leading article"published only last week in one of the London medicaljournals. Let this go forth to the people of England.Let the bone setters hear it. Let the " quacks, " let the"sham oculists " understand it, and ...... wait till some bigplaintiff or other tries to make out-and what if he shouldprove his case ?-that some surgeon in one of these gunshotor other wounds so frequent nowadays has tugged at thetransverse process of the atlas, mistaking it for a bullet. Thisis no imaginary case, it is one that has been before our lawcourts. Am I wrong in my estimate of what the generalpractitioner-the backbone, be it remembered, of our pro-fession-should be anle to undertake ? I quote from a letterin the British Medical Journal of a fortnight ago : "Thereason why so many of our general practitioners are afraidto undertake the simplest operation, or to reduce a compoundfracture, is that they have forgotten their anatomy. Con-sequently patients crowd the out-patients’ rooms of an in-firmary, or place themselves under quack bone-setters or shamoculists, for operations that should be done by the generalpractitioner in his own surgery." General practitioners arecomplaining, and rightly so, I believe, of the competition ofthe hospitals. Why is this ? To a great extent because they"have forgotten," or, rather, were never taught, "theiranatomy," except in an inefficient and unpractical manner.I verily believe that if I were suffering from strangulatedhernia in a lonely, out-of-the-way place, I would ratherattempt to operate on myself-(cocaine being injected thisshould not be impossible: it is the finger that finds thestricture, not the eye)-than place myself in the hands of alearnei surgeon taught by the new school.

If " scientific anatomy " ever comes to be regarded, as Ihope it may, as something to come after, and to be super-added to practical dissecting, then I for one would no onlydrop all opposition to the same, but would watch the experi-

,- ment with the most hearty sympathy. I would urge,t however, that this "higher order of teaching " be handed.

over to special teachers. The new and abstract line of thought.its so different from, indeed so antagonistic to, the old andt practical, that no teacher, to my mind, can well excel in.s teaching both. I am, Sirs, yours faithfully,- T. COOKE, F.R.C.S.

To the Editors of THE LANCET.

SIRS,-Mr. Cooke has unquestionably done good service indrawing pointed attention to the change that is threatening

l to come over the teaching of anatomy to medical students.No one can doubt the great charm and interest that are to befound in embryology and morphology, and the high scientific.

e value of these departments of biology. However, that is not’

the question at issue, but, rather, what form of anatomicalknowledge best fits a man for the practice of medicine and

surgery. My verdict must be given most unhesitatingly for-: the old-fashioned dissecting-room human anatomy. I would

submit that a thorough knowledge of the structure, rela-tions, and naked-eye physical characters of the different.

’ parts of the human frame is an essential preliminary to-sound diagnosis and skilful surgical treatment. Thisknowledge can only be gained by each student carefullydissecting for himself, and such work is an excellent trainingfor both the hand and the eye ; but of equal significance is.it that dissection is the best available means of making a.student observe for himself and observe accurately. Whenwe remember that in medical practice more mistakes are-made by want of looking than by want of knowing, it isimpossible to overrate the importance of training our students.in the art of observing for themselves. Embryology andmorphology fail in all these particulars. They are mostinteresting, but they do not fit a man for the practice of his.profession. By the ordinary medical student they can balearnt only from books and not from personal observation ;they may train the memory and the imagination, but not the-eye or the hand. It is said, however, that it adds great.interest to the study of anatomy to combine with it a studyof embryology and morphology. True, it does. But let us not.shut our eyes to the danger this "interest " brings with it.It may so easily excite and please the imagination at theexpense of the faculties of observation. It makes man’s.relations in the scale of nature of more pressing importancethan the relations of man’s viscera or arteries. It substitutes.speculation for exact knowledge. By all means let us havescientific anatomists, let us unravel the secrets of embryologyand unfold the wonders of morphology ; but do not let us.confuse these ’’ accomplishments" of the few with the." necessities " of the many. The medical practitioner wantsa practical knowledge of human anatomy ; this must be

gained-can only be gained-by diligent work in the dis-secting-room. After he has acquired this, by all means lethim add to it all that embryology and morphology can telhim.-I am, Sirs, yours faithfully,

A FORMER TEACHER OF ANATOMY.

T. COOKE, F.R.C.S.

"SOME POINTS WITH REFERENCE TO THEDIAGNOSIS AND TREATMENT OF

TYPHOID FEVER."To the Editors of THE LANCET.

SIRS, -In an address by Dr. Hood upon the abovesubject in THE LANCET of Nov. llth, some far-reachingpropositions are brought forward as to the use or disuseof alcohol in the treatment of enteric fever; and the sta-tistics of the cases at the London Temperance Hospital arecited to prove Dr. Hood’s views in favour of the use of alcohol,the said statistics being cited as offering "a comparison of thetwo death-rates as fair and reasonable as any such comparisonis possible to be. " The responsibility of having to prescribeor withhold alcohol from patients suffering from enteric feveris one which weighs heavily on many practitioners who readTHE LANCET. It would be interesting and helpful if Dr. Hoodwould give us a proper table of his cases, a table such as wouldbe expected by men who are accustomed to be responsible forthe lives of patients affected with typhoid fever. I willprepare a similar table of the cases to which he has referred atthe Temperance Hospital, and hope that we may obtain someadditional light upon the important question to which Dr. Hoodhas referred.