I'm out of sorts, but Symmachus is here, After the fall of the Roman Empire we find the teaching of medicine conducted like the apprenticeship of a trade. A youth who wanted to become a physician would attach himself to a friendly practitioner, much as in the preceptorial system. This arrangement in a modified form lasted until about twenty-five years ago. With the spread of Christianity and the establishment of hospitals by the ecclesiastical orders, medical practice, to a large extent fell again into the hands of the priests, particularly the Benedictines who according to Puccinotti were the first in the Middle Ages to give clinical and didactic instruction. It seems also that in the time of Charlemagne, 764-814, the teaching of medicine received some attention at his court; few data, however, have come down to us regarding this school. When celibacy became a law among ecclesiastics, priests were forbidden to practice surgery and to treat diseases of women.1 Among the Arabs at this time, medicine was at a very high level. They had hospitals with vast numbers of students, who were instructed both practically and theoretically. There were hospitals at Damascus, Bagdad, Cairo, and probably elsewhere in Europe and Northern Africa, wherever the Saracens had gained a strong foothold. Yet progress under the Arabs was not so great as it might have been, despite clinical teaching in the hospitals, for the reason that dissection was indirectly forbidden by the tenets of the Koran, a corpse being "unclean." 1 It appears that for a time celibacy was enforced among physicians also. At any rate, in 1452, Cardinal d'Estouteville, charged by Pope Nicholas V. with the reorganization of the University of Paris, obtained the suppression of celibacy "as an impious and unreasonable thing for a doctor." (Supoy, "Le moyen âge médicale,” p. 27). The first real progress in medical teaching after this time is coincident with the rise of the great University of Salerno, the origin of which is shrouded in obscurity, although, according to some of the Italian historians (as for example, Puccinotti: "Storia della medicina," vol. II, part 1, p. 247, "La Scuola detta Salernitane é benedettina e Cassinense di origine"), it is the offspring of the Benedictine monastery of Monte Cassino.2 Since Charlemagne is known to have been interested in it (Ravon: "La France médicale," 1902, p. 409), its origin certainly dates back to the eighth century. Its medical faculty was composed of Greek, Italian, Jewish, and Arabic physicians, so that almost anyone could there study medicine in his own language. It was unusually free from ecclesiastical influence; the professors were married. Strange as it may seem, some of the lectureships were held by women, usually the wives or daughters of professors. Abella wrote: "De atro bilo et de natura seminis humani"; another, the famous Trotula, published a work on diseases of women entitled, "De mulierum passionibus ante, in et post partum"; and Rebecca, one on fevers, urines and the embryo. The school received a great impetus through the Crusades, and many a wounded and sick Crusader as, for example, Robert of Normandy, son of William the Conqueror, was treated there. Clinical instruction must have been carried out at Salerno, although details are meagre. We do know, however, that special attention was paid to dietetics. Under the great emperor Frederick II, in versatility and in ruthlessness not unlike the last of the Hohenzollerns and like him of Swabian blood, the medical school at Salerno in 1213 grew into a complete university. It is a fact "Daremberg ("Histoire des Sciences Médicales," Tome I, p. 259) denies that the medical school of Salerno originated from the Benedictines, the Arabs, or the Jews, and holds that it is Neo-Latin or GrecoLatin in origin. worthy of note that the two great Continental universities of the Middle Ages, Salerno and Montpellier, arose out of medical schools. Frederick also gave to the Salernitan school an excellent code of laws and a curriculum. Three years had to be devoted to philosophy, and five to medicine, with examinations at the end. Just as in Pennsylvania at the present time, this university examination did not per se confer the right to practice; the young physician had to associate himself for one year with an older practitioner—a custom similar to our hospital year. I have just spoken of Montpellier, which is of particular interest to us, as the great Sydenham studied there. Montpellier was founded under the influence of the Saracens, who came from neighboring Spain. In 1137, the medical school had its own building. Its fame really begins with the advent of Solomon Matthæus from Salerno in the twelfth century. In 1220, Cardinal Conrad,3 a German, demanded that everyone who intended to teach there must pass an examination. Pope Clement V, in 1308, established the rule that medical students must hear lectures for five years and during eight months, or two summers must attend a physician in medical practice. An intense rivalry existed between the University of Montpellier and the University of Paris. This rivalry was probably good for medical teaching; its bitterness is well illustrated in some of the Latin verses of Gilles de Corbeil, ' It may not be without interest to quote a statute of this Cardinal dated 1220 regarding the University of Montpellier. It is a medieval example of the black list: "If a professor is in litigation with one of his pupils with respect to his salary or for any other reason, no other professor shall knowingly receive this pupil until he has given or promised satisfaction to his former master." The same statute forbids sordid competition among the professors: "No teacher shall attract to himself the disciple of another teacher, in order to take him away, by solicitation, present or any other means whatsoever." the great medical teacher of Paris in the thirteenth century. (Vieillard: La France médicale, 1902, p. 397.) Under the corroding taint of scholasticism, both the University of Salerno and that of Montpellier rapidly deteriorated; the latter suffering eclipse through the growing fame of the University of Paris. In the seventeenth century, Montpellier experienced a temporary revival through the fame of Charles Barbeyrac (1629-1699), called the Hippocrates of Languedoc, who is remembered as one of Sydenham's teachers. It seems that after the decline of the schools of Salerno and Montpellier, and at a time when learning in general was beginning to reanimate the world, in preparation for the coming of the Renaissance, medical teaching ebbed to almost the lowest possible point. Instruction degenerated into dialectical discussions and hairsplitting arguments based chiefly on the writings of Hippocrates and Galen. Even the great Rabelais was roused to wrath by the medical teaching of his day, which was "toute livresque." (Ledouble: La France médicale, 1907, p. 207.) There is extant a program of lectures in medicine at the University of Heidelberg for the year 1569. Professor Curio lectured on "De generibus morborum" of Galen, and explained "De morborum signis" of Hippocrates. Professor Erastus did not lecture, because he had gone to the fair in Frankfort. Professor Melancthon, a nephew of the great Protestant reformer, delivered lectures in medicine on the basis of Galen. Would not Hippocrates, who had taken his pupils to the bedside of his patients and had taught them physical signs and keen observation, have marveled at the fact that, twenty centuries after his time, such inane discourses should constitute the sole instruction in medicine? Another hindrance to progress was the interdiction by the Church of dissection of the human body; and even after that was lifted, the obtaining of bodies for dissection was a difficult matter. It is interesting to learn through the researches of Sudhoff ("Studien zur Geschichte der Medizin," Heft. 8) how medical students were taught in the University of Leipzig during the first hundred years after its foundation in 1409. The lectures were given from six to seven o'clock in the morning during the summer and from seven to eight during the winter. During the first and second semesters, the first canon of Avicenna, during the third and fourth the liber tegni of Galen, and during the fifth and sixth the aphorisms of Hippocrates, with commentaries by Galen, were explained. The course in "practical medicine," socalled, took place in the afternoon. The holder of the chair explained a book of Rhazes, the first chapter of the fourth book of Avicenna, and the fourth chapter of the first canon by the same author. The lectures were given in the church of St. Nicholas. As for surgery and anatomy, they were completely neglected at Leipzig during the first century of this school's existence. At the University of Montpellier, which was already ancient when the University of Leipzig was established, teaching was carried out as follows: The lectures began at six o'clock in the morning and lasted one hour. They consisted of dictation or reading of Latin texts and making comments upon them. Dissections, inaugurated in 1376, did not take place more than once or twice a year and then the entire public was permitted to attend on paying an admission fee. There was absolutely no clinical teaching. The whole course occupied a total of about six months. At the end of this time the student in order to obtain his license had to practice six months outside of the city. If then he passed his examinations as a bachelor, the beadle clothed him with a red robe, while his comrades one by one administered a good blow with the fist. To obtain the doctorate he had to pass sixteen examinations. When his studies were finally completed, the new doctor had expended about sixteen thousand francs though after the year 1550 the cost was reduced to eightyone hundred and fifty francs, still a formidable sum (Paul Delmas, Bull. mensuel de l'Académie des sciences et lettres de Montpellier, March, 1913, No. 3). Although hospitals were springing up all over Europe (in Germany, for instance, the Order of the Holy Ghost founded not less than 154), clinical instruction was not given in any of them. Not even in the great Hotel Dieu of Paris, founded in the eighth century, was any use made of its wealth of clinical material for nearly a thousand years. What practical experience the student got was obtained by his attaching himself to some obliging physician outside of the university, who acted as an extramural teacher and took him along on his rounds. This custom eventually led to the establishment of policlinics, apparently first at Montpellier. By "policlinic" is meant something quite different from that which the word polyclinic now connotes, namely, an organization for visiting patients in their homes in various parts of the city. Hence, the word poli-clinic (bus, city); the present term, "poly-clinic" (woλús, many), being really a misnomer. One of the Montpellier physicians, Theophrastus Renaudot, migrated to Paris, established a policlinic there, and became a protégé of Richelieu and physician to Louis XIII. In the Rue de Calandre at the Sign of the Golden Cock he established a sort of dispensary for the poor. He incurred, however, the enmity of the faculty of the University of Paris-particularly of its brilliant but vindictive leader, Guy Patin' (1601-1672), whose motto, "Saigner et senner" (Bleeding and senna) helped to make him famous. 4 Guy Patin anathematized William Harvey and spoke of Harvey's discovery of the circulation of the blood as "paradoxical, unintelligible, absurd, and harmful to human life." In consequence the dispensary did not last long; and yet it was practically the only attempt at clinical teaching in Paris for several centuries. It is almost inconceivable that the material of the Hotel Dieu, which at this time had a capacity of two thousand beds, was not used for medical instruction. The conditions in this famous hospital were very remarkable as we know from a graphic account written by a Saxon tailor, Christoph Rink. This man entered the hospital as a patient and was received by an old barber, who touched him in various places to determine the nature of his disease. A priest recorded his name in a book, and two assistants conducted him to his quarters, where he was placed in a large bed between two other patients, in such a way that his head lay between the feet of his bed-fellows. This sort of community of living was quite the rule in those days; and even in the eighteenth century, three, four and even five patients were often placed in a single bed. Frequently as many as four puerperal women were put together. Both of Rink's bedfellows died. The first treatment our Saxon tailor received was psychic, an attempt being made to persuade him to believe the right religious doctrine; but he was a staunch Lutheran and resisted. The following day the doctor came, with the apothecary and the barber; and the traditional bleeding began. Rink was bled not less than twenty times, and yet lived to tell his tale. For the nuns, who conducted the nursing in the hospital and of whom there were three hundred, he had only the highest praise. Molière, in his inimitable comedy, "Le malade imaginaire," has drawn a true picture of the time. The son, Thomas of Diafoirus, comes up for his baccalaureate degree in medicine; and in his behalf the following statements are made: "He is firm in dispute, and strong like a Turk in his principles; and he never recedes from his opinion, but presses the argument to the last vantage point of logic; but, above everything else, that which pleases me," says his father, "and in which he follows my example, is that he is attached blindly to the opinions of the ancients, and that he will not comprehend nor hear the reasons and the experiences of the pretended discoverers of our times touching the circulation of the blood or any other opinion of equal stripe." To all questions as to the remedies to be used in the various diseases, Thomas invariably answers: Clysterium donare, Postea seignare, Ensuita purgare, Reseignare, repurgare Et reclysterisare to which the chorus makes the following response: Bene, bene, bene, Bene respondere. Dignus est intrare In nostro corpore. In Rome, as late as the sixteenth century, in order to become a physician the medical student had to pass an examination on the physics of Aristotle and the doctrines of Galen. This was followed by a question in which one of the examiners described the symptoms of a disease and then asked the name and treatment. Having passed this test, the final act of initiation was the giving of a banquet to the examiners. About the middle of the sixteenth century, near the close of the Renaissance, Professor Dal Monte," a friend of Vesalius, Dal Monte took an active part in the battle raging between the two camps into which the profession was divided in his time on the matter of bleeding. The one upheld the Arabic method, according to which the bleeding was to be done at the point farthest removed from the disease focus; at the foot, for example, in pneumonia; the other practiced the Hippocratic method, according to which the patient was to be bled from the arm corresponding to the side affected. Dal Monte and Vesalius were Hippocraticists. made the first modern attempt at clinical teaching, in the hospital of St. Francis at Padua. Little resulted from Dal Monte's efforts, but under his successors, Oddi and Bottoni, in about 1578, real bedside teaching began. Until quite recently I accepted it as a fact, having seen it in a number of works, that the first clinical teacher was Boerhaave; but Renaudot, Petersen, Puschmann and other reliable authors have clearly demonstrated that the credit for inaugurating clinical teaching belongs to these two otherwise unknown Italians, Oddi and Bottoni. Oddi gave his clinical lectures in the women's ward and Bottoni in the men's ward of St. Francis' Hospital. They illustrated their lectures with autopsy material. Autopsies were, however, still forbidden by the ecclesiastical authorities. Not long after Oddi and Bottoni, a blight struck the University of Padua, so that when the Dane, Thomas Bartolin, visited the city, he found only a "scola de pulsibus et urinis." Nevertheless, short as the period of clinical teaching was at Padua, it bore great fruit. The new idea was transplanted first to Holland, where Jan Van Heurne, who had studied at Padua, introduced it. His own success was slight; far greater was that of his son, Otto Van Heurne, who followed him in 1601. Somewhat later, in 1636, Wilhem Van Den Straten (1593-1681) established a remarkable clinic at Utrecht. He examined patients in the presence of a class of students, and discussed the diagnosis, prognosis and treatment with them. Following this, there was a public debate concerning the nature of the disease. Under Otto Van Heurne the students in Leyden visited the clinic two days a week, four students acting as clinical clerks, as we know from an extant letter of Thomas Bartolin. The authorities, however, in their wisdom, decided that this sort of teaching was not of much use and commanded the professors to instruct their students in the knowledge that can be gained from a study of the pulse and the urine. As most of the diseases were believed to have their seat in the blood, and as the urine was looked upon as a percolate of the blood, it seemed logical to determine the chemical composition of the latter by a study of the former. This rendered diagnosis extremely easy. As an illustration, I might cite what the monk Mercurius taught (at a somewhat earlier period, it is true) regarding the pulse: "If one lays four fingers of the right hand on the pulse of the right arm of the patient, one can conclude that the disease is in the head if the pulse is felt mainly by the index finger; that the disease is in the thorax if the middle finger feels it; and that it is in the abdomen if the fourth finger perceives the chief impact." One of the notable Byzantine physicians, John Actuarius, distinguished fourteen colors of the urine, each one having a definite diagnostic meaning. In the days of Van Heurne, enemas were greatly in vogue, and much time was spent in instructing the students in their preparation.® Under the stimulus of the invention of the thermometer, the magnifying lens, the microscope, and above everything else, through the epoch-making discovery by William Harvey, of the circulation of the blood a spirit of rebellion arose against the authority of the ancients that had held medicine in bondage for so long. When a man appeared upon the scene who taught medicine at the bedside, students flocked to A famous enema of Van Heurne's had seventeen ingredients, for the mixing of which the most minute directions were given. I might also mention another famous preparation-the mystical theriacum— which had no less than seventy-two constituents, and was looked upon as the apothecary's masterpiece. It is recorded that in 1754, in Nuremberg, the completion of this drug, which had required two months' labor under the supervision of the Senate, was celebrated with many civic festivities. Both Boerhaave and Van Swieten used theriacum, although the former's motto was simplex sigillum veri. |