[Professor DePaolo, who wrote the following essay during a Spring 2017 sabbatical, would like to thank Manhattan Community College (CUNY) for the leave. — George P. Landow]

Joseph Lister’s “Reflections on Medical Education”

In the 1 August 1876 Address to the Medical School graduating class of Edinburgh University, Dr. Joseph Lister (1827-1912) advised his students that the emphasis on the memorization of facts, however necessary to medical education, should not overshadow "the faculties which are most important of all for the practitioner." These faculties, in his view, were careful observation and clinical problem-solving, the ability "to think out by patient and laborious reflection the various questions which come before you for consideration" (281).

In Lister's view, structural reform of the curriculum was needed before a new educational philosophy could be instituted. Such reform required an immediate overhaul in three specific areas: (1) British medical education's centuries'-long reliance, as a qualifying standard, on the rote learning of isolated facts; (2) the narrow and compressed curriculum, as brief as two academic years in certain programs; and (3) the conceptual disarticulation of anatomy, chemistry and physiology from each other. Lister's reformist program, which stressed the uniqueness of each patient's condition, emphasized problem-solving. He believed that an academic environment along these lines would foster new approaches to understanding both the cause and treatment of diseases. Lister also thought his new approach would encourage both interdisciplinary studies and lead to a scientific community composed of instructors and students. Lister remained hopeful that the graduating class of 1876, however "poorly furnished" as clinical thinkers, had the potential to acquire "a mental calibre very superior to what [they] now possessed" (281). A "systematic method of observation" could be acquired in "clinical clerkships" and then applied directly to patient care. A heuristic plan of this kind encouraged independent thinking, hypothetical-deductive reasoning, and original research (282-83).

This essay places Lister's reformist ideas and precepts of medical training in historical context. To show that the philosophical, rather than the fact-based, model which he advocated owed much to the influence of his teachers and directors, I will begin with a review of the undergraduate and medical instructors whose pedagogy he most admired; and second, I will focus on the testimony of former students who retrospectively extolled the merits of Lister's medical instruction, conducted according to the model he professed, and how this method benefited their practices.

Lister’s University College London Training & Mentors

Lister studied the arts beginning in 1844 and, in 1845, he matriculated with distinction in botany and classics, obtaining a B.A. degree in 1847. In the winter of 1848, after recovering from a period of emotional distress, he began his study of medicine at UCL Medical School and Hospital. He earned two of four gold medals and, in 1852, the M. B. degree in Medicine, along with the Gold Medal and Scholarship in Surgery. Before he qualified for the degree, he had served as an intern and as House Physician to Dr. William Hayle Walshe (1812-1892), professor of pathological anatomy and author of 1846 study, The Nature and Treatment of Cancer; and, in 1851, he served as House Surgeon to Dr. John Erichsen (1818-1896) (Godlee 18; G. T. Beatson 3-4). One biographer writes of how salutary and formative Lister's residency had been: not only had he shared the enthusiasm that animated his peers, but he also emerged from that experience with "broader views and a more enlightened outlook on life" (Beatson 4-5). This broader view had been imparted by the medical faculty of UCL, to whom Lister recurrently expressed his sincere gratitude. The interdisciplinary faculty of the 1840s and early 1850s, whose activities are outlined below, included John Lindley (1799-1865), George Viner Ellis (1812-1900), Thomas Graham (1805-1869), William Sharpey (1802-1880), and James Syme (1799-1870). Members of the UCL medical faculty subscribed to the idea, expressed in Lister's 1876 University of Edinburgh Address, that the prevailing emphasis in British medical schools on the assimilation of fragmentary information was an impediment to training. The emphasis on isolated facts, over physiological and anatomical systems, had overshadowed the need for careful observation and for "a critical frame of mind," both of which would provide the skill and knowledge necessary to the practice of competent medicine (Bynum 219).

John Lindley (1799-1865), Professor of Botany at London University, had inspired Lister's interest in fieldwork and in the structure of plant-life. In the winter of 1872, Joseph assisted his brother, Arthur, in the collection of fungi. Arthur would become a recognized authority in the field, by virtue of his work on the myxomycetes (Godlee 263). An example of Lister's penchant for interdisciplinary thinking is illustrated by his linkage of his early botanical fieldwork and later work on antiseptic surgery. Impressed by the rapid changes fungi underwent, Lister speculated in the winter and spring of 1872 that these transformations might eventually have some bearing on his study of bacteria (Godlee 262-4).

Lindley was a comparative thinker. In his 1836 A Natural History of Botany, for example, he had described a taxonomy based on the principle of affinity: the relatedness of plant species determined, empirically, through a consideration of all points of resemblance, parts, properties, and qualities. New knowledge, in regard to species and taxonomy was obtainable if an unknown plant were compared, structurally, to analogous aspects of species and genera that were already known. Studying plants in isolation or in terms of their parts, on the other hand, did not move in the evolutionary direction that Charles Darwin had begun to chart in the 1840s. For Lindley, an empirically-based system in botany produced an orderly classification of plants and their natural relationships, superseding the "arbitrary or artificial" one then in use. Focused narrowly on floral anatomy and identification, botanical studies, therefore, could not advance to the point where plant-life could be considered in ecological context (Preface, A Natural History, vii).

George Viner Ellis, M.D. reacted to illogical approaches to anatomical instruction. In his 1840 text, Demonstrations in Anatomy, he pointed out that his specialty had been studied either demonstratively or descriptively, neither of which was a satisfactory method (iii). On the one hand, the demonstrative method focused on parts exposed during dissection and on their relative positions; but the mere exhibition of anatomical structures, in Ellis' views, was unable to explain, or to stimulate enquiry into, how the parts interrelated with each other functionally. On the other hand, the descriptive approach was also limited because it provided minute details of organs that were indemonstrable — that is, they were described structurally in "the order in which they appear"; as a consequence, the complex interrelationships between parts and their physiological characteristics could not be adequately explored. Thus, anatomy taught these two ways displayed the parts and their arrangements as distinct from their function, as vaguely related to other structures, and not as elements of larger systems. Ellis' approach, on the other hand, was regional and comprehensive.

Ellis' 1840 textbook subscribed to a methodology that offered tangible benefits to students, "in the pursuit of practical knowledge" (iii). Instead of the dissection and rote identification of isolated parts, which Ellis considered the unsystematic disassembling of the cadaver, he advocated dissection according to "the great divisions of the body," as they had been generally established. The organization of his textbook reflects the sectional order he adopted, from which Lister benefited greatly. Ellis' plan divided the body into five sectors: the head and neck, broadly encompassing the vascular, connective, nervous, and glandular systems (1-302); the upper extremity, moving from the thorax up to shoulder and scapular region, down both arms and hands, then back to upper-extremity blood vessels, connective tissues, and nerves (303-446). The students were directed to a brief description of the female perineum (447-67), and then to the abdomen (blood vessels and muscles), pelvis, and female reproductive organs, with a directional shift to regional spinal nerves; and, finally, the lower extremities are covered, from the back of the thigh and leg, the sole of the foot, to the front of the leg, and lastly to the connective tissue, blood vessels and nerves of the area

The chemist, Thomas Graham, was also an important influence on Lister during the period of his early medical studies beginning in 1848 (Godlee 14). Graham was also attuned to new developments in research and pedagogy. One development, noted in his 1858 textbook, Inorganic Chemistry, was the "rigorous verification which numerical data of all kinds have received," in relation to physical laws or chemical properties and composition (vii). In this period, chemical properties and relations had acquired "fullness and precision": "the correction and revision of every minute branch of the science was never . . . more general and rapid than at present time." The emphasis on precision and on the interrelatedness of chemistry and physics had "enlarged the means of practical instruction in chemistry, now everywhere provided for the student, and the consequent increase in the number of able investigators." This paradigm-shift in a discipline closely allied to medicine affected "the theoretical views of chemists," promoting "sound conclusions" based on secure foundations of discovery. For Graham, the standard of rigorous verification, no doubt assured by the availability of modern technology, had transformed chemical education and had begun the process through which the discipline would become a field closely allied to every branch of medicine.

Lister probably studied Graham's Elements of Chemistry, with its claim that organic chemistry had the capacity to illuminate questions pertaining to "vegetable and animal physiology" (Preface, vi). The intersection of chemistry and medicine, and the influence of Graham's studies on Lister's later research, appear in the his work in three areas —  on blood coagulation, on the fluid constituents of blood, and on antiseptics. Lister's citations of Graham's research indicate that the principles and laws of chemistry were applicable, if not essential, to medicine. For example, while discussing the effects of ordinary solids on the blood in his 11 June 1863 Croonian Lecture, Lister alluded to Graham's finding that slight causes could "induce a change from the fluid or soluble [state] to the . . . insoluble condition of 'colloidal' forms of matter." This chemical precept had a direct bearing on clot-formation, and specifically on "the coagulation of fibrine," a physiological subject, upon which Lister experimented and wrote extensively ("On the Coagulation of the Blood," CP. I, 129). Graham is cited, in a 10 August 1871 "Address in Surgery," for his investigations of gaseous diffusion, which was directly applicable to Lister's antiseptic surgery and to dressing techniques: "the escape of the volatile antiseptic necessarily occasioned a perpetual intermingling between the external air and that between the meshes of the fabric" ("The Address in Surgery," CP. II, 178). Graham's investigation of the biochemistry of the blood was also referenced in the 4 May 1891 Oration to the Medical Society of London. In this lecture, Lister credited the experiment of the late chemist for his work on the "diffusion of liquids" and how this precept relates to the blood, its products and circulation ("On the Coagulation of the Blood in its Practical Aspects," (CP. I, 197).

UCL tried to break from the traditional curriculum in which physiology, the study of an organism's bodily processes, had been subordinated to anatomy in London hospitals and in Scottish universities. UCL began the reform of medical education in 1836, by appointing William Sharpey (1802-1880), who modified the anatomy syllabus to include more on physiology (Bonner 152-53). On 29 July 1836, he sent a letter to the Council of the University of London with plans for teaching a different kind of course, presumably one in which physiology would have a greater presence (153). Although Sharpey's teaching methods were considered didactic, by other accounts he was an innovator, introducing new concepts of experimentation into the anatomy course (153). One of the most thorough of Lister's investigations under Sharpey's tutelage was a lengthy, 1858 letter, "Preliminary Account of an Inquiry into the Functions of the Visceral Nerves, with Special Reference to the So-Called 'Inhibitory System'" (CP. I, 86-98). This paper exemplifies Lister's belief that basic principles ought to guide in the study of physiology. The inherent limitation of human knowledge was a precept Lister had conveyed to his students in 1876. In 1858, he had practiced what he would profess two decades later, with respect to his investigations of the nervous system. Although he suspected that the afferent nerve affected the entire nervous system, he took care never to outdistance experimental data. Even though he suspected this hypothesis to be valid, he acknowledged that the nerve's function remained a "fundamental truth not yet explained" (CP. I, 98).

Sharpey's influence on Lister extended beyond the lecture hall and the laboratory (i.e., from pigmentation, circulation, and visceral nerves), to curricular reform. Lister was fortunate that his father, Joseph Jackson Lister (1786-1869), an amateur optician and developer of the achromatic lens, had trained him in microscopy (Lister, "Obituary Notice," CP. II, 543-52; Godlee 11-12). At UCL, Sharpey and Thomas Wharton Jones (1808-1891), Professor of Ophthalmic Medicine and Surgery, were his physiology instructors. In 1875, Lister would strongly advocate the Royal College of Surgeons' position that practical physiology should be part of medical education; in so doing, he agreed with the Commission's recommendation that insights into the discipline depended, not only on traditional lecturing, but also on original observations and on meticulous experimentation (Tansey S20).

Of the instructors and colleagues with whom Lister worked at Edinburgh, his father-in-law, the surgeon James Syme (1799-1870), exerted the greatest influence on his philosophy of medicine and on his pedagogy. Dr. Syme, in 1833, had been Regius Chair of Clinical Surgery at Edinburgh and, in 1847, for a time was Chair of Surgery at UCL. His teaching style helped to establish the Medical School of Edinburgh University as a premier learning institution ("History of the Chair of Clinical Surgery"). Lister, who had been elected a Fellow at the Royal College of Surgeons of Edinburgh, in 1855 lectured on surgery in the winter, and he also conducted a well-received, non-compulsory summer course. On 23 April 1856, he married Agnes Syme, James' daughter; and, in October, after Joseph had been appointed Assistant-Surgeon to the Edinburgh Royal Infirmary, the couple, after their wedding trip, returned to Edinburgh to a new home, No. 11 Rutland Street (Godlee 53-8).

In the 1856 edition of The Principles of Surgery, Dr. Syme had complained about a disturbing trend in standard surgical textbooks. Instead of providing "the careful conclusions and well-digested results of experience," works in the genre too often "consist of trivial details and speculative opinions, gathered together from all sorts of sources." As a consequence, "crude and heterogeneous compilations" of this kind confused readers and impaired judgment (v). Although experiments described in his book did not always lead to "practical improvement," Syme was most concerned with method and focus, with how procedures were performed and precautions taken; for example, a series of extensive and accurate observations he had made contributed to the understanding of "the true principles" that would explain the causes of bleeding ligatures; and he suggested ways of preventing serious complications of this kind (95). This important observation combined principle (the causes of bleeding) and practice (how to prevent it).

Lister's aptitude as a teacher and his breadth of knowledge, evident while Lecturer on Surgery at the Edinburgh School of Medicine, greatly impressed Dr. Syme, who was his Director. In a testimonial letter of 1856, Syme pointed to Lister's outstanding qualifications for the post of Assistant Surgeon at the Royal Infirmary, citing the latter's skills as diagnostician, clinician, and instructor. Lister's lectures, according to Syme, clearly evidenced his power to communicate information clearly, while his clinical performance manifested "uncommon manual dexterity, extreme accuracy of observation, and remarkable judgment--a combination of qualities not less rare than valuable in the practice and teaching of Surgery" ("Testimonials," 19). In a second recommendation letter, dated 11 October 1859, written in support of Lister's candidacy for the Chairmanship of Surgery in the University of Glasgow, Syme reiterated his 1856 assessment of the candidate's skills, with the emphasis on his intelligence: his sound medical judgments were based on accurate, "extremely correct powers of observation" ("Testimonials," 8). Thus, Lister combined qualities that Syme valued greatly: he adopted, and shared with, his father-in-law the concepts that the natural sciences and medicine were "collateral" disciplines; that instruction and practice were interdependent; and that the practice of medicine, in all of its aspects, had to be grounded on "sound principles," the recognized body of laws that guided the profession.

Syme's activism in medical education is particularly important to note, for it, too, influenced Lister's thinking. In the early 1820s, while at Edinburgh, Syme had instituted a regular course of anatomical lectures but, in 1825, added surgery to the curriculum. In 1826, while in disagreement with his surgical colleague, Dr. Robert Liston (1794-1847), Syme had to abandon the teaching of surgery. When he applied for the post of Surgeon at the Edinburgh Royal Infirmary, in 1829, the managers turned him down, reputedly in the interest of institutional harmony. Syme, who favored a unified approach to medicine, then opened a private surgical clinic at Minto House, where he admitted hopeless cases and inaugurated a system of clinical teaching. He had in mind a multidisciplinary institution, the prototype of the modern University Hospital (Syme, Plarr's Lives of the Fellows). From 1829 to 1833, Minto House operated as a 24-bed private hospital, treating more than 8,000 surgical cases; and, from 1837 to 1852, more than 11,000 in-patients were attended to in wards; and almost 60,000, as out-patients (Stanley 133). Not only had Syme refined and invented procedures, he also taught and assisted numbers of students (Stanley 19).

After Minto House, Syme further developed, and defended, his theory of medical education. He published a 1 October 1864 letter in The Lancet expressing his support of clinical instruction. Fearing its undervaluation, he subscribed to the use of large, interactive clinics, accommodating several hundred students at one time. He reasoned that bedside instruction on rounds, involving only six to eight students, limited direct clinical experience. Groups at the bedside that openly discussed a case in the presence of the patient, even though limited in number, could invade privacy and increase anxiety ("Clinical Teaching," 391). Syme's alternative plan was to bring patients, one-by-one, into a room where a large audience of students was present; it was preferable that the Surgeon had not already seen the patient. Before the audience, the physician was to "ascertain the seat and nature of [the patients'] complaints" and instruct the student-observers in the "distinctive characters" of the malady. With the patient's permission, of course, students had the opportunity to witness, firsthand, the doctor-patient consultation. Once student-observers were familiar with the details of the case, the physician-instructor explained "the principles of treatment" and his reasons for choosing that particular course of action, either in the presence of the patient or after the patient had left the lecture hall. If the patient was present and had given consent, the physician-instructor would administer treatment or perform a procedure in the presence of the students (391).

The students benefited greatly from Syme's method. They had witnessed an actual consultation, conducted in accord with the patient's wishes and needs; a demonstration of clinical accuracy based on established principles; and, if circumstances permitted, the actual treatment ("Clinical Teaching," 391). Syme mentioned that, every year, 12 to 20 of his former students, who had been educated in this way, and who had been practicing for some years in the public service, many with distinction, voluntarily attended his lectures. His former students, now young colleagues, routinely recollected these vivid, clinical demonstrations and compared them to similar experiences in their own practices.

Syme concluded the "Clinical Teaching" letter by praising the curricular decision of the Edinburgh College of Surgeons, a leader in innovative medical education at the time, for choosing to install a second required course of clinical surgery, rather than "a second systematic course" as an elective. This decision benefited students incalculably, for they were no longer being required to rehash old material and to endure conjectural and disorganized instruction. Instead, they would have at their disposal the latest information, modern cases studies, and "valuable facts for future guidance and practice." Syme hoped that his testimony "to the value of lectures on clinical surgery," especially in an interactive and dynamic environment, would be recognized and developed further (391). In the concluding lecture of a winter course on clinical surgery, published in 18 April 1868, Dr. Syme characterized "the great evil of modern medical education" in these terms: "it has become a preparation, not for discharging the duties of a profession, but merely for passing examinations which, for the most part, imply neither an accurate knowledge of facts nor the possession of sound principles, being simply affairs of memory loaded with dry terminology, to be thrown overboard at the earliest opportunity" ("Concluding Lecture," 371).

University of Edinburgh Statutes Relative to the Degree of M.D.

In this 1885 document, the Medical School articulated the M.D. curriculum. The program was definitely more comprehensive than any of its predecessors. The practice of interactive medicine had been instituted on many levels: interdisciplinary study was recognized; factual and conceptual approaches to medical knowledge were integrated; and practical experience in hospitals, in clinics, and in private practice were considered integral to professional training.

Section I of the document makes it clear that, to be admitted for examinations, a student had to complete a four- instead of two-year program of study, six months of each year being given exclusively to medicine. An alternative route would be three years of medical study in an accredited University, a course of practical anatomy, and a minimum of six winter months devoted to medical or surgical practice in an 80-bed hospital. If a student satisfied these requirements, as much as three years of comparable University study were transferable to the Edinburgh Degree.

Section II, with its five corollaries, enumerates actual courses and their durations. The Governors listed nine six-month required courses in Section II.1: Anatomy (unless alternatively satisfied), Pharmacology, Institutes of Medicine, practice of Medicine, Surgery, Midwifery and both gynecology and pediatrics, General Pathology, and Clinical Medicine in a public hospital under the direction of a medical lecturer. Additional sixth-month courses in Clinical Surgery, Medical Jurisprudence, Botany, Natural History (including Zoology), were also mandatory. Section II. 2-5 called for attendance at medical lectures, for at least six months' of work in general or surgical practice in an 80-bed hospital, in Edinburgh or elsewhere; and for a half-year apprenticeship to a licensed apothecary, to master "the art of compounding and dispensing drugs at a hospital laboratory or dispensary"; and, lastly, students had to spend six-months apprenticing in a private practice or interning in a hospital. The University stipulated, in Section III, that a candidate for the medical degree had to have matriculated at Edinburgh for at least one year prior to graduation (357).

The curriculum had been redrawn: expanded from two to four years and diversified in terms of activities integrating lectures and practical experience. In addition, allied fields were incorporated and individual research promoted. A Medical Dissertation, either in Latin or English, was the ultimate aim (competency in Latin was obligatory). At this juncture, the candidate took oral or written exams in all of the fields mentioned in Section II.1. If unqualified in an area, the candidate had to devote an additional year of study to two subjects, prescribed in Section II.1. If a student were to pass every examination, he had then to present his dissertation, attain the authorization of the Medical Faculty, and finally defend it. The medical degree was then conferred (357).

H. C. Cameron & J. R. Leeson: Reminiscences

One gets a sense of Lister's innovations and of how prescient his work and 1876 Address were, if we consult the personal reminiscences of his students. Of the numerous commentaries on Lister written by former students, many reflect his teaching techniques and philosophy. Because these texts are uniformly approbative, and tend to be anecdotal, impressionistic rather than analytical, hyperbolic in places, and rather brief, one has to be selective. Since insights into Lister's conceptual plan are most relevant, I have limited the testimonial review to the writings of two former Edinburgh students, the surgeons, Drs. Hector Clare Cameron at Glasgow (1843-1928) and John Rudd Leeson at the Edinburgh Royal Infirmary (1854-1927).

Hector Clare Cameron studied medicine at the University of Glasgow, receiving the M.B and C.M. degrees in 1866 and the M.D. in 1888 ("Sir Hector," Historical Hospital; "Sir Hector: Obituary"). At the Royal Infirmary of Glasgow, he served as Lister's House Surgeon, then was visiting surgeon at the Royal Infirmary, and, eventually, appointed Chair in Clinical Surgery at Glasgow University, where he served until 1910. Cameron delivered an Oration on Lister's intelligence and teaching methods on Commemoration Day, 23 June 1914. He attempted to characterize Lister's "scientific imagination," as he had witnessed him at work, problem-solving in the hospital and in the lecture hall (Cameron 15). Cameron never forgot Lister's genuine expressions of gratitude to those who had taught him at UCL, and who, "by their teaching, had aroused in him powers which influenced both the earlier and later developments of his scientific work" (21-22). Joseph Jackson Lister, his father and an amateur optician, along with his London professors, Lindley, Graham, and Sharpey, were frequently mentioned in conversation, as having stimulated Joseph's interest in botany, chemistry, and physiology, respectively. Lister often recalled field excursions with Lindley, and, along the way, their crude dissections and pocket-lens examinations of plants and flowers. He had learned structural botany in Lindley's class, and thought that he was "an admirable teacher" (22). For a "sound acquaintance with chemical principles," without which he might never have undertaken his own biochemical and medical experiments, he was indebted to Professor Graham. Professor Sharpey became a personal friend and inspired Lister to compose 16 physiology papers (1853-1891). The pedagogical innovations of his father-in-law, James Syme, infused his lectures (22-23).

Along with Lister's formula for acquiring medical knowledge and skills, Cameron recalled his imagination and personality. He was patient and perseverant in his work. Neither adverse criticism nor difficulties encountered in the course of investigations "dampened his zeal or arrested his energy" (23). A remarkably talented problem-solver, he surmounted difficulties through logical reasoning, equipped as he was with a broad spectrum of knowledge in the natural sciences (24). Cameron mentioned that Lister's mind was open to anomaly and that he believed scientific investigation to be open-ended. He ascribed to Lister an invaluable principle of scientific cognition. Lister taught and practiced the empirical axiom that habituation to natural phenomena could inadvertently hamper learning and stifle curiosity. The danger presented by this frame of mind was to assume that "ultimate facts" could be discovered, "beyond which no enquiry can carry us and from the contemplation and examination of which no useful result can follow" (26). In his close association with Lister, as student and junior colleague, Cameron was fascinated with "the working of his mind" and especially with his power of rendering himself "strange to the familiar" (27). In biomedical studies, nothing was commonplace or immutable. Lister was, above all, a humanitarian who desired, passionately, "to lessen the sum of human misery and death" (29).

John Rudd Leeson received medical degrees at St. Thomas's and at Edinburgh, and studied in Vienna and Berlin (M. Greer). As a student, he worked with Lister in the Edinburgh Royal Infirmary. In the biography, Lister As I Knew Him (1927), Leeson also recalled how Lister often spoke highly of his teachers at UCL—Drs. Sharpey, Jones, Liston, Lindley, Graham, and Ellis—to whom "he owed his ample knowledge of the sciences upon which medicine is founded" (28). This was an important reiteration because it indicates how acutely aware of the fact that his teachers had bequeathed to him a radically new approach to medical learning. Leeson understood that Lister's philosophy of medical education, as inculcated by his teachers, informed his scientific research, clinical and surgical activities, and pedagogical method:

The effect of [the UCL faculty's] teaching was to imbue him with a philosophic attitude towards disease, and it was this that appealed to him so strongly, facts crystalizing into principles from which practice could be deduced, and the master-key was physiology, a science that was only slowly receiving the attention it deserved and which was regarded in the medical schools as of secondary importance to its elder brother anatomy. [29]

At Edinburgh, Lister flourished as an "extra-mural lecturer," a position that allowed post-graduates to hire a small lecture theater, enroll as many students as possible and have a means of publicizing their lectures (33-4; D. Guthrie). The opportunity was educationally valuable because the classes were small, and medical students received individual attention. The extra-mural teachers, newly-graduated with medical degrees, were a stimulating influence even upon the professors. Although initially Lister had only limited success, his reputation grew, and he was appointed an Assistant Surgeon to the Edinburgh Royal Infirmary. His career advanced rapidly, from that point on, to Regius Professor of Surgery in Glasgow University (1860) and to Chair of Surgery at Edinburgh (1864) (34).

Both Cameron and Leeson agreed that Lister's mind and personality were intriguing, but, in certain respects, their emphases differed from one another. Attempts to characterize Lister's intellect and perspicuity sounds abstract unless exemplified by his handling of a specific case. Whereas Leeson was interested in the possibility that Lister's Quakerism was responsible for his "abiding consciousness of the limitations of knowledge and an overpowering sense of the mystery behind phenomena," Cameron was fascinated by, but did not explore, Lister's contradictory idea that scientific enquiry, though a creative activity, was inherently limited (Cameron 26; Leeson 57).

Leeson remembered Lister's gentle, polite, and unostentatious attitude towards students (60). Exerting a profound influence on them, Lister also set the tone for seriousness. He invariably attracted talented students who realized that they had entered into a pact with their professor. Along with Lister, each student was individually concerned about the success of a new treatment and that failure of a collaborative project would be to the disparagement of all. At the time, it was well known that Lister's antiseptic system and bacteriological theories had been met with a cold and sometimes derisive reception. Leeson and his peers, therefore, had a stake in their professor's success. This realization was both a source of anxiety and of inspiration for all, having "invested us with a responsibility such as few medical students can have felt" (74). From a modern perspective, this sense of a unified effort, ideally, is fostered in laboratories and teaching hospitals. Professional rank is respected, protocol is to be followed, and students' perspectives are to be valued and their contributions encouraged.

As diagnostician or researcher, Lister was well suited. "His mind," according to Leeson, "was essentially logical, and the output was reasoned conclusion, not rapid arrival by conjectural leaps, but careful process of ordered sequence" (75). Whereas Lister's scientific method when applied to an experiment, proceeded sequentially and never outran the evidence, in his lectures "he sought to instill established principles," unlike a popular lecturer who might be content only to group facts under headings for the student to memorize and replicate on examinations. To Lister, this was "artificial and unscientific," since each case under scrutiny was unique and could not possibly be treated effectively with a disorganized set of medical facts as a primary resource. A "sound practitioner," conversely, proceeded according to "principles," employing case studies and precedents as guides. To look at a case philosophically, according to Leeson's understanding of the word, was similar to T. H. Huxley's idea, expressed in the 1863, "Method of Scientific Investigation," that confidence in a scientific law rests on the experimentally-verified absence of variation (88).

Lister's pedagogical method encouraged, and even required, students to make independent judgments: "to observe and draw out our own conclusions from what we found and from what we saw; knowledge was to be deduced rather than received" (emphasis by author; Leeson 82). Inferences about an illness, its symptoms, expected course, and possible treatment, could only be drawn if the student had prior, general knowledge of a disorder. With clinical data in hand, the student turned to disease classification. A central precept of Lister's curriculum, that diseases had to be classified in order to be readily diagnosed and treated, indicated that he had practiced nosology (Gk: υόσoV [nosos]: "disease" + -logia [-logia]: "study of- "), the origin of which, in Britain, had extended directly from Dr. Thomas Sydenham (1624-1689) and, in the University of Edinburgh, from physician and chemist, Dr. William Cullen (1710-1790). Leeson found this method of clinical teaching both "distinctive and unusual," its most current proponent being Dr. Syme who had used a philosophical modality at Minto Hospital in 1829, where patients from the ward were brought into the theater, before an audience of note-taking students. Lister unquestionably "followed the method [that Syme] had initiated" (Leeson 86). The dressers brought in the patient whom Lister greeted; the investigation was conducted, with due regard for privacy and comfort; technical terms were avoided so as not to cause alarm or confusion; and, if the case did not require surgery, a lecture relating the case study to medical principles followed. As expected, it focused on the "principles rather than the details of practice, a method which, ever since the days of Cullen, had been a prominent feature of the Edinburgh School, and was entirely in accordance with Lister's notions" (87). Although Lister was an accomplished anatomist, having been trained by Dr. Ellis at UCL, he approached surgery physiologically. His objective was to define physiology as a discipline; in so doing, to differentiate it from anatomy; and then to re-define the interlinkages between the two fields (87).

Leeson explicitly stated that the examiners wanted facts, but Lister wished to instill principles. The difference was essential to Lister's unique style. Whereas the typical lecturer tended to group facts under headings which could be recalled and "passed parrot-like to the examiner," Lister, who rejected this kind of pedagogy as "artificial and unscientific," stressed that each case was unique and posed new problems in diagnosis and treatment and that sound medical practice depended on "a foundation of sound principles" (Leeson 81). In practical terms, he believed that "one case thoroughly studied would be a guide to many others." For Lister, this constituted "the philosophic view of the case" (81).



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Last modified 6 May 2020