Part 23

It is sometimes thought that after the Roman medicine, which was an imitation of the Greek (though Galen well deserves a place by himself, and Galen is usually thought of as a Roman though he wrote in Greek and had obtained his education at Pergamos in Asia Minor), there was an interregnum in medicine until our own time. This is, however, quite as much of an assumption as to suppose that the Egyptians had no medicine--as we used to until we knew more about them--or that old-time medicine is quite negligible because we were ignorant of its value, The Middle Ages had much more of medicine than we are likely to think, and just as soon as the great universities arose at the end of the {368} twelfth and the beginning of the thirteenth centuries, medicine gained a new impetus and flourished marvellously. These university medical schools of the later Middle Ages are models in their way, and put us to shame in many things. According to a law of the Emperor Frederick II issued for the Two Sicilies in 1241, [Footnote 23] three years of preliminary study were required at the university before a student might take up the medical course, and then he had to spend four years at medicine, and practise for a year under the supervision of a physician of experience before he was allowed to practise for himself. The story of the medicine of this time is all the more wonderful because subsequent generations forgot about it until recent years, and supposed that all of this period was shrouded in darkness. It was probably one of the most brilliant periods in medical history. Some of the men who worked and taught in medicine at this time will never be forgotten.

[Footnote 23: For the complete text of this law, the first regulating the practice of medicine in modern times, also the first pure drug law, see Walsh's _The Popes and Science_, New York, Fordham University Press, 1908.]

Probably the greatest of them was Guy de Chauliac, a Papal chamberlain, whom succeeding generations have honored with the title of Father of Surgery. His great text-book, the "Chirurgia Magna," was in common use for several centuries after his death, and is full of surgical teaching that we are prone to think much {369} more modern. He trephined the skull, opened the thorax, operated within the abdomen, declared that patients suffering from wounds of the intestines would die unless these were sewed up, operated often for hernia in an exaggerated Trendelenberg position, with the patient's head down on a board, but said that many more patients were operated upon for hernia "for the benefit of the surgeon's purse than for the good of the patient." His directions for the treatment of fractures and for taxis in hernia were followed for full four centuries after his time. No wonder that Pagel, the great German historian, declared that "Chauliac laid the foundation of that primacy in surgery which the French maintained down to the nineteenth century." Portal, in his "History of Surgery," declares that "Guy de Chauliac said nearly everything which modern surgeons say, and his work is of infinite price, but unfortunately too little read, too little pondered." Malgaigne declared "the 'Chirurgia Magna' a masterpiece of learned and luminous writing."

Chauliac's [Footnote 24] personal character, however, is even more admirable than his surgical knowledge. He was at Avignon when the black death occurred and carried away one-half the population. He was one of the few physicians who had the {370} courage to stay. He tells us very simply that he did stay not because he had no fear, for he was dreadfully afraid, but he thought it his duty to stay. Toward the end of the epidemic, he caught the fever but survived it and has written a fine description of it. He was looked upon as the leader of surgery in his time, and this is his advice as to what the surgeon should be as given in the introductory chapter of his "Chirurgia Magna": "The surgeon should be learned, skilled, ingenious and of good morals; be bold in things that are sure, cautious in dangers; avoid evil cures and practices; be gracious to the sick, obliging to his colleagues, wise in his predictions; be chaste, sober, pitiful and merciful; not covetous nor extortionate of money; but let the recompense be moderate, according to the work, the means of the sick, the character of the issue or event and its dignity." No wonder that Malgaigne says of him: "Never since Hippocrates has medicine heard such language filled with so much nobility and so full of matter in so few words."

[Footnote 24: For sketch of Chauliac see _Johns Hopkins Hospital Bulletin_, 1909, or _Catholic Churchmen in Science_, second series. Dolphin Press, Philadelphia, 1909.]

The old-time medical traditions of education which in the mediaeval universities produced such men as William of Salicet and Lanfranc and Mondeville and Guy de Chauliac, persisted during the next two centuries in the southern countries of Europe, and then were transferred to America through Spain. The first American medical school was not, as has so often been said, at my own Alma Mater, the University of {371} Pennsylvania, which had its first lectures in 1767, while the Physicians and Surgeons of New York did not come for some ten years later and Harvard only in the following decade, but in the medical school of the University of Mexico, where the first lectures were held in 1578, and where a full medical school was organized before the end of the sixteenth century. In this medical school, which during the seventeenth century came to have several hundred students, the university tradition of the olden time was well preserved. Three years of preliminary study at the university were required before a student could take up the course in medicine, and four years of medical study were required before graduation. We have some of the text-books, and know much about the curriculum of this old medical school, and in every way it is worthy of the old university traditions.

Unfortunately our universities in what is now the United States developed very slowly. King's College (Columbia) did not become a university in the sense of having law and medical schools as well as an undergraduate department until the nineteenth century had almost begun. Harvard did not have a law school affiliated with it until the first quarter of the nineteenth century had almost run its course. The affiliations between the medical schools and the universities in these cases was only very slight, and the medical schools were entirely in the hands of the {372} medical faculty, whose main purpose during a great part of the nineteenth century was to make medical studies as short as possible and as inexpensive as they could possibly be made for the faculty, because that left so much more of the fees to be absorbed by the historic septennate of professors who ruled and managed the university. The consequence was that during most of the nineteenth century two terms of four months each were all that was required for the diploma in medicine in most American medical schools. Three schools maintained a very high standard by requiring twenty weeks in each of two calendar years. The medical school that was considered one of the best in the country, and whose graduates obtained the highest marks in the army and navy examinations, that of the University of Virginia, required but two terms of four and one-half months each which might be taken in the same calendar year, and then gave the doctor's degree.

It may be as well to say that the doctor's degree or diploma was a license to practise. There were no State regulations for the practice of medicine, and no matter how obtained, a diploma allowed practise. As some one has well said the diploma, then, was a license to practise, not medicine, the Lord knows! but to practise on one's patients until one had learned some medicine. It is out of this slough of despond in medical education that we have climbed in the last thirty-five years. We are getting back to the {373} old-time university traditions. Let us hope that we shall not allow ourselves to get away from them again. There are ups and downs in medical practice and medical fashions and medical education, and all depends on the men who compose the profession at any one time and not on any mythical progress that holds them up and compels them to do better than those who went before them. The highest compliment that can be paid to American medicine and medical men is that, in spite of this handicap of education they did not utterly degenerate, but, on the contrary, somehow managed to maintain the dignity of the profession and do much good work.

It is to you to-day, entering on this profession, that we look to do your share in keeping up the dignity of the medical profession and in maintaining standards in medical education. We have a glorious tradition of 6,000 years behind us with the great men of the profession worshipped as gods at the beginning, because men thought so much of them, and remembered fondly as great masters when they came in the after-time. From I-em-Hetep through AEsculapius and Hippocrates and Galen and Guy de Chauliac and Sydenham and Boerhaave down to our own time, the men whom we delight to honor are the ones who did not work with an eye single to their own success, but who tried, above all, to do things for humanity and for the profession to which they belonged. The man who is successful as a {374} money-maker in his profession is only doing half his duty. He must make medicine as well as money, that is, he must by his observations help others to recognize and treat disease better than they did before; he must labor for the benefit of humanity, and, above all, he must see that there are no decadence of professional spirit and no deterioration of medical education as far as his influence can go. It is men of this kind that we hope to send forth from Fordham, and you stand in the van of them all, and I wish you God-speed.

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UNIVERSITY MEDICAL SCHOOLS

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"Knowledge comes but wisdom lingers." --Tennyson, _Locksley Hall_.

"The foundation stones of the whole modern structure of human wisdom have all been laid by the architects of yesterday. Thrice wise is he who knows the quarries and builders of by-gone ages and is able to differentiate the stones which have been rejected from those which have been utilized." --Anon.

"Ideo Medico id in primis curandum, ut ab aegro circumstantias omnes accurate intelligat, intellectas consideret, ut inter curandum media illa adhibeat, quae tollendo morbo apta sunt, ne ex medicina nocumentum proveniat." --Basil Valentine, _Triumphal Chariot of Antimony_.

[The physician must therefore especially take care that he understand all the circumstances of his patient very clearly, and after understanding them weigh them well, so that during his treatment he may use those means which are especially suited to control the disease, lest any harm should come from his medicine.]

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UNIVERSITY MEDICAL SCHOOLS [Footnote 25]

[Footnote 25: Address to the graduates of St. Louis University Medical and Dental Schools, May 31, 1910, at the Odeon, St. Louis.]

It affords me great pleasure to accept the invitation of your Faculty to address the graduates of a university medical school here in the Middle West. I wondered, of course, what I should talk to you about, and have come to the conclusion that as an historian of medicine any message I may have for you is likely to come from my own subject. It so happens that we are just beginning to realize that the history of medicine may have much greater significance for us than we have usually been accustomed to think, and, above all, that it may mean much in furnishing incentive for the maintaining and raising of standards in medical education. In recent years there has come a very decided improvement in medical education in the United States. It is not hard to understand that the foreigner lifts his eyebrows in surprise when he is told that most of our medical schools a generation ago required but two terms of four months each, and that there was then just beginning to be a demand for a little more complete course and better facilities. There was a large number of medical schools, turning out graduates every year with the degree {378} of doctor of medicine, which was a license to practise in every state in the Union, for there were no state or federal laws regulating the practice of medicine. As for preliminary requirements the less said the better. If a man could write his name and, indeed, he did not have to write it very plainly, he found it easy to matriculate in a medical school and to be graduated at the end of two scant terms of four months each. He might come from the mines, or from the farm, or from before the mast, or from the smithy, or the carpenter shop; he need know nothing of chemistry, nor physics, nor of botany, nor of English and, above all, of English grammar, and he was at once admitted to what was called a professional school and graduated when he had served his time. Practically no one was plucked. The desire of the faculty for numbers of students forbade that in most cases. The two terms in medicine were not even successive courses. The second-year student listened, as a rule, to the same lectures that he might have heard the preceding year.

We all know the reason now for this extremely low standard of medical education. Proprietary medical schools made it their one business in life to make just as much out of medical education as possible and the historic septennate of professors, or sometimes the Dean, pocketed the fees (I came near saying spoils) every year, and robbed medical American education of {379} whatever possibilities it might have for the real training of young men in the science and art and practice of medicine. Perhaps the most interesting feature of this maintenance of extremely low standards in medical education, however, is the fact that in spite of it, men, or at least some of them, succeeded in obtaining a good foundation in medicine and then by personal work afterwards came to be excellent practitioners of medicine. Professor Welch said not long since: "One can decry the system of those days, the inadequate preliminary requirements, the short courses, the dominance of the didactic lecture, the meagre appliances for demonstrative and practical instruction, but the results were better than the system. Our teachers were men of fine character devoted to their duties; they inspired us with enthusiasm, interest in our studies and hard work, and they imparted to us sound traditions of our profession."

Nothing that I know is a better compliment to American enterprise and power of overcoming the difficulties of the situation than the life stories of some of the men who came from these completely inadequate schools. If with the maimed training and incomplete education given a generation ago American medicine not only succeeded in maintaining the dignity of the profession to a noteworthy degree, but also developed many men who made distinct contributions to world medicine, what will we not do now that {380} our medical education is gradually being lifted up out of the slough of despond in which it was and the preliminary education for medical studies set at a standard where real work of thoroughly scientific character can be looked for, from the very beginning of the medical course?

Is it any wonder, then, that those of us who have the best interests of American medicine at heart are watching with careful solicitude the movement that is now reforming medical education in this country? The one hope of medical education is, and always has been, organic connection with a university. Real University Medical Schools, that is medical schools as the genuine Post-Graduate Departments of Universities with the fine training that they give, have opened our eyes to what is needed in medical education in this country. Some of the old-time medical schools here in the United States had been connected by name with universities but this was more apparent than real, and the medical faculty ruled absolutely in its own department and throttled medical education and divided the income of the college among themselves, devoting as little as possible to equipment, to laboratories, to all that was needed for medical education.

Now has come the epoch of university medical schools in this country. I came near saying America, but we must not forget that the Spanish-American countries, having adopted their educational systems from the mother Latin country, {381} have always maintained the organic connection of the medical school with their universities, and as a consequence a good preliminary education, the equivalent of three years of college work with us, is required and has always been, and then some four years in the medical school and, indeed, in most of the countries five or six years and in one at least seven years of medical study required. I have thought, however, that this story of medical education in connection with universities and real university work will be especially interesting to the graduates of this thorough Western university, whose work in medicine is acknowledged as up to some of the best standards of professional attainment and whose organic connection with a great university assures not only the continuance, but the future development of medical education here along lines that shall place this among the serious progressive medical schools of the world.

The first university medical school that well deserves that name is the one that came into existence in connection with the University of Alexandria. I have been at some pains, because it is so delightfully amusing, to point out how closely the University of Alexandria resembles our modern universities in most particulars. It was founded by a great conqueror, who had gone forth to conquer the world, and having attained almost universal dominion sighed for more worlds to conquer. Then he set about the foundation of {382} a great city that was to be the capital of his empire, and endowed a great institution of learning in that capital that was to attract students from all over the world. When he died prematurely the Ptolemys, who inherited the African portion of his vast dominions, carried out his wishes. Money was no object at Alexandria: they put up magnificent buildings, founded a great library, bought a lot of first editions of books in the shape of author's original manuscripts, stole the archives at Athens, used Alexander's collection (made for Aristotle) as the foundation of what we would call a museum, paid professors better salaries than they received at that time anywhere else and housed them in palaces. What a strangely familiar sound all this has! Then Alexandria proceeded to do scientific work.

Euclid wrote his geometry, and, unchanged, it has come down to us and we still use it as a text-book in our colleges. Archimedes, following up Euclid's work, laid the foundation, of mechanics in his study of the lever and the screw, and of hydrostatics and of optics in his studies of specific gravity and burning mirrors and lenses. He made a series of marvellous inventions showing that he was a practical as well as a theoretic genius, who would be gladly welcomed, nay, eagerly sought for, as a member of the faculty even of a university of the highest rank or largest income in our modern times. Ptolemy elaborated the system of astronomy that had been so ably {383} developed by teachers at Alexandria before his time, and Heron invented his engines, which we have had as toys in our laboratories for centuries. We realized the true significance of one of them only when the turbine engine was invented and we found that the principle of it was in the toy engine of this old natural philosopher of Alexandria. They even did their literature scientifically at the University of Alexandria. We have no great original works from them in literature, but they invented comparative literature; for this making the Septuagint translation of the Holy Scriptures and doing the same for many other religious documents of the surrounding nations for comparative study.

It is rather easy to understand, then, that a medical school arose in connection with this scientific university, and that it did excellent work. The collections of Aristotle contained many illustrations which served as the basis for zoology, botany, comparative anatomy and probably even comparative physiology. The Ptolemys were very liberal and allowed dissection of the human body, so that human anatomy developed from a definite scientific standpoint better then ever before. The number of strangers in the town and the rather unhealthy climate of Egypt left many unclaimed bodies. It has always been the difficulty of obtaining bodies much more than prejudice against the violation of the human body on any general principle, that has been the reason {384} for the absence of human dissection in many periods of the world's history. We object to having the bodies of friends cut up, but we do not mind much if the bodies of those who are unknown to us are treated in that way. So long as men did not travel much there were few unclaimed bodies. With the advent of travel came abundant material for dissection and the Ptolemys allowed the medical school to use it.

Two great anatomists built up the structure of scientific human anatomy on the rather good foundation that had been laid on animal anatomy in the foretime. After all, the anatomy of the animal resembles that of man so much that very precious knowledge had been gained from zootomies in the previous ages. These two anatomists were Erasistratos and Herophilos. Both of them studied the brain especially, as might have been expected. For just as soon as the opportunity for dissecting man was provided, this, his most complex structure, attracted instant attention. Herophilos has named after him the _torcular herophili_, and the name he gave the curious appearance in the floor of the fourth ventricle--the _calamus scriptorius_--is still retained. He describes the membranes of the brain, the various sinuses, the choroid plexuses, the cerbral ventricles and traced the origin of the nerves from the brain and the spinal cord, recognizing, according to well-grounded tradition, the distinction between nerves of sensation and motion. {385} He described the eye and especially the vitreous body, the choroid and the retina. He did not neglect other portions of anatomy, however, and his power of exact observation, as well as his detailed study, may be judged from his remark that the left spermatic vein in certain cases joins the renal.

Erasistratos, his colleague, was perhaps even a more successful investigator than Herophilos. He represented the best tradition of Greek medicine of the time. He had two distinguished teachers, one of them Metrodoros, the son-in-law of Aristotle. It was probably through this influence that Erasistratos received his invitation from the first Ptolemy to come to Alexandria. The scientific work of Alexandria was founded on Aristotle's collections, on his books, for his library was brought to Alexandria as the foundation of the great University Library, and then best of all on the direct tradition of his scientific teaching through this pupil of his son-in-law. Erasistratos' other great teacher was the well-known Chrysippos of Cnidos. Cnidos was the great rival medical school to that of Cos. Owing to the reputation of Hippocrates we know of Cos, but we must not ignore Cnidos.